Postoperative Pain Outcomes After Nuss Procedures: Comparison of Epidural Analgesia, Continuous Infusion of Local Anesthetic, and Preoperative Self-Hypnosis Training.

BACKGROUND/PURPOSE: The Nuss procedure to correct pectus excavatum is associated with severe postoperative pain. The purpose of this retrospective study was to compare pain management outcomes of thoracic epidural analgesia and continuous infusion of local anesthetic (CILA) with and without preoperative self-hypnosis training (SHT) after Nuss procedure (4 treatment groups). METHODS: Between February 2010 and December 2013, 24 of 53 adolescents who underwent Nuss procedure received SHT. Of these, 16 received thoracic epidural analgesia and 8 received CILA postoperatively. Of the 29 patients who did not receive SHT, 19 received thoracic epidural analgesia and 10 received CILA. All patients received intravenous patient-controlled opioid analgesia and intravenous nonsteroidal anti-inflammatory drugs (IVNSAIDs) and then were transitioned to oral opioids and NSAIDs. Postoperative mean and maximum pain scores, opioid (morphine equivalents) use and side effects, and hospital length of stay (LOS) were compared between groups. RESULTS: Patients who received SHT reported lower mean (P = .0047) and maximum (P = .0028) pain scores and used less morphine equivalents/hour over time (P = .046) compared to patients who did not receive SHT. Patients who received thoracic epidural analgesia reported lower mean (P = .0092) and maximum (P = .0083) postoperative pain scores and used more morphine equivalents/hour (P = .01) compared to those who received CILA. In addition, patients who received SHT and CILA had shorter LOS (P = .0013) than patients who received thoracic epidural analgesia without SHT. CONCLUSIONS: SHT before pectus excavatum repair by Nuss procedure results in less postoperative pain and requires less morphine equivalents over time for postoperative pain management. Opioid-sparing CILA, when paired with SHT, results in shorter LOS.

National trends in the surgical management of Meckel's diverticulum.

BACKGROUND: Treatment recommendations for Meckel's diverticulum (MD) come mostly from single-institution case series. The objective of this study was to review the surgical management and outcomes of children undergoing Meckel's diverticulectomy using contemporary data from a national database. METHODS: We queried 2007 to 2008 data from the Pediatric Health Information System database and analyzed demographic and outcome variables for patients undergoing surgical resection of MD. Cases were classified as primary (symptomatic MD) or secondary (incidental MD). Outcomes in primary cases were compared between open and laparoscopic approaches. Statistical analyses were performed using SPSS (Chicago, IL). RESULTS: Eight hundred fifteen children underwent Meckel's diverticulectomy. Meckel's diverticulectomy was more common in boys (boy-girl, 2.3:1), and half (53%) of the children required surgery before their fourth birthday. More cases (n = 485; 60%) were classified as primary, and most children were approached by laparotomy (75%). The most common presentations for primary cases were obstruction (30%), bleeding (27%), and intussusception (19%). In the primary group, patients treated with the laparoscopic approach had a shorter length of stay (open approach, 5.7 ± 5.2 days; laparoscopic approach, 4.3 ± 2.7 days; P < .02). CONCLUSION: These data describe current trends in the surgical treatment of MD in the United States. Laparoscopic Meckel's diverticulectomy appears to shorten length of stay but is used much less frequently than the traditional open approach.

Pectus excavatum and carinatum: new concepts in the correction of congenital chest wall deformities in the pediatric age group.

A wide range of congenital chest wall deformities have been described over the years. The spectrum of severity may range from life threatening deformities such as cordis ectopia to those which pose functional limitations as growth and maturity approach adulthood. Until recently, pectus excavatum (PE) and carinatum(PC) malformations have generally been considered as primarily cosmetic abnormalities. "Open" surgical procedures to correct PE and PC involved extensive resection of cartilage and bone to remove the bony deformity often with lasting growth restriction of the chest wall. Minimally invasive surgery has recently been reported as an effective technique in correcting PE without removing healthy chest wall structures. Nonoperative bracing has been effectively applied to PC eliminating traditional surgical methods. This report presents the experience at the Connecticut Children's Medical Center (CCMC) in the treatment of these two common deformities using new, less invasive methods with excellent long-term results.