BOB Ped Surg 2023 - Joshua Ramjist, CAPS - Presentation

Why This Protocol Exists

Pectus excavatum — the inward depression of the sternum and costal cartilages — is the most common congenital chest wall deformity, affecting one in 400 births 0:00. The Nuss procedure, in which a curved steel bar is placed retrosternally to elevate the depressed chest wall, has been transformative for these patients 0:00. But the operation's technical success has been shadowed by a persistent problem: severe postoperative pain that extends hospital stays and drives high opioid consumption 0:00. The deformity itself affects patients during adolescence, a period when body image concerns are acute 0:00. A procedure that corrects the anatomy but leaves a teenager in agony for days has not fully solved the problem.

Enhanced recovery protocols — structured, multimodal interventions spanning the entire perioperative period — have reduced morbidity and length of stay across many surgical domains. This presentation describes a five-point ERAS protocol developed at the Hospital for Sick Children in Toronto, implemented specifically for adolescents undergoing Nuss repair 1:00.

The Core Problem

Postoperative pain after Nuss bar placement is severe and difficult to control. The bar sits against the posterior sternum, and every breath, cough, or movement of the torso stresses the repair. Traditional management — systemic opioids, epidural analgesia, prolonged bed rest — has been only partially effective and carries its own morbidity. Before this protocol, the mean length of stay was four days, and opioid consumption was high 4:00. The challenge was to address pain through multiple mechanisms while simultaneously preparing patients and families for what to expect, so that anxiety and unrealistic expectations did not compound the physical discomfort.

How the Protocol Works

The protocol has five components, introduced sequentially across the perioperative timeline 1:00.

Preoperative education and expectation-setting. Patients and families receive structured counseling and educational materials before surgery 1:00. The centerpiece is a "boarding pass" — a document that outlines what will happen at each phase of care, from admission through discharge 1:00. This is not a consent form; it is a shared roadmap. It establishes realistic expectations for pain, mobility, and recovery milestones, and it introduces the multidisciplinary team the patient will encounter. The boarding pass was designed to facilitate shared decision-making and build a therapeutic relationship before the patient ever enters the operating room 1:00.

Transitional pain service involvement. A dedicated pain team follows the patient from the preoperative visit through discharge and beyond 1:00. This team coordinates both pharmacologic interventions — scheduled non-opioid analgesics, opioid-sparing adjuncts — and non-pharmacologic strategies such as breathing exercises, positioning techniques, and psychological support 1:00. The involvement of a pain service ensures that pain management is not an afterthought delegated to the surgical team alone.

Multimodal intraoperative analgesia. At the time of bar placement, patients receive a serratus anterior plane block — a regional anesthetic technique that targets the lateral chest wall — and intercostal nerve cryoablation, in which the nerves adjacent to the bar are frozen to provide prolonged analgesia 1:00. These interventions address pain at its source rather than relying solely on systemic medications.

Perioperative bowel regimen. A structured bowel protocol was included to prevent opioid-induced constipation and facilitate early mobilization 1:00. The specifics are not detailed in the discussion, but the principle is standard: anticipate the gastrointestinal effects of opioids and intervene prophylactically.

Multidisciplinary coordination. The protocol requires coordination among surgery, anesthesia, pain service, nursing, and physiotherapy 5:00. Each discipline contributes at each phase, and the boarding pass serves as the shared reference point.

The Evidence

The Hospital for Sick Children implemented this protocol in a cohort of 53 patients undergoing Nuss repair between August 2015 and December 2021 3:00. The study compared outcomes before and after protocol implementation, with retrospective data for the pre-ERAS group and prospective data after 3:00. Patients were approximately 15 years old at the time of repair, with Haller indices — a radiographic measure of chest wall depression — typically above 4.5, indicating moderate to severe deformity 3:00 3:00.

Length of stay decreased by 50%, from four days to a mean of 1.8 days 4:00 4:00. Most patients were discharged on postoperative day one 4:00. Opioid consumption in the postoperative period fell from 6.36 to 3.12 morphine milliequivalents 4:00. Patient satisfaction was high: 92% of patients reported satisfaction with their overall experience 3:00. A run chart presented in the talk showed a stepwise decline in length of stay as each protocol element was introduced, suggesting that the effect was cumulative rather than attributable to a single intervention 4:00.

When to Refer

The discussion does not address referral criteria or timing for pectus repair. The focus is on perioperative management once the decision to operate has been made. For clinicians outside pediatric surgery, the relevant takeaway is that adolescents undergoing Nuss repair benefit from structured, multidisciplinary perioperative care, and that centers performing this operation should have the infrastructure — pain service, patient education resources, regional anesthesia capability — to support such a protocol.

The Broader Point

The presenter closes with a deliberate reframing: "Surgery remains a team sport" [q5]. Successful outcomes depend not on technical virtuosity alone but on a multidisciplinary team working across all phases of care to optimize the patient's experience 5:00. For pectus repair, that means addressing pain through multiple mechanisms, preparing patients psychologically, and coordinating care so that every clinician the patient encounters is working from the same plan. The protocol described here is specific to one operation, but the principle — that perioperative care is a system, not a series of individual interventions — applies broadly.