Skip to main content

Advertisement

Log in

The impact of an enhanced recovery perioperative pathway for pediatric pectus deformity repair

  • Original Article
  • Published:
Pediatric Surgery International Aims and scope Submit manuscript

Abstract

Purpose

Pediatric repair of chest wall deformities is associated with significant pain, morbidity, and resource utilization. We sought to determine outcomes of a perioperative enhanced recovery after surgery (ERAS) pathway for patients undergoing minimally invasive (Nuss) and traditional (Ravitch) corrective procedures.

Methods

Our ERAS protocol was implemented in 2015. We performed a retrospective review of patients for Nuss or Ravitch procedures before and after ERAS implementation. Combined and procedure segregated bivariate analyses were conducted on postoperative outcomes and resource utilization.

Results

There are 17 patients in the pre-intervention group (Nuss = 13 and Ravitch = 4) compared to 38 patients in the post-intervention group (Nuss = 28 and Ravitch = 10). Protocol implementation increased utilization of pre-operative non-narcotic medication. The combined and Nuss post-intervention groups had a significant decrease in epidural duration and time to enteral medications, but had increased total postoperative opioid usage. The Ravitch post-intervention group had a significant decrease in intra-operative narcotics and discharge pain scores. There were no differences in length of stay or complications.

Conclusion

Implementation of our ERAS protocol standardized pectus perioperative care, but did not improve postoperative opioid usage, complications, or resource utilization. Alterations in the protocol may lead to achieving desired goals of better pain management and decreased resource utilization.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Obermeyer RJ, Goretsky MJ (2012) Chest wall deformities in pediatric surgery. Surg Clin N Am 92:669–684. https://doi.org/10.1016/j.suc.2012.03.001(ix)

    Article  PubMed  Google Scholar 

  2. Cameron JL, Cameron AM, Martin L, Hackam D (2016) Congenital chest wall deformities. Current surgical therapy, 12th edn. Elsevier, Amsterdam, pp 891–898

    Google Scholar 

  3. Davis JT, Weinstein S (2004) Repair of the pectus deformity: results of the Ravitch approach in the current era. Ann Thorac Surg 78:421–426. https://doi.org/10.1016/j.athoracsur.2004.03.011

    Article  PubMed  Google Scholar 

  4. Funk JF, Gross C, Placzek R (2011) Patient satisfaction and clinical results 10 years after modified open thoracoplasty for pectus deformities. Langenbecks Arch Surg 396:1213–1220. https://doi.org/10.1007/s00423-011-0827-2

    Article  PubMed  Google Scholar 

  5. Fonkalsrud EW, Mendoza J (2006) Open repair of pectus excavatum and carinatum deformities with minimal cartilage resection. Am J Surg 191:779–784. https://doi.org/10.1016/j.amjsurg.2005.12.012

    Article  PubMed  Google Scholar 

  6. Dekonenko C, Dorman RM, Duran Y et al (2019) Postoperative pain control modalities for pectus excavatum repair: a prospective observational study of cryoablation compared to results of a randomized trial of epidural vs patient-controlled analgesia. J Pediatr Surg. https://doi.org/10.1016/j.jpedsurg.2019.09.021

    Article  PubMed  Google Scholar 

  7. Graves CE, Moyer J, Zobel MJ et al (2019) Intraoperative intercostal nerve cryoablation during the Nuss procedure reduces length of stay and opioid requirement: a randomized clinical trial. J Pediatr Surg. https://doi.org/10.1016/j.jpedsurg.2019.02.057

    Article  PubMed  Google Scholar 

  8. Mao YZ, Tang S, Li S (2017) Comparison of the Nuss versus Ravitch procedure for pectus excavatum repair: an updated meta-analysis. J Pediatr Surg 52:1545–1552. https://doi.org/10.1016/j.jpedsurg.2017.05.028

    Article  PubMed  Google Scholar 

  9. Holmes DM, Polites SF, Roskos PL, Moir CR (2019) Opioid use and length of stay following minimally invasive pectus excavatum repair in 436 patients—benefits of an enhanced recovery pathway. J Pediatr Surg. https://doi.org/10.1016/j.jpedsurg.2019.02.007

    Article  PubMed  Google Scholar 

  10. Papic JC, Finnell SME, Howenstein AM et al (2014) Postoperative opioid analgesic use after Nuss versus Ravitch pectus excavatum repair. J Pediatr Surg 49:919–923. https://doi.org/10.1016/j.jpedsurg.2014.01.025(discussion 923)

    Article  PubMed  Google Scholar 

  11. St Peter SD, Weesner KA, Weissend EE et al (2012) Epidural vs patient-controlled analgesia for postoperative pain after pectus excavatum repair: a prospective, randomized trial. J Pediatr Surg 47:148–153. https://doi.org/10.1016/j.jpedsurg.2011.10.040

    Article  PubMed  Google Scholar 

  12. Archer V, Robinson T, Kattail D et al (2020) Postoperative pain control following minimally invasive correction of pectus excavatum in pediatric patients: a systematic review. J Pediatr Surg. https://doi.org/10.1016/j.jpedsurg.2020.01.023

    Article  PubMed  Google Scholar 

  13. Leeds IL, Boss EF, George JA et al (2016) Preparing enhanced recovery after surgery for implementation in pediatric populations. J Pediatr Surg 51:2126–2129. https://doi.org/10.1016/j.jpedsurg.2016.08.029

    Article  PubMed  PubMed Central  Google Scholar 

  14. Shinnick JK, Short HL, Heiss KF et al (2016) Enhancing recovery in pediatric surgery: a review of the literature. J Surg Res 202:165–176. https://doi.org/10.1016/j.jss.2015.12.051

    Article  PubMed  Google Scholar 

  15. Varadhan KK, Neal KR, Dejong CHC et al (2010) The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: a meta-analysis of randomized controlled trials. Clin Nutr 29:434–440. https://doi.org/10.1016/j.clnu.2010.01.004

    Article  PubMed  Google Scholar 

  16. Brindle ME, Heiss K, Scott MJ et al (2019) Embracing change: the era for pediatric ERAS is here. Pediatr Surg Int 35:631–634. https://doi.org/10.1007/s00383-019-04476-3

    Article  PubMed  Google Scholar 

  17. Litz CN, Farach SM, Fernandez AM et al (2017) Enhancing recovery after minimally invasive repair of pectus excavatum. Pediatr Surg Int 33:1123–1129. https://doi.org/10.1007/s00383-017-4148-6

    Article  PubMed  Google Scholar 

  18. Wharton K, Chun Y, Hunsberger J et al (2020) Successful use of an enhanced recovery after surgery (ERAS) pathway to improve outcomes following the Nuss procedure for pectus excavatum. J Pediatr Surg. https://doi.org/10.1016/j.jpedsurg.2020.02.049

    Article  PubMed  Google Scholar 

  19. Singhal NR, Jones J, Semenova J et al (2016) Multimodal anesthesia with the addition of methadone is superior to epidural analgesia: a retrospective comparison of intraoperative anesthetic techniques and pain management for 124 pediatric patients undergoing the Nuss procedure. J Pediatr Surg 51:612–616. https://doi.org/10.1016/j.jpedsurg.2015.10.084

    Article  PubMed  Google Scholar 

  20. Health Quality Ontario (2004) Bispectral index monitor: an evidence-based analysis. Ont Health Technol Assess Ser 4:1–70

    Google Scholar 

  21. Fonkalsrud EW, Beanes S, Hebra A et al (2002) Comparison of minimally invasive and modified Ravitch pectus excavatum repair. J Pediatr Surg 37:413–417. https://doi.org/10.1053/jpsu.2002.30852

    Article  PubMed  Google Scholar 

  22. Lam MWC, Klassen AF, Montgomery CJ et al (2008) Quality-of-life outcomes after surgical correction of pectus excavatum: a comparison of the Ravitch and Nuss procedures. J Pediatr Surg 43:819–825. https://doi.org/10.1016/j.jpedsurg.2007.12.020

    Article  PubMed  Google Scholar 

  23. Stroud AM, Tulanont DD, Coates TE et al (2014) Epidural analgesia versus intravenous patient-controlled analgesia following minimally invasive pectus excavatum repair: a systematic review and meta-analysis. J Pediatr Surg 49:798–806. https://doi.org/10.1016/j.jpedsurg.2014.02.072

    Article  PubMed  PubMed Central  Google Scholar 

  24. Schlatter MG, Nguyen LV, Tecos M et al (2018) Progressive reduction of hospital length of stay following minimally invasive repair of pectus excavatum: a retrospective comparison of three analgesia modalities, the role of addressing patient anxiety, and reframing patient expectations. J Pediatr Surg 54:663–669. https://doi.org/10.1016/j.jpedsurg.2018.12.003

    Article  PubMed  Google Scholar 

  25. Loftus PD, Elder CT, Russell KW et al (2016) Paravertebral regional blocks decrease length of stay following surgery for pectus excavatum in children. J Pediatr Surg 51:149–153. https://doi.org/10.1016/j.jpedsurg.2015.10.037

    Article  PubMed  Google Scholar 

  26. Apelt N, Schaffzin J, Bates C et al (2017) Surgical site infection related to use of elastomeric pumps in pectus excavatum repair. Lessons learned from root cause analysis. J Pediatr Surg 52:1292–1295. https://doi.org/10.1016/j.jpedsurg.2017.01.002

    Article  PubMed  Google Scholar 

  27. Muhly WT, Beltran RJ, Bielsky A et al (2018) Perioperative management and in-hospital outcomes after minimally invasive repair of pectus excavatum: a multicenter registry report from the society for pediatric anesthesia improvement network. Anesth Analg. https://doi.org/10.1213/ANE.0000000000003829

    Article  Google Scholar 

  28. Cadaval Gallardo C, Martínez J, Bellía-Munzon G et al (2020) Thoracoscopic cryoanalgesia: a new strategy for postoperative pain control in minimally invasive pectus excavatum repair. Cir Pediatr 33:11–15

    CAS  PubMed  Google Scholar 

  29. Pilkington M, Harbaugh CM, Hirschl RB et al (2019) Use of cryoanalgesia for pain management for the modified ravitch procedure in children. J Pediatr Surg. https://doi.org/10.1016/j.jpedsurg.2019.09.016

    Article  PubMed  Google Scholar 

  30. Harbaugh CM, Lee JS, Hu HM et al (2018) Persistent opioid use among pediatric patients after surgery. Pediatrics. https://doi.org/10.1542/peds.2017-2439

    Article  PubMed  Google Scholar 

  31. Zobel MJ, Ewbank C, Mora R et al (2020) The incidence of neuropathic pain after intercostal cryoablation during the Nuss procedure. Pediatr Surg Int 36:317–324. https://doi.org/10.1007/s00383-019-04602-1

    Article  PubMed  Google Scholar 

  32. Harbaugh CM, Johnson KN, Kein CE et al (2018) Comparing outcomes with thoracic epidural and intercostal nerve cryoablation after Nuss procedure. J Surg Res 231:217–223. https://doi.org/10.1016/j.jss.2018.05.048

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

We would like to thank Dr. Paula D. Strassle for her guidance and assistance with the statistical review of our data.

Funding

No funding was allocated for this study.

Author information

Authors and Affiliations

Authors

Contributions

All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by SM, LH, and SEM. The first draft of the manuscript was written by SM and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Sean E. Mclean.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethics approval

This retrospective chart review study involving human participants was in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The Human Investigation Committee (IRB) of University of North Carolina approved this study.

Informed consent

Consent for this study was not required as all patient data were deidentified prior to analysis and submission.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 24 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Mangat, S., Hance, L., Ricketts, K.J. et al. The impact of an enhanced recovery perioperative pathway for pediatric pectus deformity repair. Pediatr Surg Int 36, 1035–1045 (2020). https://doi.org/10.1007/s00383-020-04695-z

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00383-020-04695-z

Keywords

Navigation