Update Course Rewind: Pectus Excavatum 2021

Dr. St. Peter's hospital completed a randomized trial of 110 patients comparing epidural and PCA for pectus pain control, and epidurals did not show superior results.

After trying cryoanalgesia with the first patient who went home on post-op day one, Dr. St. Peter's team lost equipoise and stopped enrolling patients in the epidural/PCA comparison study.

Cryoanalgesia uses cold temperatures to cause a conduction block that interrupts pain impulses to the brain.

The cryoanalgesia technique involves freezing underneath ribs four through seven for two minutes per rib; ribs eight and below should not be treated due to risk of abdominal wall paralysis.

After implementing cryoanalgesia, Dr. St. Peter's length of stay decreased from four days (which they could not get below previously) to one day.

Cryoanalgesia dramatically reduced median morphine equivalents compared to previous pain control methods at Dr. St. Peter's hospital.

Dr. Garcia acknowledges cryoanalgesia works but is concerned about lack of long-term studies and unknown potential for chronic neuropathic pain.

Medical devices and techniques are not required to undergo clinical trials before introduction to market, unlike medications which require FDA clinical trials with long-term results.

Dr. Garcia's hospital uses erector spinae catheters placed by the pain team with ultrasound guidance, which stay in for five days with hospital stay of two days and catheter removal by family on day three at home.

Dr. Garcia's hospital achieved two-day hospital stays and reduced opioid requirements both in-hospital and post-discharge using erector spinae catheters.

Dr. Rothenberg was initially a cryo skeptic due to concerns about added time and neuralgia complications, but after four cases realized the benefit was not just early discharge but how patients feel at discharge.

Dr. Wagner recommends multimodal pain control including Tylenol, NSAIDs, precedex for gentle wake-up, dexamethasone for post-anesthetic nausea, ketamine to avoid opioids, and support from child life specialists and physical therapists.

Dr. Ponsky's multimodal therapy regimen includes preoperative counseling, gabapentin pre and postoperatively, methadone, clonidine, bowel regimen medications, and antiemetics.

At the Nebraska program where Dr. Rayner trained, length of stay is under two days and patients are off opioids by one week using multimodal pain control.

Bar flipping typically occurs early and is due to surgical factors: bar sitting in wrong intercostal space, bad positioning, insufficient wrapping, or inadequate securing.

Computational modeling by physics-minded surgeons showed that shorter flat bars create more pressure on the sternum compared to traditional U-shaped bars, making them more stable.

Dr. Wolkine uses sternal elevator in about 10% of cases at Akron Children's, primarily in younger patients where thoracoscopy provides adequate visualization.

Sternal elevation in deep stiff pectus cases allows less tissue damage and better repair.

Dr. St. Peter uses sternal elevator in every case because it eliminates guesswork and allows consistent entry and exit at the same intercostal space.

Techniques including thoracoscopy, sternal elevator, vacuum bell in the operating room, and sub-xiphoid incision all serve the same purpose: avoiding cardiac injury during introducer passage.

Dr. Holcomb passes the bar from left chest to right chest because passing right to left directs the instrument toward the ventricle.

Dr. Slater has always performed the procedure right to left and had not considered left to right direction.

Bar passage direction (left-to-right versus right-to-left) is surgeon preference and probably does not make significant difference as long as the sub-sternal space is well dissected and visualization is clear.