Same Day Discharge for Repair of Pectus Excavatum

Background: Despite minimally invasive repair of pectus excavatum (MIRPE), patients have continued to struggle with postoperative pain control. Adequate pain management has strongly impacted length of stay in the majority of studies. Recent advances in placement of paravertebral blocks and cryoablation of intercostal nerves have led to dramatic improvements. We report on a multimodal regimen using combination bilateral single shot paravertebral blocks (single shot PVB), bilateral thoracoscopic intercostal nerve (T3-T7) cryoablation, and perioperative administration of Gabapentin, Miralax and Scopolamine.

Methods: We conducted an IRB-approved prospective comparative study of patients undergoing MIRPE at a single quaternary pediatric hospital during the period of October 2019 through Oct 2020. Patients underwent either bilateral paravertebral block with catheter (PVB-catheter) for continuous infusion (Group 1, n=12), bilateral PVB-catheter and right side cryoablation (Group 2, n=9), or bilateral single shot paravertebral block (single shot PVB) along with bilateral cryoablation (Group 3, n=17). This study compared the retrospective cohorts (Group 1 and Group 2) to the primary study group (Group 3). Primary outcome was length of stay (LOS) and secondary outcome was opioid usage. Opioids were converted to oral morphine milligram equivalents per kilogram. Significance of distributional differences between groups were assessed by Kruskal-Wallis test overall and Mann-Whitney U test for two group comparisons.

Results: Eleven out of seventeen patients (65 %) undergoing MIRPE with bilateral single shot PVB and bilateral cryoablation (Group 3) were able to be discharged on the evening of surgery. Figure 1 (LOS) showed Group 3 having diminished length of stay compared to those in Group 1(median 4.4 days vs 0.7 days, p<.001). Figure 2 (opioid use as oral morphine equivalents) showed significant decrease comparing Group 3 to Group 1 on day of surgery (median 49.2 mg with range from 39.9-78.8 vs 25 mg with range from 20-34, p=.006). Overall opioid use was substantially lower in Group 3 by using this multimodal regimen for pain management.

Conclusion: Pain control with modalities such as PCA or epidural are not ideal in isolation given the substantial improvement in pain management achieved through intercostal nerve cryoablation. The majority of patients (65%) in Group 3 were able to be discharged home on the evening of surgery. Of the six patients that were not able to go home on the same day as surgery, all were discharged the following day with no overnight complications or interventions. Same day discharge for pectus excavatum can be achieved safely and with significant patient benefit.