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 Apsa from Apsa. And for this whole event, so here's we have Dr. Luke Redig. Um, he we're going to see his presentation on whether Pectus patients can be discharged the same day from the hospital after their repair. Then we'll hear from Dr. Victor Garcia from Cincinnati Children's Hospital and get his thoughts on the matter. Hello everyone. My name is Luke Redig 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 one in about 400 patients. It has a male predominance at about a 4 to one ratio. And the NUSS procedure is the gold standard for fixation. Historically, the NUSS 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 NUSS procedure with intercostal nerve cryoablation and an enhanced recovery after surgery protocol in addition to intercostal nerve block. And this was compared to the NUSS 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 intercostal nerve block was we used Bupivacaine proximal to the site of intercostal nerve cryoablation and we thought that this would help with perioperative pain. Our 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 IB 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 five in the IB group being able to be discharged on postoperative day one. None of the patients in the INC group were discharged prior to postoperative day two. The length of stay was decreased in the IB 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 IB group compared to the INC group, and the amount of opioids that were used were statistically significantly less in the IB group than the INC group. We found that 10 patients in the IB group never even used opioids after discharge, whereas five, the remaining five, used them sparingly. All patients had resolution of symptoms. Now, the complication, 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 difference between the group groups. In the IB group though, um zero return to the ED, whereas in the INC group, four return to the emergency department. We concluded that the NUSS procedure and intercostal nerve cryoablation with enhanced recovery after surgery protocol and intercostal nerve block was better than just the NUSS procedure and intercostal nerve cryoablation. So same day discharge is possible with patients. If you would like a copy of the Erats protocol, please email me below at Robert@l.redagkp.org and thank you so much for listening. Well, Dr. Redig, I want to thank you for that presentation and I want to thank the organizers for this opportunity. I want to begin with the question, uh, just because it can be done, uh, should it be done? And I personally don't feel that cryoblation 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 these devices typically are not subjected to the same rigorous robust trials that to let's say drugs are. Um, and from the standpoint of is this approved for by the FDA, uh, is is is a question of whether it should be used, uh, frankly because it has not been subjected to the clinical trials that drugs 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, uh suggested by the Kaiser Health News. Uh, so we don't know what the long-term consequences of this device are, this procedure, nor do we know what the long-term consequences are, uh particularly for children. So, I'm going to be cautious about this uh Luke because we really are concerned about chronic neuropathic pain. And I'm reminded about the consequences of the leucotomy, uh that were really introduced by a well-intended surgeon who thought that he could address uh consequences as far as health and mental illness. Uh, so I say cryoblation is not ready for prime time uh and just because you can do it doesn't really justify us. I'm arguing for a trial, randomized control trial as well as a registry so that we can track the. All right, Dr. Re. Sorry, sorry. Thank you Dr. Garcia, Dr. Redig. Any response? Thank you for your comment, Dr. Garcia. I I understand where you're coming from. Um there have been some papers and we have followed these patients for a few years now and our uh 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. Um and all the a lot of these patients, you know, come back to our clinic, they're super happy, um 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 seven days, eight, nine days in the hospital and then I saw the introduction of intercoastal nerve cryoablation and then these patients were staying in the hospital for three 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 I understand your concern with the long-term, you know, effects of intercostal 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 Dr. Redig, 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.