Update Course Rewind: Pectus Excavatum 2021
With Dr. Todd Ponsky · hosted by Dr. Cecilia Higiena & Dr. Ellen Ncisco · Dr. Lee Ponsky
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
A randomized trial of 110 patients comparing epidural and PCA for pectus excavatum pain control showed that epidurals did not provide superior pain relief
After implementing cryoanalgesia, a patient went home on post-operative day one, which was a dramatic improvement over previous pain control methods
Cryoanalgesia uses cold temperatures to cause a conduction block that interrupts pain impulses to the brain
The cryoanalgesia technique involves freezing underneath ribs four through seven for two minutes per rib
Cryoanalgesia should not be performed on rib eight or below because it can cause abdominal wall paralysis
With cryoanalgesia, hospital length of stay decreased from four days to one day
Cryoanalgesia dramatically reduced median morphine equivalents compared to previous pain control methods
There are no long-term studies on cryoanalgesia outcomes
Medical devices and techniques are not required to undergo clinical trials before introduction to market, unlike medications
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 for five days, with hospital stay of two days, and catheters are pulled out by the family on the third day while at home
Erector spinae catheters reduced opioid requirements both in the hospital and outside of the hospital
With erector spinae catheters, hospital stay is two days, which is much less than the four or five days seen with epidurals
Cryoanalgesia changed not just when patients go home but how they feel when they go home
For multimodal pain therapy, the best treatments are preoperative counseling, gabapentin both pre and postoperatively, methadone, clonidine, bowel regimen medications and antiemetics
With multimodal pain control at one institution, length of stay is under two days and patients are off opioids by one week
If bars are going to flip, they flip early because they were sitting in a bad spot, the bar was not wrapped tight enough, or it was not secured well
Bar flippage is completely a surgical issue related to bar positioning and securing technique
Computational modeling showed that shorter flat bars have more pressure on the sternum compared to traditionally U-shaped bars, making them more stable
Sternal elevator is used in about 10% of cases at one institution
In younger patients with average anatomy, thoracoscopy provides adequate visualization without needing a sternal elevator
In really deep stiff pectus cases, sternal elevation allows less tissue damage and a better repair
One surgeon uses the sternal elevator in every case to eliminate guesswork and enable passage in and out at the same intercostal space
Thoracoscopy, sternal elevator, vacuum bell in the operating room, or subxiphoid incision all serve the purpose of avoiding cardiac injury
Passing the bar from left chest to right chest is preferred by some surgeons because going right to left means the introducer points directly at the ventricle
Bar passage direction probably does not make a significant difference as long as the substernal space is well dissected and everything is clear