Six Years of Quality Improvement in Pectus Excavatum Repair: Implementation of Intercostal Nerve Cryoablation and ERAS Protocols for Patients Undergoing Nuss Procedure

• Published in: Journal of pediatric surgery p. 161634
• Main Authors: Rook, Jordan M., Lee, Lisa K., Wagner, Justin P., Sullins, Veronica F., Lee, Steven L., Shekherdimian, Shant, DeUgarte, Daniel A., Dichter, Christine E., Jen, Howard C.
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 20.07.2024
• Subjects: Cryoablation; ERAS; Methadone; Nuss procedure; Pectus excavatum; LOS; OR; PACU; Pectus excavatum; POD1; Cryoablation; MMEs; Methadone; Nuss procedure; ERAS
• ISSN: 0022-3468; 1531-5037; 1531-5037
• DOI: 10.1016/j.jpedsurg.2024.07.019

The Nuss procedure for pectus excavatum is associated with prolonged hospitalizations due to pain. We evaluated implementation of intercostal nerve cryoablation and enhanced recovery after surgery (ERAS) protocols on outcomes of Nuss procedures performed over six years at a single institution. This retrospective cohort study included patients who underwent Nuss procedure from 10/2017 to 09/2023. Patients received epidurals prior to 06/2019, cryoablation from 06/2019 to 07/2021, and ERAS with cryoablation and intraoperative methadone administration after 07/2021. We used multivariable linear regression to evaluate length of stay (LOS), inpatient morphine milligram equivalents (MMEs), and discharge opioids. We assessed the balancing measures of operative time, postoperative pain scores, and complications. We identified 62 patients; 15 who received epidurals, 18 cryoablation, and 29 cryoablation with ERAS. Cryoablation was associated with a 62.3% (p < 0.001) decrease in length of stay, an 86.6% (p < 0.001) decrease in inpatient MMEs, and a 72.9% (p < 0.001) decrease in discharge opioids. Cryoablation was additionally associated with 24.5% (p = 0.02) longer operative times and 46.4% (p = 0.04) higher postoperative day one pain scores. Subsequent implementation of an ERAS protocol was associated with a further 82.8% (p = 0.04) decrease in discharge opioids and a 25.0% (p = 0.04) decrease in postoperative day one pain scores. Over six years of quality improvement efforts, we found the implementation of cryoablation and ERAS protocols to be associated with a significant decrease in length of stay and opioid exposures. Protocolized pain management and cryoablation may work synergistically to improve outcomes without compromising patient experience. Level III – Retrospective comparative study. •It is unknown whether patients receiving cryoablation for the Nuss procedure derive additional benefit from ERAS protocols.•ERAS and cryoablation protocols were associated with decreased length of stay and opioid exposures without negatively impacting patient experience.