Transcript Pectus Excavatum: The Kansas City Experience

Pectus Excavatum:
The Kansas City Experience
George W. Holcomb, III, M.D., M.B.A.
Surgeon-in-Chief
Children’s Mercy Hospital
Kansas City, MO
Pectus Excavatum
Jan 1998 – August 2011
• 520 Nuss Operations
• Surgeons: Ashcraft, Sharp, Ostlie,
Snyder, St. Peter, Holcomb
The Kansas City Experience
• Major variation in technique is the use of
a sub-xiphoid incision for insertion of a
finger to guide the bar passer and bar
across the mediastinum.
The Kansas City Experience
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The Kansas City Experience
• 520 Patients
• No cardiac injuries using the subxiphoid
incision
• I.V. narcotics (PCA) preferred over
epidural catheter for postoperative pain
control
The Kansas City Experience
December ‘99 – March ‘09
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307 Pts
Mean age 14 yrs – 78% males
Mean O.R. time – 50 ±16 minutes
Two bars – 16 (5%)
Mean length hospitalization 4.1 ± 1.1 days
Mean time bar removal 33 ± 7 months
J Pediatr Surg 45:1361-1364, 2010
The Kansas City Experience
307 Patients
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
J Pediatr Surg 45:1361-1364, 2010
The Kansas City Experience
Retrospective Study On Pain Management
Jan 2000 – Feb 2006
• 203 Pts
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188 epidural
15 I.V. narcotics (PCA)
• Epidural removed w/in 24 hours in 65 pts
(34.5%)
J Pediatr Surg 43:79-82, 2008
The Kansas City Experience
Retrospective Study On Pain Management
J Pediatr Surg 43:79-82, 2008
The Kansas City Experience
Prospective Randomized Trial On Pain
Management
Sept 2006 – May 2010
• Epidural catheter vs I.V. narcotics (PCA)
• Power 0.80; α 0.05
• 110 Pts (55 each arm)
• Epidural removed w/in 24 hrs – 12 pts (22%)
• PCA required after epidural removal in 7
patients (16%)
APSA 2011
Accepted, J Pediatr Surg
The Kansas City Experience
Operation Times – Epidural vs PCA
Epidural
PCA
P Value
53 ± 18
53 ± 16
0.92
1:58 ± :21
1:35 ± :20
< 0.001
Epidural
PCA
P Value
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 Time (Mins)
Total OR Time (Hrs:Mins)
Calls to Anesthesia
The Kansas City Experience
Hospital 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
QUESTIONS
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