APSA - Is same day discharge possible following the Nuss repair for pectus excavatum - R. Luke Rettig

We just have one more presentation to go in ABSA, from ABSA, and for this whole event, so here's, we have Doctor Luke Reddick. Um, he, we're gonna see his presentation on whether pectus patients can be discharged the same day from the hospital after their repair. Then we'll hear from Doctor Victor Garcia from Cincinnati Children's Hospital and get his thoughts on the matter. Hello, everyone. My name is Luke Reddick, and I'm a surgical resident at Kaiser Permanente Los Angeles Medical Center. And thank you for the opportunity for me to present our research on pectus excavatum and same-day discharge at APSA 2021. Pectus excavatum affects 1 in about 400 patients. It has a male predominance at about a 4:1 ratio, and the Nest procedure is the gold standard for fixation. Historically, the NEST procedure has been associated with a significant amount of pain, and this pain leads to increased hospital lengths of stay, which increase hospital costs. Now, with the introduction of intercostal nerve cryoablation, this has helped patients with their pain and also has helped to decrease the length of stay. Our study looked at the NUS procedure with intercostal nerve cryoablation and an enhanced recovery after surgery protocol in addition to intercostal nerve block, and this was compared to the NUS procedure with intercostal nerve cryoablation alone. The intercostal nerve cryoablation was performed at sites T3 through T7 on both sides of the chest. And historically, as we know from some of our previous papers, patients have been in pain for about 24 hours after this intercostal nerve cryoablation, uh, because it sometimes takes that long for the full effects to kick in. We hypothesized that using an enhanced recovery after surgery protocol, in addition to intercostal nerve block, that this would help them with their pain. So what we did with the intercostal nerve block was we used buppivacaine proximal to the site of intercostal nerve cryoablation, and we thought that this would help with perioperative pain. A primary outcome was same-day discharge, and secondary outcomes included returns to the emergency department, returns to urgent care, returns to the operating room, a cost analysis, and an analysis of inpatient and outpatient opioid use. We had 15 patients in both groups. All patients were male, and the patient characteristics were similar in both groups with regards to Haller index, pectus correction index, age, and ethnicity. The follow-up in the IMD group was 7.5 months, whereas the follow-up in the INC group was 29 months. We found that 10 out of 15 patients were able to be discharged on postoperative day zero, with the remaining 5 in the INB group being able to be discharged on postoperative day one. None of the patients in the INC group were discharged prior to postoperative day 2. The length of stay was decreased in the I&D group at 12 hours compared to 58 hours. The OR time was the same in both groups. The cost was statistically significantly less in the IND group compared to the INC group, and the amount of opioids that were used were statistically significantly less in the IMB group than the INC group. We found that 10 patients in the IMD group never even used opioids after discharge, whereas 5, the remaining 5, use them sparingly. All patients had resolution of syndrome. Now, the complications, we looked at Foley catheter removal and replacement. We looked at pneumothorax requiring chest tube placement. We looked at infections, surgical site, and also UTIs, and we looked at returns to urgent care. And none of those were a difference between the group, groups. In the INB group, though, um, 0 returned to the EED, whereas in the INC group, 4 returned to the emergency department. We concluded that the NUS procedure and intercostal nerve cryoablation with enhanced recovery after surgery protocol and intercostal nerve block was better than just the NUS procedure and intercostal nerve cryoablation. The same day discharge is possible in Ped Ecoban and patients. If you would like a copy of the ERATS protocol, please email me below at robert@el. Reddick@kP.org, and thank you so much for listening. Bye. Well, Doctor Riddick, uh, I wanna thank you for that presentation and I wanna thank the organizers for this opportunity. I wanna begin with the question, uh, just because it can be done, uh, should it be done? And I personally don't feel that cryoablation is ready for prime time. Uh, and the reason is, is that we really don't know what the long-term consequences of this. You know, when we look at medical devices, uh, the track record is not a very positive one from the standpoint that, uh, these devices typically are not, uh, subjected to the same rigorous, robust trials that, so, let's say drugs are. Um, and from the standpoint of, is this approved for by the FDA, uh, is, is a question of whether it should be used. Uh, frankly, because it has not been subjected to the clinical trials that drugs, uh, have, have been and should be used. And the drug industry, and the medical device industry rather, has been, I think, fairly conspicuous by the fact that many of the adverse consequences for medical devices are either underreported or not reported, as suggested by the Kaiser Health News. Uh, so we don't know what the long-term, uh, consequences of this device, uh, are, of this procedure, nor do we know what the long-term consequences are, uh, particularly for children. So, I'm gonna be cautious about this, uh, Luke, because we really are concerned about chronic neuropathic pain. And I'm reminded about the consequences of uh lecotomy, uh, that were really introduced by a well-intended surgeon who thought that he could address, uh, consequences as far as health, um, and mental illness. Uh, so I say cryoablation is not ready for prime time, uh, and just because you can't do it doesn't really justify us. I'm arguing for a trial, randomized controlled trial, as well as a registry so that we can track right Doctor Red results. Sorry, sorry. Thank you, Doctor Garcia. Doctor Reddick, any response? Thank you for your comment, Doctor Garcia. I, I understand where you're coming. From there have been some papers and we have followed these patients for a few years now, and our long term neuropathy rate is essentially very low, if not anything. Um, so this has been going on for a few years and we've shown that it's been actually been safe and all the, a lot of these patients, you know, come back to our clinic, they're super happy and They really went through that original surgery and their pain was incredibly controlled. So I've seen before how we would do it, you know, with thoracic epidurals, and these patients would stay 7 days, 89 days in the hospital. And then I saw the introduction of intracostal nerve cryoablation, and then these patients were staying in the hospital for 3 days, which is incredible. And then we did this. protocol, and now these patients are able to go home the same day of discharge. So I understand your concern with the long term, you know, effects of intercostalal cryoablation, but I've also seen, haven't seen really high rates of neuropathy. And in our patients specifically, that's really not an issue. So I think the benefits 100% outweigh whatever potential long-term effects that we actually haven't seen. Thank you, Doctor Reddick. A little bit of blows after the bell, but I think the judges were looking the other way, so they didn't notice. Uh, all right. Uh, phenomenal papers.