Update Course Rewind: Pectus Excavatum 2021

A randomized trial of 110 patients comparing epidural and PCA for pectus excavatum pain control showed epidurals did not provide superior pain relief

After implementing cryoanalgesia, a patient went home on postoperative day one, leading to loss of equipoise in the trial comparing cryotherapy to epidural/PCA

Cryoanalgesia uses cold temperatures to cause a conduction block that interrupts pain impulses to the brain

Cryoanalgesia technique involves freezing underneath ribs 4 through 7 for two minutes per rib

Cryoanalgesia should not be applied to rib 8 or below because it can cause abdominal wall paralysis

After implementing cryoanalgesia, length of stay decreased from four days (previous baseline) to one day

Cryoanalgesia dramatically reduced median morphine equivalents compared to previous pain control methods

There are no long-term studies on cryoanalgesia outcomes for pectus excavatum repair

Medical devices and implants are not required to undergo clinical trials before introduction to market, unlike drugs

FDA requires clinical trials with long-term results before approving medications for use

A comparison study of approximately 100 patients examined epidurals versus erector spinae catheters for pectus excavatum pain control

Erector spinae catheters are placed by the pain team with ultrasound guidance and are juxtaposed to but not in the vertebral space

Erector spinae catheters stay in place for five days on an automated pump, with families removing them on day three while patients are at home

With erector spinae catheters, hospital length of stay is two days

Erector spinae catheters reduced opioid requirements both in the hospital and outside the hospital

Cryoanalgesia changes not just when patients go home but how they feel when they go home

Multimodal pain control for pectus excavatum includes Tylenol, NSAIDs, precedex for gentle wake up, dexamethasone for post-anesthetic nausea, ketamine to avoid opioids, child life specialists, mindfulness resources, and physical therapists

Optimal multimodal therapy includes preoperative counseling, gabapentin both pre and postoperatively, methadone, clonidine, bowel regimen medications, and antiemetics

At one center using multimodal pain control, length of stay is under two days and patients are off opioids by one week

When bars flip, they typically flip early due to sitting in a funky intercostal space, sitting in a bad spot, insufficient bar wrapping, or inadequate securing

Bar flipping is completely a surgical technique issue, not related to the securing method

Computational modeling shows that shorter flat bars create more pressure on the sternum compared to traditionally U-shaped bars, making them more stable

One center uses sternal elevator in about 10% of cases, primarily in younger patients where thoracoscopy provides adequate visualization

Sternal elevation in really deep stiff pectus cases allows less tissue damage and better repair

One center uses sternal elevator in every case to eliminate guesswork and enable consistent access to the same intercostal space

Thoracoscopy, sternal elevator, vacuum bell in the operating room, and sub-xiphoid incision are all techniques aimed at preventing cardiac injury during pectus repair

Passing the bar from right chest to left chest means the introducer is pointing directly at the ventricle

Bar passage direction (left-to-right versus right-to-left) probably does not make a significant difference as long as the sub-sternal space is well dissected and everything is clear