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Jennifer Kasten, MD, MSc(Oxon), MSc(London) PGY-1, University of Washington 26 August 2010 Pectus Excavatum: Overview Most common congenital chest wall deformity Incidence: 1/400– 7.9/1000 live births Male predominance, roughly 4:1 Created by posterior angulation of sternum, as well as posterior angulation of costal cartilages May be symmetric or asymmetric 90% of cases: noticed in first year of life Presentation Most common symptoms: shortness of breath during exercise, limited physical activity Improvement after repair is often noted Multiple studies have demonstrated a restrictive defect on PFTs Relief of symptoms is likely related to decompression of the right ventricle as much as intrathoracic volume expansion Adolescents often troubled by cosmetic implications Shamberger, R. Congenital Chest Wall Deformities. Current Problems in Surgery 1996: 33: 471-542. Cosmesis is an important operative indication Operative Techniques Ravitch versus Nuss Ravitch: open technique involves resection of costal cartilage and perichondrium, sternal osteotomies, anterior fixation of the sternum with wires Nuss: thoracoscopic repair: place introducer in deepest apex of chest, flip to correct deformity, place permanent bar Meta-Analysis Comparing the Two Techniques Shows Equivalency Sick Kids group reviewed 9 retrospective & prospective studies; no RTCs exist No difference: 1) overall complication rates 2) hospital stay 3) time to ambulation post-op 4) patient satisfaction with outcome Ravitch superior to Nuss in: 1) rates of bar migration 2) persistent deformity 3) post-op PTX, hemothorax Nuss superior to Ravich in: 1) operative time 1. Nasr A, Fecteau A, Wales PW. Comparison of the Nuss and the Ravitch procedure for pectus excavatum repair: a meta-analysis.J Pediatr Surg. 2010 May;45(5):880-6. “Learning Curve” “One hundred and sixty seven patients… were included in this study. Major complications occurred in seven patients (4.2%) and consisted of one intraoperative heart perforation, one piercing of the liver with the trocar, bar infections (n = 2) and significant bar displacement (n = 3). Minor complications were seen in 122 patients (73.1%) and consisted of breakage of wires used to secure the lateral stabilizer plate (n = 48), pleural effusions (n = 28), intraoperative rupture of the intercostal muscle (n = 15), pericardial tears without clinical significance (n = 7) and lung atelectasia (n = 4). Major complications related to the Nuss procedure were rare but preventable and could mainly be attributed to the learning curve.” Castellani C, Schalamon J, Saxena AK, Höellwarth ME. Early complications of the Nuss procedure for pectus excavatum: a prospective study. Pediatr Surg Int. 2008 Jun;24(6):659-66. Criteria for Operation Need two or more of the following per Dr Nuss: 1) Haller Index >3.25 2) PFTs demonstrating restrictive/obstructive pulmonary airway disease 3) EKG or ECHO showing cardiac compression, murmurs, MVP, or conduction anomalies 4) physical symptomatology Nuss D. “Surgical Treatment of Chest Wall Deformities.” Operative Pediatric Surgery, 6th Edition (2006). Cardiopulmonary Benefits of the Nuss are Questionable One study reviewed all data published on CP outcomes of pectus correction since 1965 5 studies had homogenous definition criteria and could be meta-analyzed No improvements were found in left ventricular size, stroke volume, and cardiac output 1. Guntheroth WG, Spiers PS. Cardiac function before and after surgery for pectus excavatum. Am J Cardiol. 2007 Jun 15;99(12):1762-4. Epub 2007 Apr 25. The Ravitch Procedure Might Temporarily Impede Pulmonary Function Postoperative total lung capacity for patients who had Ravitch repair was significantly lower (SMD, 0.71) than preoperative after removal of the Nuss bar, FEV(1) was significantly increased from preoperative values (SMD, 0.39) In this study, stroke volume increased after surgery (SMD, 0.40) 1. Johnson JN, Hartman TK, Pianosi PT, Driscoll DJ. Cardiorespiratory function after operation for pectus excavatum. J Pediatr. 2008 Sep;153(3):359-64. “Satisfactory” Results are Primarily Cosmetic Long-term studies measuring outcomes nearly always define a satisfactory result in aesthetic terms A worthwhile reason to operate Pt subjectively report an increase in exercise tolerance, activity level which is not borne out by cardiopulmonary testing Perioperative Care: Pain Control Studies have repeatedly demonstrated the superiority of epidural anesthesia postoperatively. -- versus PCA alone, pts use less opioid and are weaned from opioids earlier (1); they had lower pain scores and a greater sense of well-being (4) -- in a randomized study, epidural anesthesia was superior to PCA in terms of length of therapy (2.3 versus 3.3 days) and inpatient pain scores (2) -- Just don’t get your epidural in Kansas City; 65/188 (34.6%) lost their catheter within 24h; PCA was superior re: hospital stay, transition to PO medications (3) 1. Reinoso-Barbero F, Fernández A, Durán P, Castro LE, Campo G, Melo MM. Thoracic epidural analgesia vs patient-controlled analgesia with intravenous fentanyl in children treated for pectus excavatum with the Nuss procedureRev Esp Anestesiol Reanim. 2010 Apr;57(4):214-9. 2. Soliman IE, Apuya JS, Fertal KM, Simpson PM, Tobias JD. Intravenous versus epidural analgesia after surgical repair of pectus excavatum. Am J Ther. 2009 Sep-Oct;16(5):398-403 3. St Peter SD, Weesner KA, Sharp RJ, Sharp SW, Ostlie DJ, Holcomb GW3rd Is epidural anesthesia truly the best pain management strategy after minimally invasive pectus excavatum repair?.J Pediatr Surg. 2008 Jan;43(1):7982; discussion 82. 4. Weber T, Mätzl J, Rokitansky A, Klimscha W, Neumann K, Deusch E; Superior postoperative pain relief with thoracic epidural analgesia versus intravenous patient-controlled analgesia after minimally invasive pectus excavatum repair. J Thorac Cardiovasc Surg. 2007 Oct;134(4):865-70. Severity of Pectus Predicts Opioid Use Survey of 236 patients undergoing Nuss Procedure: preoperative CT measuring Haller Index linearly regressed to opoid use Found each 1cm increase accounted for a 6% increase in opiate consumption Grosen K, Pfeiffer-Jensen M, Pilegaard HK. Postoperative consumption of opioid analgesics following correction of pectus excavatum is influenced by pectus severity: a single-centre study of 236 patients undergoing minimally invasive correction of pectus excavatum. Eur J Cardiothorac Surg. 2010 Apr;37(4):833-9. Physical Therapy: Useful in the Acute Inpatient Setting Postural/skeletal defects common in pectus kids Need for teaching re: sternal precauations, monitoring mobility Use in acute, inpatient setting validated (1) 1. Schoenmakers MA, Gulmans VA, Bax NM, Helders PJ. Physiotherapy as an adjuvant to the surgical treatment of anterior chest wall deformities: a necessity? A prospective descriptive study in 21 patients. J Pediatr Surg. 2000 Oct;35(10):1440-3. Pectus Kids Value Pain Control over Emesis Control Intriguing study questioned 45 Nuss patients re: their preferences : if they could have zero pain, how much vomiting were they willing to accept? The maximum risk of vomiting that the overall study population was willing to accept to decrease the pain level to zero was 32% +/- 24%. Girls were willing to take a significantly higher risk (41% +/24%) compared to boys (25% +/- 22%). 1. Cucchiaro G, Farrar JT, Guite JW, Li Y.What postoperative outcomes matter to pediatric patients? Anesth Analg. 2006 May;102(5):1376-82. Chart Review: Inclusion Criteria Underwent pectus repair at SCH in 2009 or 2010: 39 patients Primary repairs only (exclude bar removal procedures): 37 patients Chart available for review 8/25/2010: 32 patients, of whom 2 are current inpatients Therefore 32 charts thoroughly reviewed Demographics Males: 26; Females: 6 2 Hispanic, 2 East/South Asian, 28 Caucasian Average age at surgery: 16 years, 3 months (range: 11.67 y – 22.5y) No age difference between males & females: 16.13y (F) versus 16.31y (M) Procedure undergone: 1 bar Nuss (20); 2 bar Nuss (2); Ravitch (0) Body Habitus Slim and asthenic Scoliosis documented in 2/32 (6.25%) Average BMI: 19.63 (range: 13.6 – 24.2) Females slimmer: (18.57 versus 19.88) Pre-Op Workup 31/32 (96.9%) of patients received preoperative Pulmonary Function Tests and cardiovascular stress tests 13/31 (41.9%) had demonstrable restrictive lung deficits, cardiac compression, or both 28/32 (87.5%) had a documented preoperative CT scan to assess the Haller Index Average Haller Index 4.36 (normal ~2.5; upper limit of normal 3.25) Males more severe: 4.10 (F) versus 4.43 (M) Length of Stay Average Length of Stay: 3.96 days Females had slightly shorter stays: 3.8 days versus 4.0 days 1d: 2d: 3d: 4d: 5d: 6d: 7d: 0 0 13 10 5 0 2 Epidural Anesthesia Epidural catheters were used for postoperative pain control in 100% (32/32) patients A variety of local anesthetics were used, most often ropivucaine PCEAs were used in 8/32 (25%) Additional morphine or dilaudid PCAs were used in 13/32 (40.6%) in 2 of these cases, the epidural failed 10 patients had an epidural alone Epidural Out? On average, the epidural was successfully discontinued after 2.54 days POD #2: 15 pts (46.9%); POD#3: 12 pts (37.5%); POD #5: 1 patient (3.1%); failed: 2 patients (6.25%) 14/32 patients experienced moderate-severe nausea while an inpatient (43.4%); this was not associated with time till dc of epidural Discharge Pain Regimens Known regimens: 25/30 (83.3%) documented in discharge summaries, paper chart. Tylenol: 25/25 (100%) ibuprofen: 23/25 (92%) oxycodone: 25/25 (100%) oxyContin: 17/25 (68%) flexeril: 1/25 (4%) lorezapam: 1/25 (4%) Physical Therapy PT advised for mobilization, teaching re: sternal precautions 10/30 (33%) patients who have completed their hospital course were formally seen by Physical Therapy Postoperative Complications Pneumothorax: 20/30 Inadequate pain control: 19/30 Nausea & vomiting: 12/30 Presented to Emergency Room/ Surgery Clinic within 3 days of discharge: 7/30 (23.3%) Significant weight loss, > 5% preop weight: 4/30 Constipation requiring medical attention: 4/30 Readmitted to SCH: 3/30 (10%!) Hallucinations: 2/30 Fever, urinary retention, hematoma, RUQ pain, diarrhea: 1 each Suggestions for the Future Standardize criteria for discharge with long-lasting opioids (i.e. OxyContin); potentially use Haller index as predictor Incorporate physical therapy for mobilization, sternal precautions teaching Aggressive bowel regimens as outpatient and inpatient Closer look at inpatient pain regimens; descriptive statistics on patient outcomes regressed to specific pain regimens Standardizing a Pathway Per IT we can amend the existing “Pectus” orderset; turnaround is 2-3 weeks Existing set: Labs (CBC, coags); CXR/CT; EKG/ECHO; Consults Could include standard medications (esp bowel prep, muscle relaxants[1]), physical therapy consult, antiemetics 1. Inge TH, Owings E, Blewett CJ, Baldwin CE, Cain WS, Hardin W, Georgeson KE. Reduced hospitalization cost for patients with pectus excavatum treated using minimally invasive surgery. Surg Endosc. 2003 Oct;17(10):1609-13.