Comparison of the Nuss versus Ravitch procedure for pectus excavatum repair: an updated meta-analysis

Opioid Prescriptions at Discharge After Minimally Invasive Repair of Pectus Excavatum Are Reduced With Cryoablation

BACKGROUND

The minimally invasive repair of pectus excavatum (MIRPE) is associated with significant postoperative pain and opioid use. The objective of this study was to determine the effect of intercostal nerve cryoablation (Cryo) on inpatient and post-hospital opioid prescription practices following MIPRE.

METHODS

A retrospective review at a single pediatric center was conducted of patients ≤21 years old who underwent MIRPE. Oral morphine equivalents (OME) of inpatient and discharge opioids were compared between Cryo and no-Cryo cohorts.

RESULTS

579 patients were identified (82.8% male, mean age 15.4 ± 2.0 years). Cryo was performed in 73.5% of patients. The total inpatient OME use was less in the Cryo group (0.89 ± 0.68 vs. 1.6 ± 0.5 OME/kg/day; p < 0.001). Patients who underwent Cryo were prescribed significantly less OME at discharge compared to the no-Cryo group (3.9 ± 1.7 vs. 10.0 ± 4.1 OME mg/kg, p < 0.001). There was no statistically significant difference in the proportion of patients who required an opioid prescription refill (Cryo 12.4% vs. no-Cryo 11.5%, p = 0.884) or were readmitted (Cryo 5.3% vs. no-Cryo 4.6%, p = 0.833).

CONCLUSION

Patients who underwent cryoablation during MIRPE were prescribed significantly less opioid at the time of discharge without increasing the need for opioid refills or hospital readmissions.

LEVEL OF EVIDENCE

Treatment study; Level III evidence.

Implementing Change: Sustaining Enhanced Recovery After Surgery Protocols in Pediatric Surgery Using Iterative Assessments

INTRODUCTION

While Enhanced Recovery After Surgery (ERAS) protocols are becoming more common in pediatric surgery, there is still little published about protocol compliance and sustainability.

METHODS

This is a prospective observational study to evaluate the compliance of an ERAS protocol for pectus repair at a large academic children's hospital. Our primary outcome was overall protocol compliance at 1-y postimplementation of the ERAS protocol. Our comparison group included all pectus repairs for 2 y before protocol implementation.

RESULTS

Overall protocol compliance at 12 mo was 89%. Of the 16 pectus repairs included in the ERAS protocol group, 94% (n = 15) and 94% (n = 15) received preoperative acetaminophen and gabapentin, respectively, which was significantly greater than the historical control group (P < 0.001). For the intraoperative components analyzed, only the intrathecal morphine was significantly different than historical controls (100% versus 49%, P < 0.001). Postoperatively, the time from operating room to return to normal diet was shorter for the ERAS group (0.53 d versus 1.16 d, P < 0.001). There was no significant difference in readmission rates between the two groups.

CONCLUSIONS

ERAS protocol compliance varies based on phase of care. Solutions to sustain protocols depend on the institution and the patient population. However, the utilization of implementation science fundamentals was invaluable in this study to identify and address areas for improvement in protocol compliance. Other institutions may adapt these strategies to improve protocol compliance at their centers.

Is pregnancy safe with an implanted pectus bar? An uneventful pregnancy with implanted pectus bar following correction of pectus excavatum

Limited data are available on the implications on pregnancy following pectus bar implantation for correction of pectus excavatum (Nuss procedure), while the pectus bars are in place. Limited data is also available on long-term reproductive implications following pectus bar removal.Providers at times need to consider the necessity to counsel a woman desiring pectus excavatum correction and pregnancy whether to postpone one of the two in favour of the other.We present the case of a woman of reproductive age with an uneventful pregnancy and delivery while carrying an implanted pectus bar and subsequent uneventful pregnancy and delivery after bar removal.

Impact of delayed removal of pectus bar on outcomes following Nuss repair: a retrospective analysis

BACKGROUND

Usually, pectus bars are removed 3 years after the Nuss procedure in patients with pectus excavatum. However, the optimal timing for postoperative pectus bar removal remains undefined. Our study investigated the effects of delayed pectus bar removal after Nuss repairs.

METHODS

Retrospective data were collected on patients who underwent Nuss procedures for pectus excavatum and had their bars removed from August 2014 to December 2020. Patients with correction periods > 3 years were divided into group A (< 6 years) and group B (≥ 6 years). Propensity score matching was used to compare complications and radiological outcomes associated with bar removal.

RESULTS

Of the 542 patients who underwent bar removal, 451 (Group A: 419 patients, Group B: 32) had correction duration > 3 years. The average correction duration was 4.5 ± 1.4 years. After propensity score matching analysis, group B [median duration: 8.0 (6.0-16.2) years] exhibited significantly longer median operative times (85 vs. 55 min; P = 0.026), higher callus formation rates (68.8% vs. 46.9%; P = 0.029), and greater median intraoperative blood loss (35 vs. 10 mL; P = 0.017) than group A [median duration: 4.2 (3.0-5.9) years]. However, following bar removal, the groups showed no statistical differences in the surgical complication rates (group A: 6.3% vs. group B: 9.4%; P = 0.648) or median ratio of radiological improvement (an improvement on the Haller index on chest radiography; 21.0% vs. 22.2%; P = 0.308).

CONCLUSIONS

Delaying pectus bar removal after Nuss repair presents certain challenges but does not compromise overall outcomes. These findings suggest that a longer correction period may be unnecessary. However, further multicenter studies with long-term follow-up are warranted to assess long-term outcomes.

Long-Term Sensory Function 3 years after Minimally Invasive Repair of Pectus Excavatum with Cryoablation

INTRODUCTION

Minimally invasive repair of pectus excavatum (MIRPE) with intercostal nerve cryoablation (Cryo) decreases length of hospitalization and opioid use, but long-term recovery of sensation has been poorly described. The purpose of this study was to quantify long-term hypoesthesia and neuropathic pain after MIRPE with Cryo.

METHODS

A prospective cohort study was conducted single-institution of patients ≤21 years who presented for bar removal. Consented patients underwent chest wall sensory testing and completed neuropathic pain screening. Chest wall hypoesthesia to cold, soft touch, and pinprick were measured as the percent of the treated anterior chest wall surface area (TACWSA); neuropathic pain was evaluated by questionnaire.

RESULTS

The study enrolled 47 patients; 87% male; median age 18.4 years. The median bar dwell time was 2.9 years. A median of 2 bars were placed; 80.9% were secured with pericostal sutures. At enrollment, 46.8% of patients had identifiable chest wall hypoesthesia. The mean percentage of TACWSA with hypoesthesia was 4.7 ± 9.3% (cold), 3.9 ± 7.7% (soft touch), and 5.9 ± 11.8% (pinprick). Hypoesthesia to cold was found in 0 dermatomes in 62%, 1 dermatome in 11%, 2 dermatomes in 17% and ≥3 dermatomes in 11%. T5 was the most common dermatome with hypoesthesia. Neuropathic symptoms were identified by 13% of patients; none required treatment.

CONCLUSION

In long-term follow up after MIRPE with Cryo, 46.8% of patients experienced some chest wall hypoesthesia; the average TACWSA with hypoesthesia was 4-6%. Hypoesthesia was mostly limited to 1-2 dermatomes, most commonly T5. Chronic symptomatic neuropathic pain was rare.

LEVEL OF EVIDENCE

Level IV.

Post-operative arrest following pectus excavatum repair: A case report with a systematic review of the published case reports

Key Clinical Message

Common complications after PE surgery include ventricular tachycardia, cardiac arrest, pneumothorax, and bar displacement. These can lead to severe outcomes, emphasizing the need for caution and meticulous post-operative monitoring. Patients and their families should be well-informed about potential risks during the consent process.

Abstract

The objective of this study was to raise awareness among medical staff and surgeons about potential complications, particularly rare and life-threatening ones, associated with pectus excavatum (PE) surgery. PE is the most common chest wall deformity, characterized by sternal depression. Patients primarily seek treatment for cosmetic concerns, but some also report exercise intolerance and shortness of breath. Although surgical repair is the standard treatment, the incidence and nature of severe complications remain unclear and underreported. This study presents a case of a lethal cardiac event following PE surgery and conducts a systematic review of published case reports. This study describes a case of a lethal complication of ventricular fibrillation and cardiac arrest following the Ravitch procedure for correction of PE in a 10-year-old boy. A systematic review of relevant cases of PE surgery complications was conducted. Of the 506 initial records retrieved, 93 case reports from 83 articles were identified over the 23 years. Among them, 72 patients were male, and 20 cases were female. The average age of patients was 19.2 ± 7.7 years (range: 5-53). Complications had occurred up to 37 years from the time of surgery, with most of the cases (22.5%) occurring during the operation. The most frequent complications included cardiothoracic issues and displacement of the implanted steel bar. In nine patients, complications led to fatal outcomes. Due to the possible risks of PE surgery, particularly in cosmetically motivated cases, surgeons must exercise extreme caution and remain vigilant for rare and potentially life-threatening complications.

Maximum Pain at Rest in Pediatric Patients Undergoing Elective Thoracic Surgery and the Predictors of Moderate-to-Severe Pain-Secondary Data Analysis

INTRODUCTION

Pain management among children following thoracic surgery is an area of significant practice variability. Understanding the risk factors of moderate-to-severe pain intensity will allow for adequate pain relief. The aim of the study was to assess the maximum intensity of pain at rest in pediatric patients within 24 h of thoracic surgery and to investigate the prevalence and predictors of moderate-to-severe pain.

METHODS AND FINDINGS

This is a prospective cohort study of patients in observational and randomized controlled trials following thoracic surgery. A secondary analysis of data was conducted using data collected from 446 patients aged 7-18 years undergoing thoracic surgery. The primary endpoint was maximum pain intensity (Numerical Rating Scale; NRS; range: 0-10) and the secondary endpoint was the prevalence and predictors of moderate-to-severe pain (NRS > 2/10). The median maximum pain in the cohort was 3 [0; 4]. During the immediate postoperative period, 54% of patients reported a maximum NRS > 2/10. The infusion of morphine by an intravenous route (vs. epidural route) was a protective factor against moderate-to-severe pain. Taking into account the findings related to the type of epidural analgesia (vs. intravenous morphine), it was found that only the administration of 0.25% bupivacaine combined with morphine or fentanyl was a protective factor against moderate-to-severe postoperative pain. Patients aged 14-18 years (vs. aged 7-13 years) had an increased risk of reporting pain as moderate-to-severe.

CONCLUSIONS

The route of analgesic administration, type of multimodal analgesia, and patients' age predict moderate-to-severe pain in pediatric patients after thoracic surgery.

Evaluation of Analgesic Practice Changes Following the Nuss Procedure in Pediatric Patients

INTRODUCTION

Pectus excavatum repair by the Nuss procedure results in severe postoperative pain. Regional blocks and intercostal nerve cryoablation (INC) have emerged as potential strategies to manage analgesia. This study compares pain-related outcomes following these perioperative interventions.

METHODS

We reviewed charts of patients <18 y who underwent the Nuss procedure at Duke Children's Hospital from July 2018 to June 2022. Patients were divided into three groups by analgesic strategy: no block, regional catheters, or INC, representing the chronologic change in our practice. The primary outcome was total and daily in-hospital opioid utilization measured by oral morphine equivalents (OMEs). Secondary outcomes included average daily pain scores, length of stay, opioid refills after discharge, and complications.

RESULTS

Twenty-one patients were included and analyzed: no block (n = 6), regional catheters (n = 7), and INC (n = 8). INC-treated patients required significantly lower total postoperative, in-hospital OMEs (64 ± 47 [mean ± standard deviation]) than those with no block (270 ± 217, P = 0.04) or those with regional catheters (273 ± 176, P = 0.03). INC was associated with longer average operative times (161 ± 36 min) than no block (105 ± 21 min, P = 0.005) or regional catheters (90 ± 11 min, P < 0.001). INC-treated patients had shorter hospital length of stays (median 68 h) than those with regional catheters (median 74 h, P = 0.006).

CONCLUSIONS

INC was associated with longer operative times but decreased in-hospital OMEs when compared to bilateral regional block catheters and multimodal analgesia alone.

Association of Intercostal Nerve Cryoablation During Nuss Procedure With Complications and Costs

BACKGROUND

Intercostal nerve cryoablation with the Nuss procedure has been shown to decrease opioid requirements and hospital length of stay; however, few studies have evaluated the impact on complications and hospital costs.

METHODS

A retrospective cohort study was performed for all Nuss procedures at our institution from 2016 through 2020. Outcomes were compared across 4 pain modalities: cryoablation with standardized pain regimen (n = 98), patient-controlled analgesia (PCA; n = 96), epidural (n = 36), and PCA with peripheral nerve block (PNB; n = 35). Outcomes collected included length of stay, opioid use, variable direct costs, and postoperative complications. Univariate and multivariate hierarchical regression analysis was used to compare outcomes between the pain modalities.

RESULTS

Cryoablation was associated with increased total hospital cost compared with PCA (cryoablation, $11 145; PCA, $8975; P < .01), but not when compared with epidural ($9678) or PCA with PNB ($10 303). The primary driver for increased costs was operating room supplies (PCA, $2741; epidural, $2767; PCA with PNB, $3157; and cryoablation, $5938; P < .01). With multivariate analysis, cryoablation was associated with decreased length of stay (-1.94; 95% CI, -2.30 to -1.57), opioid use during hospitalization (-3.54; 95% CI, -4.81 to -2.28), and urinary retention (0.13; 95% CI, 0.05-0.35).

CONCLUSIONS

Cryoablation significantly reduces opioid requirements and length of stay relative to alternative modalities, but it was associated with an increase in total hospital costs relative to PCA, but not epidural or PCA with PNB. Cryoablation was not associated with allodynia or slipped bars requiring reoperation.

Changes in Pulmonary Functions of Adolescents with Pectus Excavatum Throughout the Nuss Procedure

BACKGROUND

We aimed to determine the longitudinal changes in pulmonary functions of adolescents with Pectus Excavatum who underwent the Nuss procedure, the minimally invasive repair of pectus excavatum (MIRPE).

METHODS

Lung function measurements were performed before bar implantation (T0), at least six weeks to ten months after implantation (T1a), at least eleven months to sixty-one months after bar implantation (T1b) and at least two weeks after bar explantation (T2).

RESULTS

Data of 114 patients (83.3% male) whose median age at implantation was 15.6 years and at explantation 18.7 years were analyzed. Shortly after implantation at T1a a significant decline of vital capacity (VC; n = 82), forced vital capacity (FVC; n = 78) and forced expiratory volume in 1 second (FEV1; n = 80) compared to T0 was seen. At T1b a significant decline for the residual volume (RV; n = 83), the residual volume/total lung capacity ratio (RV/TLC; n = 81), the total specific airway resistance (sRaw; n = 80) and the total airway resistance (Raw; n = 84) also compared to T0 was measured. In the comparison of T1b to T2 a significant increase of VC, FVC (n = 67), FEV1 (n = 69), TLC (n = 67) and a significant decrease of Raw (n = 66), sRaw, RV (n = 65) and the RV/TLC (n = 64) ratio could be observed. In the direct analysis between T0 and T2, after the explantation of the bar a significant increase in VC (n = 54), FVC (n = 52), and TLC (n = 55) and a significant decrease of RV (n = 51) and the RV/TLC index (n = 50), and in airway resistance parameters like Raw (n = 52) and sRaw (n = 51) could be detected.

CONCLUSIONS

Lung function values along with markers of airway resistance improve in patients after the complete procedure of MIRPE.

LEVEL OF EVIDENCE

Level II.

Intercostal nerve cryoablation therapy for the repair of pectus excavatum: a systematic review

Introduction

The minimally invasive repair of pectus excavatum (PE) is a painful procedure that can result in long-term hospitalization and opioid use. To mitigate the length of stay and opioid consumption, many different analgesia strategies have been implemented. The aim of this study is to review the use and patient outcomes of intercostal nerve cryoablation (INC) during PE repair reported in the literature.

Methods

An unfunded literature search using PubMed identifying articles discussing INC during PE repair from 1946 to 1 July 2023 was performed. Articles were included if they discussed patient outcomes with INC use during PE repair. Articles were excluded if they were reviews/meta-analyses, editorials, or not available in English. Each article was reviewed for bias by analyzing the study methods, data analysis, patient selection, and patient follow-up. Articles comparing outcomes of INC were considered significant if p-value was <0.05.

Results

A total of 34 articles were included in this review that described INC use during pectus repair. Most supported a decreased hospital length of stay and opioid use with INC. Overall, INC was associated with fewer short-term and long-term complications. However, the researchers reported varied results of total hospital costs with the use of INC.

Conclusion

The review was limited by a paucity of prospective studies and low number of patients who received INC. Despite this, the present data support INC as a safe and effective analgesic strategy during the repair of PE.

Continuous nerve block versus thoracic epidural analgesia for post-operative pain of pectus excavatum repair: a systematic review and meta-analysis

Surgery to repair pectus excavatum (PE) is often associated with severe postoperative pain, which can impact the length of hospital stay (LOS). While thoracic epidural analgesia (TEA) has traditionally been used for pain management in PE, its placement can sometimes result in severe neurological complications. Recently, paravertebral block (PVB) and erector spinae plane block (ESPB) have been recommended for many other chest and abdominal surgeries. However, due to the more severe and prolonged pain associated with PE repair, it is still unclear whether continuous administration of these blocks is as effective as TEA. Therefore, we conducted this systematic review and meta-analysis to demonstrate the equivalence of continuous PVB and ESPB to TEA.

Cardiac anomalies in pediatric patients with pectus excavatum

OBJECTIVE

Pectus excavatum is the most prevalently encountered deformity of the thoracic wall. It can be accompanied by congenital anomalies.

METHODS

The cardiac findings of 36 children who were diagnosed at the Thoracic surgery outpatient clinic of our university between 10 February 2021 and 1 October 2021 and 57 healthy children in a similar age group were analyzed.

RESULTS

We determined that the pectus excavatum patients in our study had a higher risk of having mitral insufficiency, mitral valve prolapse, tricuspid valve prolapse, cardiac malposition, and congenital heart disease.

CONCLUSION

Our study showed that the prevalence of cardiac pathologies was higher in pediatric pectus excavatum patients than in healthy children in the control group. Thus, we recommend clinicians to refer pediatric pectus excavatum patients to pediatric cardiology outpatient clinics for the early diagnosis of potential cardiac pathologies.

Erector Spinae Plane Block With Liposomal Bupivacaine: Analgesic Adjunct in Adult Pectus Surgery

INTRODUCTION

Pain management may be challenging in patients undergoing pectus excavatum (PE) bar removal surgery. To enhance recovery, opioid sparing strategies with regional anesthesia including ultrasound-guided erector spinae plane block (ESPB) have been implemented. The purpose of this study was to evaluate the safety and efficacy of bilateral ESPB with a liposomal bupivacaine/traditional bupivacaine mixture as part of an enhanced patient recovery pathway.

MATERIALS AND METHODS

A retrospective review of adult patients who underwent PE bar removal from January 2019 to December 2020 was performed. Perioperative data were reviewed and recorded. Patients who received ESPB were compared to historical controls (non-ESPB patients).

RESULTS

A total of 202 patients were included (non-ESPB: 124 patients; ESPB: 78 patients). No adverse events were attributed to ESPB. Non-ESPB patients received more intraoperative opioids (milligram morphine equivalents; 41.8 ± 17.0 mg versus 36.7 ± 17.1, P = 0.05) and were more likely to present to the emergency department within 7 d postoperatively (4.8% versus 0%, P = 0.05) when compared to ESPB patients. No significant difference in total perioperative milligram morphine equivalents, severe pain in postanesthesia care unit (PACU), time from PACU arrival to analgesic administration, PACU length of stay, or postprocedure admission rates between groups were observed.

CONCLUSIONS

In patients undergoing PE bar removal surgery, bilateral ESPB with liposomal bupivacaine was performed without complications. ESPB with liposomal bupivacaine may be considered as an analgesic adjunct to enhance recovery in patients undergoing cardiothoracic procedures but further prospective randomized clinical trials comparing liposomal bupivacaine to traditional local anesthetics with and without indwelling nerve catheters are necessary.

Cost and outcomes of intercostal nerve cryoablation versus thoracic epidural following the Nuss procedure

BACKGROUND

Pectus excavatum is the most common congenital chest wall abnormality, with the Nuss procedure being the most commonly performed repair. Pain control is the predominant factor in the postoperative treatment of these patients. This study aims to compare the cost and outcomes of intercostal nerve cryoablation (INC) and thoracic epidural (TE) in patients undergoing the Nuss procedure.

METHODS

A retrospective chart review was conducted at our institution for all patients who underwent the Nuss procedure for pectus excavatum from 2002 to 2020. Patients were stratified by pain management strategy, INC vs. TE. Chi-square and Fisher's exact were used to compare categorical variables. Wilcoxon tests were used to evaluate continuous variables and costs.

RESULTS

A total of 158 patients were identified. Of these, 80.4% (N = 127) were treated with epidural, while 19.6% (N = 31) were treated with intercostal nerve cryoablation. The INC group had lower rates of PCA use (35.5% vs. 93.7%, p < 0.001), lower total morphine milligram equivalent requirement (27.0 vs. 290.8, p < 0.001), and shorter length of stay (3.2 days vs. 5.3 days, p < 0.001) compared to the TE group. INC was also associated with longer operative times (153.0 min vs. 89.0 min, p < 0.001). The total hospitalization cost for the INC group was higher compared to the TE group ($24,742.5 vs $21,621.9, p = 0.001).

CONCLUSIONS

In patients undergoing the Nuss procedure, compared to thoracic epidural, INC was associated with lower opioid use and shorter length of stay but at the cost of longer operative time and increased hospitalization cost.

LEVEL OF EVIDENCE

Treatment Study, Level III.

A pilot study of multi-modal pain management for same-day discharge after minimally invasive repair of pectus excavatum (Nuss procedure) in children

BACKGROUND

Despite advancements in minimally invasive repair of pectus excavatum (MIRPE), Nuss procedure, postoperative pain control remains challenging. This report covers a multimodal regimen using bilateral single-shot paravertebral block (PVB) and bilateral thoracoscopic intercostal nerve (T3-T7) cryoablation, leading to significant reduction in length of stay (LOS) and high rate of same-day discharge.

METHODS

This is a comparative study of pain management protocols for patients undergoing the Nuss procedure at a single center from 2016 through 2020. All patients underwent the the same surgical technique for the treatment of pectus excavatum at a single center. Patients received bilateral PVB with continuous infusion (Group 1, n = 12), bilateral PVB with infusion and right-side cryoablation (Group 2, n = 9), or bilateral single-shot PVB and bilateral cryoablation (Group 3, n = 17). The primary outcome was LOS with focus on same-day discharge, and the secondary outcome was decreased opioid usage.

RESULTS

Eleven of 17 patients in Group 3 (65%) (bilateral single-shot PVB and bilateral cryoablation) were discharged the same day as surgery. The remaining Group 3 patients were discharged the following day with no complications or interventions. Compared to Group 1 (no cryoablation), Group 3 had shorter LOS (median 4.4 days vs. 0.7 days, respectively, p < 0.001) and significantly decreased median opioid use on the day of surgery (0.92 mg/kg vs. 0.47 mg/kg, p = 0.006).

CONCLUSION

Findings demonstrate the feasibility of multimodal pain management for same-day discharge after the Nuss procedure. Future multisite studies are needed to investigate the superiority of this approach to established methods.

LEVEL OF EVIDENCE

III.

Implementation Science Fundamentals: Pediatric Surgery Enhanced Recovery After Surgery Protocol for Pectus Repair

INTRODUCTION

Surgical repair of pectus excavatum and carinatum in children has historically been associated with severe postoperative pain and prolonged hospitalization. Enhanced Recovery After Surgery (ERAS) is a multidisciplinary, multimodal approach designed to fast-track surgical care. However, obstacles to implementation have led to very few within pediatric surgery. The aim of this study is to outline the process of development and implementation of an ERAS protocol for pectus surgical repair using fundamental principles of implementation science.

METHODS

A multidisciplinary team of providers worked collaboratively to develop an ERAS protocol for surgical repair of pectus excavatum and carinatum and methods for identifying eligible patients. The surgical champion collaborated with all end users to review and revise the ERAS protocol, assessing all foreseeable barriers and facilitators prior to implementation.

RESULTS

Our entire pediatric surgery team, nurses at every stage (clinic/preoperative/recovery/floor), physical therapy, and information technology contributed to the creation and implementation of an ERAS protocol with seven phases of care. The finalized version was implemented by end users focusing on four main areas: pain control, ambulation, diet, and education. Barriers and facilitators were continually addressed with an iterative process to improve the success of implementation.

CONCLUSIONS

This is one of the first studies in children which details the step-by-step process of developing and implementing an ERAS protocol for pectus excavatum and carinatum. The process of development and implementation of an ERAS protocol as outlined in this manuscript can serve as a model for future ERAS protocols in pediatric surgery.

Retrospective study comparing outcomes of multimodal epidural and erector spinae catheter pain protocols after pectus surgery

INTRODUCTION

There are no optimal postoperative analgesia regimens for Nuss procedures. We compared the effectiveness of thoracic epidurals (EPI) and novel ambulatory erector spinae plane (ESP) catheters as part of multimodal pain protocols after Nuss surgery.

METHODS

Data on demographics, comorbidities, perioperative details, length of stay (LOS), in hospital and post discharge pain/opioid use, side effects, and emergency department (ED) visits were collected retrospectively in children who underwent Nuss repair with EPI (N = 114) and ESP protocols (N = 97). Association of the group with length of stay (LOS), in hospital opioid use (intravenous morphine equivalents (MEq)/kg over postoperative day (POD) 0-2), and oral opioid use beyond POD7 was analyzed using inverse probability of treatment weighting (IPTW) with propensity scores, followed by multivariable regression.

RESULTS

Groups had similar demographics. Compared to EPI, ESP had longer block time and higher rate of ketamine and dexmedetomidine use. LOS for ESP was 2 days IQR (2, 2) compared to 3 days IQR (3, 4) for EPI (p < 0.01). Compared to EPI, ESP group had higher opioid use (in MEq/kg) intraoperatively (0.32 (IQR 0.27, 0.36) vs. 0.28 (0.24, 0.32); p < 0.01) but lower opioid use on POD 0 (0.09 (IQR 0.04, 0.17) vs. 0.11 (0.08, 0.17); p = 0.03) and POD2 (0.00 (IQR 0.00, 0.00) vs. 0.04 (0.00, 0.06) ; p < 0.01). ESP group also had lower total in hospital opioid use (0.57 (IQR 0.42, 0.73) vs.0.82 (0.71, 0.91); p < 0.01), and shorter duration of post discharge opioid use (6 days (IQR 5,8) vs. 9 days (IQR 7,12) (p < 0.01). After IPTW adjustment, ESP continued to be associated with shorter LOS (difference -1.20, 95% CI: -1.38, -1.01, p < 0.01) and decreased odds for opioid use beyond POD7 (OR 0.11, 95% CI: 0.05, 0.24); p < 0.01). However, total in hospital opioid use in MEq/kg (POD0-2) was now similar between groups (difference -0.02 (95% CI: -0.09, -0.04); p = 0.50). The EPI group had higher incidence of emesis (29% v 4%, p < 0.01), while ESP had higher catheter malfunction rates (23% v 0%; p < 0.01) but both groups had comparable ED visits/readmissions.

DISCUSSION/CONCLUSION

Compared to EPI, multimodal ambulatory ESP protocol decreased LOS and postoperative opioid use, with comparable ED visits/readmissions. Disadvantages included higher postoperative pain scores, longer block times and higher catheter leakage/malfunction.

LEVELS OF EVIDENCE

Level III.

Pectus Excavatum in Cardiac Surgery Patients

BACKGROUND

Pectus excavatum frequently accompanies congenital heart disease and connective tissue diseases requiring cardiac surgery. Sometimes the indication is cardiac repair, with the pectus being incidentally noticed; other times, the pectus subsequently develops or becomes more significant after cardiac surgery. This review arms cardiac and congenital surgeons with background about the physiologic impact of pectus, indications for repair and repair strategies, and outcomes for cardiac surgery patients requiring pectus repair.

METHODS

A comprehensive literature review was performed using keywords related to pectus excavatum, pectus repair, and cardiac/congenital heart surgery within the PubMed database.

RESULTS

The risks of complications related to pectus repair, including in the setting of cardiac surgery or after cardiac surgery, are low in experienced hands, and patients demonstrate cardiopulmonary benefits and symptom relief. Concomitant pectus and cardiac surgery should be considered if it is performed in conjunction with those experienced in pectus repair, particularly given the increased cardiopulmonary impact of pectus after bypass. In the setting of potential bleeding or hemodynamic instability, delayed sternal closure is recommended. For those with anticipated pectus repair after cardiac surgery, the pericardium should be reconstructed for cardiac protection. For those undergoing pectus repair after cardiac surgery without a membrane placed, a "hybrid" approach is safe and effective.

CONCLUSIONS

Patients undergoing cardiac surgery noted to have pectus should be considered for possible concomitant or staged pectus repair. For those who will undergo a staged procedure, a barrier membrane should be placed before chest closure.

Ultrasound-Guided Percutaneous Cryoanalgesia for Pectus Excavatum: When Should It be Applied?

INTRODUCTION

 The addition of ultrasound-guided percutaneous cryoanalgesia (PCr) for pain management after pectus excavatum (PE) surgery offers a new and advantageous approach. Our aim is to describe our experience with PCr applied on the same day, 24 hours, and 48 hours prior to PE surgery.

MATERIAL AND METHODS

 Prospective pilot study in patients undergoing ultrasound-guided PCr (2019-2022) was divided into three groups: PCr on the same day of surgery (PCrSD), PCr 24 hours before (PCr24), and PCr 48 hours before (PCr48). We describe the application of technique and data obtained by comparing the three groups.

RESULTS

 We present 42 patients (25 PCrSD, 11 PCr24, 6 PCr48). PCr24 had a shorter procedure duration than PCrSD (65.8 vs. 91.2 minute; p = 0.048). Related to analgesia, PCr24 and PCr48 showed lower opioid consumption than PCrSD in PCA volume (48.5 and 49.6 vs. 75.1 mL; p = 0.015) and PCA time (23.3 and 23.8 vs. 34.3 hours; p = 0.01). Degree of pain (VAS scale) on the day of surgery and on the second postoperative day was lower in PCr24 and PCr48 than in PCrSD (4 and 2 vs. 5; p = 0.012; 0 and 1 vs. 2; p = 0.01, respectively) as well as shorter hospital stay (3 and 3.5 vs. 5 days; p = 0.021). In addition, PCr24 showed lower opioid consumption and hospital stay than PCr48 (p > 0.05). The greatest savings in hospital costs were obtained in the PCr24 group.

CONCLUSION

 PCr48 and PCr24 prior to PE surgery offers lower opioid consumption, less pain and shorter hospital stay than PCrSD. PCr24 is comparable to PCr48, but seems to show advantages and simpler logistics for the patient and the hospital.

Combined minimally invasive repair of pectus excavatum and robotically assisted mitral valve repair: A case report and considerations

INTRODUCTION

Severe pectus excavatum (PE) is considered a relative contraindication to robotic cardiac surgery and information is lacking on surgical solutions to allow for a robotic approach in this setting.

OBJECTIVE

We present a case of concomitant minimally invasive treatment of severe PE with initial pectus correction with Nuss bar insertion followed by robotically assisted mitral valve repair.

METHODS

A multidisciplinary team planned and executed the operation. Thoracoscopic assessment at the onset of the case demonstrated mediastinal exposure was inadequate for robotic repar without PE correction. Forced sternal elevation demonstrated sternal laxity sufficient to provide adequate exposure. Nuss bars were placed and robotic repair proceeded uneventfully.

RESULTS

The patient underwent successful concomitant minimally invasive PE and robotically assisted mitral repair.

CONCLUSION

Successful combined minimally invasive pectus repair and robotic mitral valve can be achieved if sufficient chest wall laxity is present on forced sternal elevation and access sites are planned properly in a multidisciplinary approach.

Associated risk factors for patients undergoing a unique or double Nuss bar placement for pectus excavatum

Background

Pectus excavatum is the most common chest wall deformity. Surgical correction via Nuss Procedure is a common approach. Patients with long-segment sternal depression require more than one Nuss bar to be inserted. Complications of Nuss procedure include surgical site infection and bar migration which may necessitate surgical re-intervention. There has been conflicting evidence regarding the safety profile of inserting two Nuss bars. We aim to specifically review the safety profile of two Nuss bar insertion and its complications.

Method

179 consecutive patients who had undergone Nuss procedure between November 2013 and November 2021 were identified. Data analysis was performed on patient's age at time of operation, gender, height, weight, Haller index, pre-existing medical conditions, indication for surgery, duration of operation, numbers of bars placed, length of stay, post-operative pneumothorax, bar migration, superficial and deep infections, need for surgical intervention and mortality.

Result

Patients receiving two Nuss bars were at a significantly higher risk of developing infective complications. Lower weight and Haller index increase the risk of surgical site infection and infection requiring re-operation in this group of patients. A cut-off of 50 kg has a specificity of 92.1% with a sensitivity of 68.8% in regards to surgical site infection.

Conclusion

Patients receiving two Nuss bars as a part of their Nuss procedure are at a significantly higher risk of developing infective complications. Selecting patients more than 50 kg to receive two Nuss bars appear to be a reasonable measure to reduce surgical site infection.

Co-existing obstructive sleep apnea reduces Nuss surgery efficacy in pectus excavatum

Nuss surgery is effective in correcting pectus excavatum (PE), with a recurrence rate of 1.2–27%. Re-do surgery is successful but still has a 6% failure rate. Patients with obstructive sleep apnea (OSA) experience repetitive PE-associated sternal depression during sleep. As the prevalence of OSA among PE patients is higher than the average, co-existing OSA in PE patients might negatively affect the efficacy of Nuss surgery. This study aimed to evaluate the impact of co-existing OSA on Nuss surgery in patients with PE. In total, 20 adult patients with PE only and 9 patients with PE and OSA were analyzed. Polysomnography was performed before Nuss surgery to evaluate OSA. Sternovertebral distance (SVD) and radiographic Haller index (RHI) were recorded before surgery and at 3, 6, and 24 months postoperatively. The results showed that percentage changes in SVD in patients with PE only at 3, 6, and 24 months postoperatively were significantly increased compared with those in the patients with PE and OSA (31.1% vs. 14.1% at 3 months; 37.5% vs. 21.4% at 6 months; 42.5% vs. 19.2% at 24 months). Meanwhile, percentage changes in RHI were significantly lower in patients with PE alone than in the patients with PE and OSA (-22.9% vs. -9.3% at 3 months; -27.9% vs. -18.7% at 6 months; -30.6% vs. -16.7% at 24 months). This study showed that co-existing OSA might reduce the efficacy of Nuss surgery for patients with PE. We recommend that patients with PE should be evaluated and treated for OSA before surgery to prevent surgical failure after bar removal.

Neurolysis for analgesia following pectus repair in a national cohort

INTRODUCTION

Pectus excavatum and pectus carinatum are the most common chest wall deformities of childhood. Surgical repair can be complicated by post-operative analgesic challenges. Thoracic epidural analgesia, patient-controlled analgesia, and multimodal pain control are among the most common strategies. We sought to define the current utilization of intraoperative thoracic neurolysis, hypothesizing that this would minimize length of stay (LOS) and post-operative narcotic use with relatively higher proportion of non-narcotic post-operative analgesia.

METHODS

We performed a retrospective review of the Pediatric Health Information System (PHIS) database between 2017 and 2020. We first identified patients who underwent a pectus repair via ICD-10-PCS codes. We used ICD-10-PCS codes 01580ZZ and 01584ZZ to identify those patients who underwent concomitant thoracic neurolysis. Statistical analyses were performed using R; p value less than 0.05 was considered significant.

RESULTS

We identified 2979 patients who underwent a pectus repair. 184 underwent a concomitant thoracic nerve destruction procedure (6.7%); 13 were performed in 2017 (2.01%), 76 in 2018 (10.7%), and 84 in 2019 (9.6%). LOS was shorter in those patients who underwent neurolysis (mean=2.55 vs 3.73 days, SD=1.33 vs 1.78 days, p<0.001). There were fewer post-operative ICU admissions in neurolysis patients (3/184 vs. 193/2795, p = 0.003). The cost of procedures that included a neurolysis were higher, though not significantly so (mean=$24,885.64 vs $22,200.59).

CONCLUSION

Thoracic neurolysis may be a useful analgesic strategy, expediating post-operative discharge and potentially obviating the need for intensive care. Further larger-scale prospective trials should be considered to further elucidate the role of this analgesia method.

LEVEL OF EVIDENCE

Level III.

Same day discharge for pectus excavatum-is it possible?

PURPOSE

The use of intercostal nerve cryoablation (INC) has been an effective modality for treating pain in patients undergoing pectus excavatum (PE) repair. This study sought to evaluate if PE patients undergoing Nuss procedures with INC and intercostal nerve block (INB) could safely be discharged the same day of surgery.

METHODS

A prospective study with IRB approval of 15 consecutive patients undergoing PE Nuss repair with INC, INB, and an enhanced recovery after surgery (ERAS) protocol was conducted. The primary outcome measure was hospital length of stay (LOS) in hours. Secondary variables included same day discharge, postoperative complications, emergency department (ED) visits, urgent care (UC) visits, opioid use, and return to the operating room (OR).

RESULTS

LOS averaged 11.9 h amongst 15 patients. Ten patients (66.7%) went home on postoperative day (POD) 0, and the rest went home on POD 1. No patients stayed in the hospital due to pain. Reasons for failure to discharge included urinary retention, drowsiness, vomiting, and anxiety, but not pain. No patients were readmitted to the ED. One patient visited UC for constipation. One patient had bar migration requiring return to the OR for revision. Ten (66.7%) patients did not use opioids after discharge.

CONCLUSIONS

Same day discharge is feasible and safe in PE patients undergoing Nuss procedure with INC and INB. INC with INB can adequately control pain without significant complications. Same day discharge can be safely considered for PE patients undergoing Nuss procedure with INC with INB.

TYPE OF STUDY

Prognosis study LEVEL-OF-EVIDENCE RATING: Level II.

Limited cryoablation reduces hospital stay and opioid consumption compared to thoracic epidural analgesia after minimally invasive repair of pectus excavatum

pain following minimally invasive repair of pectus excavatum (MIRPE) is a critical concern that leads to a prolonged hospital stay and high doses of opiates administered to the patients. This study aimed to evaluate the efficacy of intraoperative cryoanalgesia (cryoablation of the intercostal nerves) during MIRPE. We retrospectively analyzed the data of 64 patients who underwent MIRPE and received cryoanalgesia or epidural analgesia between January 2019 and January 2021. The oral morphine milligram equivalent (MME) was used to calculate the dosage of opioid agents. The median age was 15 years (range, 4-33 years). The median postoperative hospital stay was 4 days (range, 2-6 days), with a median oral MME consumption of 45 mg (ranging from 0 to 1360 mg). Cryoanalgesia was performed in 38 patients, and epidural analgesia was administered to the remaining 26 patients. The cryoanalgesia group had a significantly lesser pain score, shorter postoperative hospital stay and lower oral MME consumption than the epidural analgesia group (5 vs 2; P < .001, 3 days vs 5 days; P < .001, 19 mg vs 634 mg; P < .001). Cryoanalgesia appears to reduce postoperative hospital stay and opioid consumption compared with epidural analgesia. The outcomes of this study indicate that cryoanalgesia might be a safe and effective method for pain control following MIRPE.

Variations in Nuss Procedure Operative Techniques and Complications: A Retrospective Review

INTRODUCTION

 The Nuss procedure is the most common and preferred operative correction of pectus excavatum. Surgeon preference and patient factors can result in variations in Nuss procedure technique. We hypothesize that certain techniques are associated with increased risk of complications.

MATERIALS AND METHODS

 We performed a single-center retrospective review of Nuss operations from 2016 to 2020. Variations in intraoperative techniques included sternal elevator (SE) use, number of bars placed, and usage of bilateral stabilizing sutures. Patient demographics, intraoperative data, and postoperative outcomes were reported as median with interquartile ranges or percentages. Statistical significance (p < 0.05) was determined with Wilcoxon's rank-sum and chi-square tests. Multivariate analysis was performed to control for introduction of intercostal nerve cryoablation and surgeon volume, and reported as odds ratio with 95% confidence interval.

RESULTS

 Two hundred and sixty-five patients were identified. Patients repaired with two bars were older with a larger Haller index (HI). Patient demographics were not significantly different for SE or stabilizing suture use. Placement of two bars was associated with significantly increased risk of readmission. Similarly, SE use was associated with increased risk of pleural effusion and readmission. Finally, the use of bilateral stabilizing sutures resulted in less frequent slipped bars without statistical significance.

CONCLUSION

 Older patients with a larger HI were more likely to need two bars placed to repair pectus excavatum. Placement of multiple bars and SE use are associated with significantly higher odds of certain complications.

Comparison of the Standard vs. Thoracoscopic Extrapleural Modification of the Nuss Procedure—Two Centers’ Experiences

Pectus excavatum is the most common congenital anterior chest wall deformity, with an incidence of 1:400 to 1:1000. Surgical strategy has evolved with the revolutionary idea of Donald Nuss, who was a pioneer in the operative correction of this deformity using minimally invasive surgery. The aim of this paper is to compare the preliminary results of pectus excavatum repair in two University Centers with a moderate number of patients using the standard Nuss procedure and its modification, the extrapleural thoracoscopic approach. The statistical analysis showed no significant difference for the patient’s age (14.52 ± 3.70 vs. 14.57 ± 1.86; p = 0.95) and the CT Haller index (4.17 ± 1.58 vs. 3.78 ± 0.95; p = 0.32). A statistically significant difference was noted for the duration of a pectus bar implant (2.16 ± 0.24 vs. 2.48 ± 0.68; p = 0.03) between the Maribor and Novi Sad Center. We report 14 complications (28%), including dislocation of the pectus bar (10%), pleural effusion (8%), wound inflammation (6%), pericarditis (2%) and an allergic reaction to the pectus bar (2%). Standard and thoracoscopic extrapleural Nuss procedures are both safe and effective procedures used to correct a pectus excavatum deformity. The choice of surgical procedure should be made according to a surgeon’s reliability in performing a particular procedure. Our study found no advantages of one procedure over the other.

Percutaneous Cryoanalgesia: A New Strategy for Pain Management in Pectus Excavatum Surgery

INTRODUCTION

 In recent years, pain protocols for pectus excavatum (PE) have incorporated cryoanalgesia through thoracoscopic approach. Since 2019, ultrasound-guided percutaneous cryoanalgesia (PCr) has been applied at our institution, either on the same day as the Nuss procedure or 48 hours before surgery. We carried out a preliminary retrospective review of patients with PE in whom PCr prior to surgery was performed at our institution between 2019 and 2021.

MATERIALS AND METHODS

 Two groups were evaluated: PCr on the same day (PCrSD) and PCr 48 hours before surgery (PCr48). Despite PCr, patients were treated with "patient-controlled analgesia" (PCA) with opioids for at least 24 hours, switching to conventional intravenous analgesia and oral analgesia in the following days. Demographic, clinical-radiological variables, PCA opioid use, pain grade according to the visual analog scale (VAS), and length of stay (LOS) were compared between the groups. A total of 20 patients were included (12 with PCrSD and 8 with PCr48), without significant differences in demographics or clinical-radiological variables. The overall median time of PCr was 65 minutes (55-127), with no differences between the groups.

RESULTS

 PCr48 group presented with significantly lower median number of hours of continuous PCA (24 vs. 32 hours; p = 0.031), lower median number of rescue boluses (11 vs. 18; p = 0.042), lower median VAS in the early postoperative hours (2 vs. 5.5; p = 0.043), and lower median LOS (3.5 vs. 5 days).

CONCLUSION

 PCr performed 48 hours prior to surgery is more effective in terms of PCA requirements, VAS, and LOS when compared with cryoanalgesia on the same day.

A Modfied Nuss Procedure for Recurrent Pectus Excavatum of Adults

Background

Limited data exist for adults with recurrent pectus excavatum (PE) treated with minimally invasive surgical repair.

Methods

Between July 2008 and December 2020, forty-two adult patients with recurrent PE underwent a modified Nuss procedure with a newly designed bar in our center. A small vertical subxiphoid incision was used to separate severe adhesions when necessary. Multiple steel wires were sutured, and the rib space was narrowed to firmly fix the bar. The primary end point was Haller index change after operation. The secondary end points included length of stay after operation, short-term and long-term complications.

Results

The mean patient age was 22.02 ± 3.49 years. The mean Haller index was 4.59 ± 1.09. A subxiphoid incision was performed in 12 patients. Thirty-nine patients had one bar placed, and 3 patients required two bars. Sixteen patients had 3 or more wires fixation, and 4 patients needed to have their intercostal space narrowed. There was no perioperative death, and the mean hospitalization was 5.57 ± 2.47 days. The Haller index reduced to 3.03 ± 0.41 after the operation (t = 11.85, p < 0.001). During the follow-up, there were 3 patients who developed non-infective wound effusion; bar rotations occurred in 3 patients. Twenty patients had the bar removed, post-bar removal Haller index was significantly reduced compared to the preoperative Haller index (2.89 ± 0.37 vs. 4.72 ± 1.05, t = 8.96, p < 0.001).

Conclusions

The modified Nuss procedure with a new titanium alloy bar can achieve good results for adult patients with recurrent PE.

Same-day discharge following the Nuss repair: A comparison

PURPOSE

Intercostal Nerve Cryoablation (INC) has significantly improved pain control following the Nuss repair of pectus excavatum (PE). This study sought to evaluate patients undergoing the Nuss repair with INC compared to the Nuss repair with an ERAS protocol, INC, and intercostal nerve blocks (INB).

METHODS

In June 2020, a new protocol was implemented involving surgery, anesthesia, nursing, physical therapy, and child life with the goal of safe same day discharge for patients undergoing the Nuss repair. They were compared to a control group who underwent the Nuss repair with INC alone in 2017-2019. The primary outcome measure was hospital length of stay (LOS) in hours, secondary outcomes were number of patients discharged on postoperative day (POD) 0, and returns to the emergency department (ED), urgent care (UC), and operating room (OR).

RESULTS

The characteristics between the groups were the same (Table 1). The mean LOS was 11.8 h in the INB group versus 58.2 h in the INC group, p < 0.01. 10 of 15 patients in the INB group went home on POD 0 (average of 5.5 h postop), versus 0 patients in the INC only group, p < 0.01. Five patients in the INB stayed overnight. Two patients stayed owing to anxiety, one owing to urinary retention, one owing to nausea, and one owing to drowsiness. None stayed for pain control. Four patients in the INC group returned to the ED for pain control, versus 0 in the INB group, and 1 patient in the INB returned to UC for constipation.

CONCLUSIONS

The majority of patients undergoing the Nuss repair of PE with a multidisciplinary regimen of pre and postoperative nursing education, precise intraoperative anesthesia care, performance of direct vision INB and INC, as well as careful surgery can go home on the day of surgery without adverse outcomes or unanticipated returns to the hospital.

LEVEL-OF-EVIDENCE

Level II.

Evolution of Technique and Results Following Permanent Open Repair for Pectus Deformities

Objective

Open correction of pectus deformities has evolved since its origin. We performed a Ravitch type repair using a permanent titanium plate fixed with screws and describe the procedure with outcomes after our modifications.

Methods

A retrospective review of 61 pectus excavatum and pectus carinatum cases from August 2013 to April 2021 was performed. Data were extracted from medical records and reported. In January 2016, we began administering satisfaction surveys at the 6-month postoperative visit; results are reported.

Results

The mean age of our cohort was 24.5 years; 43 (70%) were male. Fifty-four underwent pectus excavatum repair, 6 pectus carinatum repair, and 1 mixed repair. Median Haller index was 3.8. Mean operative duration was 98 minutes; mean blood loss was 116.4 mL. Median chest tube duration was 5.0 days; median hospital stay was 4 days. Reexploration for bleeding was 30% in the first 10 patients. Protocol changes including postponing chemical deep vein thrombosis prophylaxis, using intraoperative hemostatic agents, and using shorter implantation screws decreased this to 0% for the remaining cases. The most frequent complication was urinary retention (21.3%). Postoperative surveys were completed for 37 of 50 patients. Seventy-five percent reported health improved, 65% reported exercise capacity improved, 75% reported breathing improved, and 59% reported chest pain improved. Self-esteem improved from 6.6 ± 2.5 (of 10) before surgery to 8.2 ± 2.1 after surgery. Ninety percent were satisfied and 86% would have the operation again.

Conclusions

Ravitch type repair with permanent titanium plate fixation is a safe and effective procedure for correction of pectus excavatum and carinatum. Most patients experience improvement in preoperative symptoms.

Efficacy and Safety of Taulinoplasty Compared with the Minimally Invasive Repair of Pectus Excavatum Approach to Correct Pectus Excavatum

Background: Minimally invasive repair of pectus excavatum (MIRPE) technique is the current most used surgical method for pectus excavatum (PE) correction. To avoid MIRPE-required invasion of the mediastinum or pleural cavity, we developed taulinoplasty approach as an alternative option for the reduction of the sunken chest. Materials and Methods: This is a single-center unblind nonrandomized prospective pilot study, involving 26 MIRPE and 23 taulinoplasty patients. The primary safety endpoint was the presence of surgical complications, and the primary efficacy endpoint was Haller index measured postoperatively in taulinoplasty patients. Secondary endpoints were intensive care unit (ICU) and hospital length of stay (LOS), duration of surgical procedure, and postoperative pain management. Chi-square, Mann-Whitney, or Student "t" tests were used for comparison as appropriate. Results: There were no difference in median age (14.5 and 14 years), Haller index (4.63 and 4.17), or comorbidities. MIRPE and taulinoplasty procedures showed no difference regarding major or minor surgical complications. The efficacy endpoint of taulinoplasty was measured 5.5 (1.5-12) months after the procedure, exhibiting a significant reduction in the Haller index [4.17 (3.7-4.7) at baseline and 3.7 (2.9-4.1) postoperatively, P = .03]. Taulinoplasty required less surgical time (60.4 ± 15.5 versus 70.7 ± 15.9 minutes, P < .01); shorter ICU and hospital LOS (P < .01, respectively); and required fewer days of peridural, intravenous, and oral analgesia (P < .01, respectively). Conclusions: In this pilot study, taulinoplasty technique was as safe as the MIRPE approach and effective for the correction of PE, reducing surgical time, ICU and hospital LOS, and achieving better postoperative pain control.

Intercostal cryoablation during Nuss procedure: A large volume single surgeon's experience and outcomes

BACKGROUND

Recent studies have shown intercostal cryoablation(IC) during the Nuss procedure decreases hospital length of stay(LOS) and opioid administration. However, few studies have also evaluated the risk of postoperative complications related to IC.

METHODS

We performed a single center retrospective analysis of all patients who underwent Nuss procedure by one surgeon from 2/2016 to 2/2020, comparing intraoperative IC to other pain management modalities(non-IC). Primary outcomes were postoperative complications, hospital LOS, and opioid administration. Multivariate analysis was performed with outcomes reported as regression coefficients(RC) or odds ratios(OR) with 95% confidence interval.

RESULTS

IC was associated with decreased hospital LOS (RC -1.91[-2.29 to -1.54], less hospital opioid administration (RC -4.28[-5.13 to -3.43]), and less discharge opioid administration (RC -3.82[-5.23 to -2.41]). With respect to postoperative complications, IC decreased the odds of urinary retention (OR 0.16[0.06 to 0.44]); however, increased the odds of slipped bars requiring reoperation (OR 36.65[5.04-266.39]).

CONCLUSIONS

Our single surgeon experience controls for surgeon variability and demonstrates intraoperative IC for the Nuss procedure is an effective pain management modality that decreases hospital LOS and opioid use during hospitalization and at discharge; however, it is associated with increased odds of slipped bars requiring reoperation.

LEVEL OF EVIDENCE

III.

Minimally Invasive Modified Nuss Procedure for Repair of Pectus Excavatum in Pediatric Patients: Single-Centre Retrospective Observational Study

Background: The treatment of pectus excavatum can be conservative or surgical. The aim of this study was to determine the factors influencing the outcomes of treatment after a minimally invasive Nuss corrective surgery procedure in pediatric patients. Methods: A total of 30 patient who underwent a minimally invasive Nuss corrective procedure for pectus excavatum from 1 January 2014 to 31 December 2020 were included in thisretrospective study. The collected data included thepatient’s demographic characteristics (age, sex, height, weight, body mass index—BMI, Haller index), treatment outcomes (duration of surgery, length of hospital stay, intraoperative complications, early and late complications, postoperative analgesia), and overall patient and legal guardian satisfaction two years after the procedure. Results: A total of 22 male and 8 female patients were included in the study. The median age was 15 years (interquartile range—IQR 14, 16), and the median BMI was 18.5 kg/m2 (IQR 17.7, 20.4) and 18.2 kg/m2 (IQR 16.9, 18.6) for males and females, respectively. The median CT Haller index was 3.67 (IQR 3.48, 4.09) for male and 3.69 (IQR 3.45, 3.9) for female patients. The median surgery duration was 120 min (IQR 100, 130), and the median hospital stay length was 8.5 days (IQR 8, 9.75). Indications for surgery were psychological (47%), followed by respiratory (30%) and combined respiratory-cardiac (20%) and respiratory-psychological disorders (3%). Early complications were observed in 18 patients (60%), and late complications were observed in 7 patients (23.3%). Intraoperative complications were not recorded. The most common early complications were pneumothorax and subcutaneous emphysema (30%), while late complications included bar displacement (10%) and deformity recurrence (6.6%). Overall, the procedure was successful in 93.1% of patients. Upon arrival home, 22 patients (81.5%) used analgesics for at least one day, up to a maximum of six months. A total of 23 (76.7%) operated patients determined that the surgical procedure had excellent results (grade 5), 4 (13.3%) patients report a good result (grade 4), 1(3.3%) patient reported a mediocre result, and one patient (3.3%) reported a bad result (grades 3 and 2, respectively). Conclusion: The Nuss procedure is a safe and effective method for treating funnel chest in children and adolescents. It also providesexcellent cosmetic and aesthetic results as well as subjective satisfaction with the outcome of surgical treatment.

Sternal elevation by the crane technique during pectus excavatum repair: A quantitative analysis

Introduction

The crane technique is used to facilitate sternal elevation to provide safe mediastinal passage during the Nuss procedure. The aim was to objectively quantitate the elevation of the crane by 3-dimensional chest images acquired during the Nuss procedure.

Methods

A prospective cohort study was conducted. Patients undergoing the Nuss procedure were eligible. Sternal elevation was achieved by the crane technique providing a simultaneous lift of the anterior chest wall and reduction of the pectus excavatum depth. Both effects were evaluated. Three-dimensional surface images were acquired before incision, following sternal lift, and after bar implantation and quantitatively compared. Reduction of the external pectus excavatum depth was expressed as a percentage.

Results

Thirty patients were included. Ninety percent were male, with a median age of 15.5 years (interquartile range [IQR], 14.5-17.4), Haller index of 3.56 (IQR, 3.09-4.65), and external pectus depth of 18 mm (IQR, 11-23). Sternal elevation by the crane provided a median 78% (IQR, 63-100) reduction of the deformity, corresponding with a residual depth of 3 mm (IQR, 0-7). The percentual reduction diminished with increasing depth of the sternal depression (correlation, –0.86). Besides reducing the deformity, the crane caused an elevation of the anterior chest over a large surface area with a maximum lift of 26 mm (IQR, 19-32).

Conclusions

The crane is an effective sternal elevation technique, providing 78% reduction of the sternal depression, although its effect lessens with increasing depth. In addition, it produces an elevation of the anterior chest over a large surface area.

Intercostal nerve cryoablation is associated with lower hospital cost during minimally invasive Nuss procedure for pectus excavatum

Minimally invasive repair of pectus excavatum (Nuss procedure) is associated with significant pain, and efforts to control pain impact resource utilization. Bilateral thoracic intercostal nerve cryoablation has been proposed as a novel technique to improve post-operative pain control, though the impact on hospital cost is unknown.

METHODS

We conducted a retrospective study of patients undergoing a Nuss procedure from 2016 to 2019. Patients who received cryoablation were compared to those that received traditional pain control (patient-controlled analgesia or epidural). Outcome variables included postoperative opioid usage (milligram morphine equivalents, MME), length of stay (LOS), and hospital cost.

RESULTS

Thirty-five of 73 patients studied (48%) received intercostal nerve cryoablation. LOS (1.0 vs 4.0 days, p < 0.01) and total hospital cost ($21,924 versus $23,694, p = 0.04) were decreased in the cryoablation cohort, despite longer operative time (152 vs 74 min, p < 0.01). Cryoablation was associated with decreased opioid usage (15.0 versus 148.6 MME, p < 0.01) during the 24 h following surgery and this persisted over the entire postoperative period, including discharge opioid prescription (112.5 vs 300.0 MME, p < 0.01).

CONCLUSION

Bilateral intercostal nerve cryoablation is associated with decreased postoperative opioid usage and decreased resource utilization in pediatric patients undergoing a minimally invasive Nuss procedure for pectus excavatum.

LEVEL OF EVIDENCE

Retrospective comparative study, level III.

[Intercostal nerve cryoablation in correction of pectus excavatum in adults]

OBJECTIVE

To evaluate an effectiveness of cryoanalgesia in older patients with pectus excavatum and to determine feasibility of further research.

MATERIAL AND METHODS

We have developed an original technique of intercostal nerve cryoablation for correction of pectus excavatum in adults. The results of intercostal nerve cryoablation during correction of pectus excavatum in 10 older patients were analyzed.

RESULTS

Postoperative outcomes were followed-up over a period of 4 - 12 months. There were no perioperative surgical complications. In 1 case, moderate pain syndrome persisted for 3 months after surgery (mean VAS score 2±1.3). In 9 months, mean VAS score was 0.6±0.6 in a month after surgery.

CONCLUSION

Intercostal nerve cryoablation in correction of pectus excavatum in adults may be an alternative to the current methods of regional analgesia. Further research is requried to achieve objective information.

Safety and feasibility of rigid fixation by SternaLock Blu plates during the modified Ravitch procedure: a pilot study

Background

Patients with anterior chest wall deformities unsuitable for minimally invasive repair are commonly treated by the modified Ravitch procedure. Although rigid plate fixation of the sternal osteotomy has previously shown to facilitate adequate sternal union, its use is troubled by an implant removal rate of up to 23% due to local complaints or complications associated with bulky plates. In contrast, the use of thinner and therefore biomechanically weaker plates may result in a higher incidence of non- or mal-union. In this pilot study, we evaluate the feasibility, efficacy and safety of rigid sternal fixation by thin pre-shaped anatomical locking plates during the modified Ravitch procedure.

Methods

Between June 2018 and December 2019, all consecutive patients who underwent anterior chest wall deformity repair by the modified Ravitch procedure in our tertiary referral centre were included. Data was collected retrospectively. All pectus types were included. The sternal osteotomy was fixated using thin SternaLock Blu plates. Patients were followed for at least one year.

Results

Nine patients were included. The group consisted of six male and three female patients, with a median age of 20 years [interquartile range (IQR), 16–35 years]. Median duration of follow-up was 25 months (IQR, 16–28 months). No intraoperative complications occurred. No patients presented with symptomatic non- or mal-union. Plate removal was performed in one patient for atypical pain without relief. No other postoperative complications occurred.

Conclusions

Based on these pilot results, thin SternaLock Blu plates are deemed to be safe and effective in providing adequate rigid fixation of the sternal osteotomy during the modified Ravitch procedure. Compared to literature, the need for plate removal within 25 months after surgery was reduced.

Wire fracture in postoperative Nuss procedure: a problem that cannot be ignored

BACKGROUND

Surgical stainless wire has been widely used to stabilize pectus bar and ribs in Nuss procedure for pectus excavatum correction. However, wire fracture and its secondary complications are problems easily to be ignored but very important. The purpose of this article was to describe a series of cases with wire breakage, hoping to arouse the attention of worldwide thoracic surgeons to this potential threat, and to share our modifications on the fixation patterns and materials in Nuss procedure.

METHODS

From September 2011 to January 2020, 44 patients underwent Nuss procedure at Chongqing University Three Gorges Hospital. In the initial 25 patients (Group A), each bar was secured by stainless wires, and the latter 19 patients (Group B) received stainless wires and polyblend polyethylene sutures (PDS) in the bar fixation. Patient demographics, Haller index (HI), wire fracture rate, characteristics of the broken wires, and operation time were recorded.

RESULTS

The mean operation age was 8.1±4.3 years in group A and 10.4±2.9 years in group B. There was no statistical difference in HIs between the two groups (P>0.05). The wire fracture occurred in 88.0% of the patients in Group A, while the wires in Group B were all intact. There was no bar displacement or other serious complication requiring surgical intervention in the two groups. The mean operation time of bar removal when encountering wire fracture was 104.6±42.8 minutes, which was significantly higher than that in Group B (P≤0.001).

CONCLUSIONS

The wire fracture in the bar fixation could pose potential hazards to patients deserving special attention from thoracic surgeons. Cancel the wire fixation in the non-stabilizer side while simultaneously using wires and PDS in the pectus bar fixation may achieve the pectus bar stability while overcoming the problem of wire fracture.

Adult pectus excavatum repair: national outcomes of the Nuss and Ravitch procedures

Background

National data is limited on pectus excavatum, the most common chest wall deformity which is often repaired using the Ravitch and Nuss procedures. The purpose of the study was to describe demographics and outcomes of adult patients who underwent surgical repair of pectus excavatum via open and minimally invasive thoracoscopic methods.

Methods

A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database from 2015 to 2018 was performed, capturing patients 18 years or older with pectus excavatum as the postoperative diagnosis. Patients were placed into two groups of minimally invasive (Nuss) and open (Ravitch) repair procedure code. Baseline characteristics and postoperative outcomes were analyzed.

Results

A total of 168 adult patients were captured. Most of these patients were white (84.52%) male (69.64%) and 26 years old on average. Median operative time was longer in the open repair group [250 (IQR, 173-308) versus 122 (IQR, 94-160) minutes, P<0.0001]. Median length of stay was five days (IQR, 4-6) in the open group and three days (IQR, 2-4) in the minimally invasive group (P=0.2873).

Conclusions

Complications after repair of pectus excavatum occur at similar rates between open and minimally invasive repair. Though minimally invasive repair decreases operative time and may decrease length of stay, the decision of type of procedure depends upon clinical scenario and factors unique to the individual patient.

Amianthoid transformation of costal cartilage matrix in children with pectus excavatum and pectus carinatum

Background

It is unclear if amianthoid transformation (AT) of costal cartilage extracellular matrix (ECM) has an impact on the development of pectus excavatum (PE) and pectus carinatum (PC).

Methods

AT foci were examined in intrasurgical biopsy specimens of costal cartilages of children (8–17 years old) with PE (n = 12) and PC (n = 12) and in age-matching autopsy control samples (n = 10) using histological and immunohistochemical staining, atomic force and nonlinear optical microscopy, transmission and scanning electron microscopy, morphometry and statistics.

Results

AT areas were identified in the costal cartilage ECM in children with normal chest, PE and PC. Each type of the AT areas (“canonical”, “intertwined”, “fine-fibred” and “intralacunary”) had a unique morphological pattern of thickness and alignment of amianthoid fibers (AFs). AFs were formed via lateral aggregation of collagen type II fibrils in the intact ECM. Foci of the AT were observed significantly more frequently in the PE and PC groups. The AT areas had unique quantitative features in each study group.

Conclusion

AT is a structurally diverse form of ECM alteration present in healthy and pathological costal cartilage. PE and PC are associated with specific AT disorders.

Complications after Ravitch versus Nuss repair of pectus excavatum: A Society of Thoracic Surgeons (STS) General Thoracic Surgery Database analysis

BACKGROUND

There are conflicting reports in the literature comparing outcomes after open Ravitch and minimally invasive Nuss procedures for pectus excavatum repair, and there is relatively little data available comparing the outcomes of these procedures performed by thoracic surgeons.

METHODS

The 2010 to 2018 Society of Thoracic Surgeons General Thoracic Surgery Database was queried for patients age 12 or greater undergoing open or minimally invasive repair of pectus excavatum. Patients were stratified by operative approach. Multivariable logistic regression was performed with a composite outcome of 30-day complications.

RESULTS

A total of 1,767 patients met inclusion criteria, including 1,017 and 750 patients who underwent minimally invasive pectus repair and open repair, respectively. Open repair patients were more likely to be American Society of Anesthesiologists (ASA) class III or greater (24% vs 14%; P < .001), have a history of prior cardiothoracic surgery (26% vs 14%; P < .001), and require longer operations (median 268 vs 185 minutes; P < .001). Open repair patients were more likely to require greater than 6 days of hospitalization (18% vs 7%; P < .001), undergo transfusion (7% vs 2%; P < .001), and be readmitted (8% vs 5%; P = .004). After adjustment, open repair was not associated with an increased risk of a composite of postoperative complications (odds ratio 0.99, 95% confidence interval 0.67-1.46). This finding persisted after propensity score matching (odds ratio 1.11, 95% confidence interval 0.74-1.67).

CONCLUSION

Pectus excavatum repair procedure type was not associated with the risk of postoperative complications after adjustment. Further investigation is necessary to determine the impact of pectus excavatum repair type on recurrence and patient reported outcomes, including satisfaction, quality of life, and pain control.

Long-term results after the modified Ravitch procedure performed in children and adolescents - a one-time procedure without the need to use additional support of the sternum. A retrospective study

Introduction

Pectus excavatum is a depression of the sternum. Pectus carinatum, in contrast, is the convexity of the sternum. The mixed form is an intermediate condition. Surgical intervention is the treatment of choice. The techniques most commonly used include the Ravitch and the Nuss procedures.

Aim

To assess the immediate and long-term results of the original modification of the surgical treatment for anterior chest wall deformation.

Material and methods

The modification is based on the Ravitch procedure. The difference is that the ends of the resected cartilages are shaped like a blade in order to be inserted into the previously prepared wedge-shaped hollows located on both edges of the sternum. The result is long lasting without the need to use additional brackets.

Results

The follow-up examinations performed in 72 patients, including 57 boys and 15 girls, were the basis to produce long-term results. As for the type of deformity, out of 57 patients operated on due to pectus excavatum, 43 expressed satisfaction with the very good result. Similar satisfaction was reported in 7 out of 11 patients operated on due to pectus carinatum. There were 4 cases with the mixed form who had very good long-term results. Wound dehiscence was observed in 13 subjects, with one documented recurrence.

Conclusions

The alternative treatment we propose is a one-time procedure without the need to use additional support of the sternum. Good long-term results make the procedure suitable to be used more frequently in all types of deformities.

Cryoablation is associated with shorter length of stay and reduced opioid use in pectus excavatum repair

PURPOSE

The use of intercostal nerve cryoablation (INC) is becoming increasingly common in patients undergoing pectus excavatum (PE) repair. This study sought to evaluate the use of INC compared to traditional use of thoracic epidural (TE).

METHODS

A retrospective review of 79 patients undergoing PE repair with either INC or TE from May 2009 to December 2019 was conducted. The operations were performed by four surgeons who worked together at four different hospitals and have the same standardized practice. The primary outcome measure was hospital length of stay (LOS). Secondary variables included surgical time, total operating room time, operating room time cost, total hospital cost, inpatient opioid use, long-term opioid use after discharge, and postoperative complications.

RESULTS

LOS decreased to 2.5 days in the INC group compared to 5 days in the TE group (p < 0.0001). Surgical time was increased in the INC group, but there was no difference in total OR time. The INC group experienced significantly lower hospital costs. Total hospital opioid administration was significantly lower in INC group, and there was a significant decrease in long-term opioid use in the INC group.

CONCLUSIONS

INC is a newer modality that decreases LOS, controls pain, and results in overall cost savings. We recommend that INC be included in the current practice for postoperative pain control in PE patients undergoing Nuss procedure.

Minimally invasive repair of pectus excavatum by the Nuss procedure: The learning curve

OBJECTIVES

To define the learning process of minimally invasive repair of pectus excavatum by the Nuss procedure through assessment of consecutive procedural metrics.

METHODS

A single-center retrospective observational cohort study was conducted of all consecutive Nuss procedures performed by individual surgeons without previous experience between June 2006 and December 2018. Surgeons were proctored during their initial 10 procedures. The learning process after the proctoring period was evaluated using nonrisk-adjusted cumulative sum (ie, observed minus expected) failure charts of complications. An acceptable and unacceptable complication rate of 10% and 20% were used. Logarithmic trend lines were used to assess over-time performance regarding operation time.

RESULTS

Two-hundred twenty-two consecutive Nuss procedures by 3 general thoracic surgeons were evaluated. Cumulative sum charts showed an average performance from the first procedure after being proctored onward for all surgeons, whereas surgeon B demonstrated a statistically significant complication rate equal to or less than 10% after 59 cases. Post-hoc sensitivity analyses using a stricter acceptable and unacceptable complication rate of 6% and 12% also showed an average performance for all surgeons. Although, the median time between consecutive procedures ranged from 7 to 35 days, no frequency-outcome relationship was observed. In addition, surgeons required the same average operation time throughout their entire experience.

CONCLUSIONS

After a 10-procedure proctoring period, repair of pectus excavatum by the Nuss procedure is a safe procedure to adopt and perform without a typical (complication based) learning curve while performing at least 1 procedure per 35 days.

Nuss Procedure for Pectus Excavatum: A Comparison of Complications Between Young and Adult Patients

BACKGROUND

The Nuss procedure is the gold standard surgical treatment for pectus excavatum in young patients. Its use in adults has also been described, although it may be associated with increased postoperative morbidity resulting from higher chest wall rigidity. This study aimed to examine the risk of complications after the Nuss procedure in adult patients compared with young patients with pectus excavatum.

METHODS

This single-center retrospective cohort study evaluated all patients who underwent the Nuss procedure between 2006 and 2018. Patients were stratified by age as young (≤24 years old) and adult (>24 years old). The primary end point was the occurrence of perioperative or postoperative complications, subdivided into major (Clavien-Dindo class III_a or higher) and minor (less severe than Clavien-Dindo class III). Between-group differences were analyzed using the Mann-Whitney U and the χ² test with post hoc analysis.

RESULTS

A total of 327 participants were included, 272 in the young group (median age, 16 years; interquartile range [IQR], 15 to 18 years; range, 11 to 24 years) and 55 in the adult group (median age, 32 years; IQR, 27 to 38 years; range, 25 to 47 years). The median Haller index was similar between groups (young, 3.7; IQR, 3.2 to 4.4 vs adult,3.6; IQR, 3.0 to 4.3; P = .44). The median follow-up was 34 and 36 months, respectively. The incidence of major complications was comparable between young and adult participants (P = .43). Minor complications occurred more often among adults (young, 4% vs adult, 11%; P = .002). Chronic postoperative pain was the only minor complication with a significant difference in incidence (young, 1% vs adult, 7%; P = .008).

CONCLUSIONS

The Nuss procedure is a safe surgical treatment for pectus excavatum in both young and adult patients. The risk of major complications is comparable. However, adults more often have chronic pain.

Intercostal nerve cryoablation versus thoracic epidural for postoperative analgesia following pectus excavatum repair: a systematic review and meta-analysis

OBJECTIVES

Minimally invasive pectus excavatum repair via the Nuss procedure is associated with significant postoperative pain that is considered as the dominant factor affecting the duration of hospitalization. Postoperative pain after the Nuss procedures is commonly controlled by thoracic epidural analgesia. Recently, intercostal nerve cryoablation has been proposed as an alternative method with long-acting pain control and shortened hospitalization. The subsequent objective was to systematically review the outcomes of intercostal nerve cryoablation in comparison to thoracic epidural after the Nuss procedure.

METHODS

Six scientific databases were searched. Data concerning the length of hospital stay, operative time and postoperative opioid usage were extracted. If possible, data were submitted to meta-analysis using the mean of differences, random-effects model with inverse variance method and I2 test for heterogeneity.

RESULTS

Four observational and 1 randomized study were included, enrolling a total of 196 patients. Meta-analyses demonstrated a significantly shortened length of hospital stay [mean difference -2.91 days; 95% confidence interval (CI) -3.68 to -2.15; P < 0.001] and increased operative time (mean difference 40.91 min; 95% CI 14.42-67.40; P < 0.001) for cryoablation. Both analyses demonstrated significant heterogeneity (both I2 = 91%; P < 0.001). Qualitative analysis demonstrated the amount of postoperative opioid usage to be significantly lower for cryoablation in 3 out of 4 reporting studies.

CONCLUSIONS

Intercostal nerve cryoablation during the Nuss procedure may be an attractive alternative to thoracic epidural analgesia, resulting in shortened hospitalization. However, given the low quality and heterogeneity of studies, more randomized controlled trials are needed.

Pectus excavatum and scoliosis: a review about the patient's surgical management

Although Nuss procedure is performed with satisfactory results, there has been a controversy in the literature regarding the effect of a Nuss procedure on the spine. This review article aims to perform an updated overview of the literature about the effect of pectus excavatum correction at the spine and the management of patients with both pectus excavatum and scoliosis. Although acquired scoliosis has been rarely reported after a Nuss procedure, studies show that the Nuss procedure can have a beneficial effect in mild coexisting scoliosis especially when it is performed during the adolescence. The management of cases presented with both pectus excavatum and scoliosis depends on the severity of pre-operative scoliosis and demands detailed evaluation of the spine pre and postoperatively. In the rare condition of post-operative scoliosis following a Nuss procedure, the removal of the metallic bar and conservative measures may have satisfactory results on the spine.