Pectus Excavatum:Pectus Excavatum:The Kansas City ExperienceThe Kansas City Experience

George W. Holcomb, III, M.D., M.B.A.George W. Holcomb, III, M.D., M.B.A.Surgeon-in-ChiefSurgeon-in-Chief

Children’s Mercy HospitalChildren’s Mercy HospitalKansas City, MOKansas City, MO

Pectus ExcavatumPectus ExcavatumJan 1998 – August 2011Jan 1998 – August 2011

• 520 Nuss Operations520 Nuss Operations

• Surgeons: Ashcraft, Sharp, Ostlie, Surgeons: Ashcraft, Sharp, Ostlie, Snyder, St. Peter, HolcombSnyder, St. Peter, Holcomb

The Kansas City ExperienceThe Kansas City Experience

• Major variation in technique is the use of Major variation in technique is the use of a sub-xiphoid incision for insertion of a a sub-xiphoid incision for insertion of a finger to guide the bar passer and bar finger to guide the bar passer and bar across the mediastinum.across the mediastinum.

The Kansas City ExperienceThe Kansas City Experience

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The Kansas City ExperienceThe Kansas City Experience

• 520 Patients520 Patients

• No cardiac injuries using the subxiphoid No cardiac injuries using the subxiphoid incisionincision

• I.V. narcotics (PCA) preferred over I.V. narcotics (PCA) preferred over epidural catheter for postoperative pain epidural catheter for postoperative pain controlcontrol

The Kansas City ExperienceThe Kansas City ExperienceDecember ‘99 – March ‘09December ‘99 – March ‘09

• 307 Pts307 Pts

• Mean age 14 yrs – 78% malesMean age 14 yrs – 78% males

• Mean O.R. time – 50 ±16 minutesMean O.R. time – 50 ±16 minutes

• Two bars – 16 (5%)Two bars – 16 (5%)

• Mean length hospitalization 4.1 ± 1.1 daysMean length hospitalization 4.1 ± 1.1 days

• Mean time bar removal 33 ± 7 monthsMean time bar removal 33 ± 7 months

J Pediatr Surg 45:1361-1364, 2010J Pediatr Surg 45:1361-1364, 2010

The Kansas City ExperienceThe Kansas City Experience307 Patients307 Patients

J Pediatr Surg 45:1361-1364, 2010J Pediatr Surg 45:1361-1364, 2010

Infection 13 pts (4.2%)

Stabilizer discomfort/dislodgement requiring removal

5 pts (1.6%)

Bar rotation 4 pts (1.3%)

PTX req. chest tube 2 pts (0.6%)

Recurrence requiring reoperation 0

Cardiac injury 0

The Kansas City ExperienceThe Kansas City ExperienceRetrospective Study On Pain ManagementRetrospective Study On Pain Management

Jan 2000 – Feb 2006Jan 2000 – Feb 2006

• 203 Pts203 Pts• 188 epidural188 epidural• 15 I.V. narcotics (PCA)15 I.V. narcotics (PCA)

• Epidural removed w/in 24 hours in 65 pts Epidural removed w/in 24 hours in 65 pts (34.5%)(34.5%)

J Pediatr Surg 43:79-82, 2008J Pediatr Surg 43:79-82, 2008

The Kansas City ExperienceThe Kansas City Experience Retrospective Study On Pain Management Retrospective Study On Pain Management

J Pediatr Surg 43:79-82, 2008J Pediatr Surg 43:79-82, 2008

Prospective Randomized Trial On Pain Prospective Randomized Trial On Pain ManagementManagement

Sept 2006 – May 2010Sept 2006 – May 2010• Epidural catheter vs I.V. narcotics (PCA)Epidural catheter vs I.V. narcotics (PCA)

• Power 0.80; α 0.05Power 0.80; α 0.05

• 110 Pts (55 each arm)110 Pts (55 each arm)

• Epidural removed w/in 24 hrs – 12 pts (22%)Epidural removed w/in 24 hrs – 12 pts (22%)

• PCA required after epidural removal in 7 PCA required after epidural removal in 7 patients (16%)patients (16%)

APSA 2011APSA 2011Accepted, J Pediatr SurgAccepted, J Pediatr Surg

The Kansas City ExperienceThe Kansas City Experience

The Kansas City ExperienceThe Kansas City Experience

Epidural PCA P Value

Operation Time (Mins) 53 ± 18 53 ± 16 0.92

Total OR Time (Hrs:Mins) 1:58 ± :21 1:35 ± :20 < 0.001

Epidural PCA P Value

Calls to Anesthesia 1.6 ± 2.0 0.4 ± 0.7 < 0.001

Hrs to Foley Removal 64.6 ± 14.5 52.3 ± 27.1 0.004

Hours to Regular Diet 18.5 ± 14.2 19.9 ± 16.2 0.63

Hours to Oral Medications 67.1 ± 21.2 60.8 ± 20.7 0.12

Post-operative Length of Stay (Days)

4.54 ± 1.01 4.25 ± 1.0 0.13

Operation Times – Epidural vs PCA

The Kansas City ExperienceThe Kansas City Experience

Hospital Charges – Epidural vs PCAHospital Charges – Epidural vs PCA

Epidural PCA P Value

Procedure Charges ($) $22.7K ± 3.0 K $19.3.6K ± < 0.001

Anesthesia Charges ($) $4.4K ± 0.8K $3.7K ± 0.5K < 0.001

Total Hospital Charges ($) $45.4K ± 7.3K $38.6K ± 6.7K < 0.001

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