Update Course Rewind: Pectus Excavatum 2021

If you missed 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 practice. We are going to see what is new about perioperative pain control and some rapid fire updates techniques. This is Cecilia Gena and I'm a research fellow at Cincinnati's Children's Hospital. And this is Ellen Ancisco, also a research fellow at Cincinnati Children's Hospital Medical Center. First, Doctor Steven Lee from UCLA Mattel 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 Doctor 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 post-operative 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 Doctor St. Peter's Hospital, so I decided to start a new trial looking into cryoanalgesia. So in this study. We had about 30 patients in each group when we tried the cryotherapy and when that patient went home on post-op day one, equipoise was lost. Once you, once you see it, it's, it's sort of a different game. So what Doctor Saint Peter is saying is that after cryo analgesia he didn't want to try any more epidural or PCA, but what is cryo analgesia? 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 can see how they're separated. Um, one's an inner space above. That just keeps them out of each other's way. And you literally just count down to the 4th rib and then freeze underneath it. It's 2 minutes per rib. We do 4 through 7. You're not supposed to go 8 or below because you can get some abdominal 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 4 days, all of a sudden became 1. And what about the use of opioids? What impact we have on our median morphine equivalents, and they're not even really on the same planet. But not everyone is so excited about cryo analgesia, and Doctor 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. Doctor Garcia is explaining that even though cryoanalgesia seemed to work, he's worried 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. Um, 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 cryoanalgesia, there are just not as many long-term results reported. And so what do you use in your hospital, Doctor Garcia? About 100 patients, uh, looking to Sean's point as far as, and this was a comparison between epidurals as well as not paravertebral, but erector spinal catheters. An erector spinal catheter, what is that? Very, very, very brief. Ba, ectrosiny catheters, they are placed by the pain team with ultrasound guidance. Uh, they're not in the vertebral space, but they are juxtaposed to it. Those catheters stay in for 5 days. The hospital stay is 2 days. 3rd day, while they're outside, the catheters are pulled out by the family. Uh, it is on a pump. It's automated. OK, great. And our hospital stays are 2 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'm, from the perspective, at least with our experience, that we do have an alternative. Is it gonna be one day? Uh, no, but is it certainly much less than 4 or 5 days that we saw with epidurals? Absolutely, yes. I was a cryo skeptic. That's Dr. Steven Rothenberg from Rocky Mountain Children's Hospital. My, my biggest issues with it were 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 4 cases to realize because most of our patients went home on day 2 or 3, but it's not just when they go home, it's how they feel when they go home, and the cryo has been unbelievable. I mean, I feel bad that I waited so long. I accept Vic's 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 Doctor Justin Wagner from UCLA had to say about multimodal pain control. Uh, you know, Tylenol and NSAIDs are already widely used. Uh, Presodex can help for a gentle wake up. A dose of dexamethasone can help with post-anesthetic nausea. Ketamine 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 postoperatively, and then methadone, clonidine, bowel regimen medications, and anti-emetics. That was Doctor Todd Ponsky from Cincinnati Children's Hospital. In Nebraska, where I trained Steve Rayner, will tell you the length of stay there is under 2 days still, and they're off opioids by 1 week. Well, Doctor Wagner's numbers are almost as good as crayon Antezia. I've heard that with cry anesthesia there's 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 inner space. 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. OK, so now we have the pain control management set. Cryoanalgesia has great results, but still don't know long-term consequences. Erecrospinal catheters seem to be better than epidural, and a good multimodal pain control regimen could reach a two-day length of day. But what about the actual NAS procedure? Let's see what Doctor 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 just 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 Doctor 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. So 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 Wolon from Akron Children's Hospital. I use a 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 thoracoscopy, you don't need to do it. Having The sternum elevated in those really deep stiff pectuses 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 subxiphoid incision now that you've adopted cryo and have thoracoscopy. Yeah. Yeah, we do. Thoracoscopy or sternal elevator or vacuum bell in the operating room or subxiphoid 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 Doctor With Holcomb, a 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 I think that's a really fascinating idea. That was Doctor Bethany Slater from the University of Chicago. It's interesting. I learned left to right, and then I I went back to right to left and found personally right to left being easy, but I'm also using external elevator and thoracoscopy, so I go the whole, whole distance as far as ensuring safety and uh, I actually, uh, always did it left or 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. OK, 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 spinal catheters, epidurals, and multimodal pain regimens. Regarding the NUS procedure, ways to ensure safe passage of the introducer include sternal elevation or subxiphoid 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 course session on pain management and repair techniques for pectus excavatum. 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 Podcasts or on Spotify, please leave us a rating and a review, and be sure to download the Stay Current and 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 Ponsky, and remember, knowledge should be free.