Update Course Rewind: Pectus Excavatum 2021

If you miss our stay current pediatric surgery update course, don't worry, because we are going to summarize our favorite sessions right here on this podcast. Today's episode is all about Pectus. We are going to see what is new about perioperative pain control and some rapid fire updates techniques. This is Cecilia Higiena, and I'm a research fellow at Cincinnati's Children's Hospital. And this is Ellen and Cisco, also research fellow at Cincinnati Children's Hospital Medical Center. First, Dr. Stephen Lee from UCLA Matell Children's Hospital presented a case. So this is a 16-year-old uh young man with shortness of breath on exertion. He has no comorbidities and a Pectus index of 5.5. The plan was to do a chest wall reconstruction. And the first question is in addition to multimodal pain medication, what do you recommend for perioperative pain control? There's so many options. So, let's see what Dr. Sean Saint Peter had to tell us about this. He's a pediatric surgeon at Children's Mercy Hospital in Kansas City. We of course struggled with postoperative pain management as everybody did. And we had completed a randomized trial, 110 patients to epidural and PCA. And in that study, the epidurals didn't really drop off. So neither epidural or PCA was doing the trick at Dr. Saint Peter's hospital. So I decided to start a new trial looking into cryoanalgesia. So, we were enrolling in this study. We had about 30 patients in each group when we tried the first cryo therapy, and when that patient went home on post-op day one, equipois was lost. Once you once you see it, it's it's sort of a different game. So, what Dr. Saint Peter is saying is that after cryoanalgesia, he didn't want to try anymore epidural or PCA. But, what is cryoanalgesia? Cryoanalgesia consists of the use of cold temperatures for analgesia. The low temperatures cause a conduction block, resulting in an interruption of pain impulses to the brain. Awesome, and how do you do it? We currently put the camera on the top and the probe through the bottom, but you could see how they're separated. Um, one's an interspace above. That just keeps them out of each other's way. And you literally just count down to the fourth rib and then freeze underneath it. It's two minutes per rib, we do four through seven. You're not supposed to go eight or below because you can get some abnormal wall paralysis. And what impact did you see in the patients? What we saw there is the length of stay where we just couldn't get below four days all of a sudden became one. And what about the use of opioids? What impact we have on our median morphine equivalence and they're not even really on the same planet. But not everyone is so excited about cryoanalgesia and Dr. Victor Garcia, a pediatric surgeon from Cincinnati Children's Hospital explained why. I agree with Sean, it works. I mean it is great, one day. Yeah, no. So, um, what I'm concerned about is is that there are no long-term studies. But I believe we just don't know. We don't have the long-term data. Dr. Garcia is explaining that even though cryoanalgesia seem to work, he is worry about future adverse effects, such as chronic neuropathic pain. You know, unlike drugs, medical devices and implants are not, are not required to undergo clinical trials before they're introduced into the market. What does that mean? For medications, the FDA requires clinical trials with long-term clinical results before approving them for use. For medical devices and techniques, this is not a requirement and therefore for things like cryo analgesia, there just not as many long-term results reported. And so, what do you use in your hospital, Dr. Garcia? About the 100 patients uh looking to Sean's point as far as and this was a comparison between epidural as well as not paravable but erector spine catheter. An erector spine catheter? What is that? Very very very briefly, erector spine catheters, they are placed by the pain team with an ultrasound guidance. Uh, they're not in the verbral space, but they are juxtaposed to it. Those catheters stay in for five days. The hospital stay is two days. Third day, while they're outside, the catheters are pulled out by the family. Uh, it is on a pump, it's automated. Okay, great. And our hospital stays are two days. Uh, we've been able to reduce the opioid requirements uh not only in the hospital but also outside of the hospital. So I am from the perspective at least with our experience that we do have an alternative. Is it going to be one day? Uh no, but is it certainly much less than the four or five days that we saw with epideros, absolutely yes. I was a cryo uh uh skeptic. That's Dr. Stephen Rottenberg from Rocky Mountain Children's Hospital. My my biggest issues with it were with the added time. The other is concerned about the neuralgia and the complications that I'd heard about. And I will tell you that it took me about four cases to realize because most of our patients went home on day two or three, but it's not just when they go home, it's how they feel when they go home and the cryo it's been unbelievable. I mean, I feel bad that I waited so long. I accept Vic's um concerns and criticisms and I agree, perhaps, you know, that we do need to have a registry for this, but it has totally changed the management of these patients. And let's see what Dr. Justin Wagner from UCLA had to say about multimodal pain control. Uh, you know, Tylenol and inset are already widely pre used. Uh, Prex can help for a gentle wake up, a dose of Dexamethasone can help with post anesthetic nausea. Kemine in the hands of someone who's used it might be a good way to avoid opioids. Um, and if you have child life specialists, mindfulness resources and a supportive group of physical therapists, they can be enormously helpful. So for multimodal therapy, the best treatments are preoperative counseling, Gabapentin both pre and post-operatively, and then methadone, clonidine, bowel regimen medications and anti-emetics. That was Dr. Todd Poninski from Cincinnati Children's Hospital. In Nebraska where I train Steve Rayner, will tell you the length of stay there is under two days still and they're off opioids by one week. Well, Dr. Wagner's numbers are almost as good as cryoanalgesia. I've heard that with cryoanalgesia, there are more percentage of flippage. Can you say what you think about that? So, typically if bars are going to flip, they're going to flip early and it's going to be because they were sitting in a in a funky interspace, they were sitting in a bad spot. The bar wasn't wrapped tight enough or it wasn't secured well. And even then I would say it's not the securing that does it. That bar's got to sit in a comfortable position before you start to secure it or it's probably not going to stay there. I do think that bar flippage is completely a surgical issue. Okay. So now we have the pain control management set. Cryoanalgesia has great results, but still don't know long-term consequences. Erect spinal catheters seem to be better than epidural, and a good multimodal pain control regimen could reach a two-day length of stay. But what about the actual NAS procedure? Let's see what Dr. Lee had to ask the experts. How do you base your bar measurements, uh the length of your bar? I think things have changed and maybe the bars are more stable with different lengths. I mean what a what a great transition from talking about bar flippage and technique. I wanted to bring up that some physics minded surgeons did this really interesting computational model to show the sites of stress points with traditionally U-shaped bars in contrast to shorter flat bars. So, what Dr. Wagner is explaining is that shorter bars have more pressure on the sternum, therefore they are more stable. So the tendency is to have shorter bars, though this is not standardized. Are there any special maneuvers when passing the introducer behind the sternum that is uh found useful? Um, you know, I I now do a sternal elevator. So we we use the sternal elevator at Akron Children's. That was Dr. Mark Wolkon from Akron Children's Hospital. I use the sternal elevator in about 10% of the cases. I think in the average kid that we do that's younger, you see well enough with scopy, you don't need to do it. Having the sternum elevated in those really deep stip Pectus allows you less tissue damage and have a better repair. Steve, we use the um elevator in every case. Uh, but it offers uh there's no guesswork. I mean so I mean I think one of the things that Steve mentioned is being able to go in and out at the same interspace, I think is important. And so yes, we use the elevator in every every instance. still use the subzyfoid incision now that you've adopted cryo and have scopy? Yeah, yeah, we do. Thoracopic your sternal elevator or vacuum bell in the operating room or subzyfoid incision. The idea is to uh not injure the heart. So whatever technique helps you do that, I I think is the technique you ought to use. That was Dr. With Hollum, clinical professor of surgery at the Vanderbilt University Medical School. Totally agree. Safety first. Uh, we talked about right to left, left to right, the age old question. I I'm interested to see what the current thoughts are when you pass the bar. I go from the left chest to the right chest because if you go from the right chest to the left chest, you're coming down and whatever you're passing across is pointing right at the ventricle. I've always done right to left. Um, I never even thought about doing left to right. I must admit. So I'm also learning something new and think that's a really fascinating idea. That was Dr. Bethany Slater from the University of Chicago. It's interesting. I learned left to right and then I went back to right to left and found personally right to left being easy, but I'm also using a sternal elevator and scopy, so I go the whole whole distance as far as ensuring safety and uh I actually always did it left to right. I I think it's surgeon preference and as and as long as you have the um substernal space well dissected and and uh everything's clear then it it probably doesn't make a whole lot of difference. Okay, great. So to sum up, remember that for pain management, cryoanalgesia has a lot of interest and support, but we still have to figure out long-term data. Other methods of analgesia include erector spine catheters, epidural and multimodal pain regiments. Regarding the NAS procedure, ways to ensure safe passage of the introducer include sternal elevation or subzyfoid incisions. Many people pass the bar from left to right, but whatever ensures good visualization and safety is the most important. And there you have it, our 2021 update call session on pain management and repair techniques for pecus excabatum. Now, if you love this episode, go ahead and like and subscribe to our YouTube channel. Follow us on social media. If you're listening on Apple podcast or on Spotify, please leave us a reading and a review and be sure to download the Stay Current in Pediatric Surgery app. It's in the Apple App Store and in the Google Play Store. And as a reminder, don't forget we have another virtual event coming up soon at the end of August. It's the 10th annual pediatric surgery update course. Todd has been doing this for 10 years and it's awesome. We'll have it in person in Cleveland and everyone can join us virtually. It's happening on Tuesday 30, starting at 9:00 a.m. Eastern Time. Check out the link in the description below to join us. But until next time, I'm Cecilia. I'm Ellen. I'm Todd Ponski. And remember Knowledge should be free.