Talk Description
Introduction
Pectus excavatum is characterised by the inward growth of the ribs and sternum, resulting in chest indentation. This anatomical variation can negatively impact on the individual’s social, psychological and functional status. Corrective surgery can be performed by inserting metal bar(s) behind the chest wall. Originally described in children, increasingly this surgery is being performed in adults where it carries a different burden of morbidity. This quality assurance audit retrospectively analysed the Royal Melbourne Hospital (RMH) patient cohort to assess if outcomes and standard of care provided is equivalent to other centres providing this intervention for people over the age of sixteen. This data can then guide development of a structured clinical care pathway for pectus excavatum procedures.
Pectus excavatum is characterised by the inward growth of the ribs and sternum, resulting in chest indentation. This anatomical variation can negatively impact on the individual’s social, psychological and functional status. Corrective surgery can be performed by inserting metal bar(s) behind the chest wall. Originally described in children, increasingly this surgery is being performed in adults where it carries a different burden of morbidity. This quality assurance audit retrospectively analysed the Royal Melbourne Hospital (RMH) patient cohort to assess if outcomes and standard of care provided is equivalent to other centres providing this intervention for people over the age of sixteen. This data can then guide development of a structured clinical care pathway for pectus excavatum procedures.
Methods:
Prospective ethics approval was sought from the RMH Human Research Ethics Committee (approval- QA2023063). Following ethics approval, an application was made to the clinical coding team to identify patients who have had Nuss Bar(s) inserted or removed at RMH from 2014 to 2023. Individual patient data was retrieved from the electronic medical record to analyse demographics, indications, perioperative management and postoperative outcomes. Comparisons were then made to internationally published data and research.
Results
57 patients underwent pectus excavatum procedures from April 2014 to September 2023, including 39 insertions, 1 revision and 17 removals. Indications for insertion were multifactorial with progression of deformity, cosmesis or psychological impacts present in ~60% of patients. Intraoperative analgesia was universally multimodal with moderate opioid use and frequent usage of advanced pain management strategies including ketamine, clonidine, dexmedetomidine and lignocaine. Only 13% of patients received regional techniques. Multimodal approaches continued postoperatively with frequent usage of PCAs (94%), ketamine infusions (80%) and gabapentinoids (81%). Despite this, poorly controlled pain occurred in 80% of patients and chronic pain was identified in 37.5% of patients asked. 55% of chronic pain patients were referred to pain management services.
57 patients underwent pectus excavatum procedures from April 2014 to September 2023, including 39 insertions, 1 revision and 17 removals. Indications for insertion were multifactorial with progression of deformity, cosmesis or psychological impacts present in ~60% of patients. Intraoperative analgesia was universally multimodal with moderate opioid use and frequent usage of advanced pain management strategies including ketamine, clonidine, dexmedetomidine and lignocaine. Only 13% of patients received regional techniques. Multimodal approaches continued postoperatively with frequent usage of PCAs (94%), ketamine infusions (80%) and gabapentinoids (81%). Despite this, poorly controlled pain occurred in 80% of patients and chronic pain was identified in 37.5% of patients asked. 55% of chronic pain patients were referred to pain management services.
Discussion [1,2]
When comparing demographic data, average age (26) and male to female ratios (4:1) were similar between the RMH and international cohorts. Indications for procedures were similarly multifactorial with psychosocial influences common. The impact of COVID on elective operating resulted in the average length of bar insertion in the RMH cohort being longer than international cohorts. Perioperatively, operative duration, mean length of stay and rates of acute and chronic pain were comparable to international data. High rates of acute postoperative and chronic pain in local and international data require consideration of approaches beyond currently utilised multimodal analgesia. There is currently inadequate interrogation to identify long term complications and dissatisfaction, limiting the ability to intervene with these patients.
When comparing demographic data, average age (26) and male to female ratios (4:1) were similar between the RMH and international cohorts. Indications for procedures were similarly multifactorial with psychosocial influences common. The impact of COVID on elective operating resulted in the average length of bar insertion in the RMH cohort being longer than international cohorts. Perioperatively, operative duration, mean length of stay and rates of acute and chronic pain were comparable to international data. High rates of acute postoperative and chronic pain in local and international data require consideration of approaches beyond currently utilised multimodal analgesia. There is currently inadequate interrogation to identify long term complications and dissatisfaction, limiting the ability to intervene with these patients.
Conclusion
When comparing the 2014 to 2023 RMH cohort of pectus excavatum patients to international cohorts, the demographics, standard of care and data considering patient and institutional centred outcomes remain similar. High rates of acute postoperative and persistent pain require an ongoing multimodal, multidisciplinary approach to reduce any long-term sequelae. Further detailed assessment is required to identify the functional impacts of this pain and influence on overall satisfaction. With a rising number of patients proceeding for pectus excavatum surgery, this data will support introduction of a clinical pathway designed to improve patient outcomes.
When comparing the 2014 to 2023 RMH cohort of pectus excavatum patients to international cohorts, the demographics, standard of care and data considering patient and institutional centred outcomes remain similar. High rates of acute postoperative and persistent pain require an ongoing multimodal, multidisciplinary approach to reduce any long-term sequelae. Further detailed assessment is required to identify the functional impacts of this pain and influence on overall satisfaction. With a rising number of patients proceeding for pectus excavatum surgery, this data will support introduction of a clinical pathway designed to improve patient outcomes.
No conflicts of interest.
References:
1. Hanna WC, Ko MA, Blitz M, Shargall Y, Compeau CG. Thoracoscopic Nuss procedure for young adults with pectus excavatum: excellent midterm results and patient satisfaction. The Annals of Thoracic Surgery. 2013 Sep 1;96(3):1033-8.
1. Hanna WC, Ko MA, Blitz M, Shargall Y, Compeau CG. Thoracoscopic Nuss procedure for young adults with pectus excavatum: excellent midterm results and patient satisfaction. The Annals of Thoracic Surgery. 2013 Sep 1;96(3):1033-8.
2. Ewais MM, Chaparala S, Uhl R, Jaroszewski DE. Outcomes in adult pectus excavatum patients undergoing Nuss repair. Patient Related Outcome Measures. 2018 Jan 30:65-90.