1. 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

2. Pectus Excavatum Jan 1998 – August 2011 520 Nuss Operations520 Nuss Operations Surgeons: Ashcraft, Sharp, Ostlie, Snyder, St. Peter, HolcombSurgeons: Ashcraft, Sharp, Ostlie, Snyder, St. Peter, Holcomb

3. 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.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.

4. The Kansas City Experience Please use this link if you experience problems viewing the video above.this link

5. The Kansas City Experience 520 Patients520 Patients No cardiac injuries using the subxiphoid incisionNo cardiac injuries using the subxiphoid incision I.V. narcotics (PCA) preferred over epidural catheter for postoperative pain controlI.V. narcotics (PCA) preferred over epidural catheter for postoperative pain control

6. The Kansas City Experience December ‘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, 2010

7. The Kansas City Experience 307 Patients J Pediatr Surg 45:1361-1364, 2010 Infection13 pts (4.2%) Stabilizer discomfort/dislodgement requiring removal 5 pts (1.6%) Bar rotation4 pts (1.3%) PTX req. chest tube2 pts (0.6%) Recurrence requiring reoperation0 Cardiac injury0

8. The Kansas City Experience Retrospective Study On Pain Management Jan 2000 – Feb 2006 203 Pts203 Pts 188 epidural 188 epidural 15 I.V. narcotics (PCA) 15 I.V. narcotics (PCA) Epidural removed w/in 24 hours in 65 pts (34.5%)Epidural removed w/in 24 hours in 65 pts (34.5%) J Pediatr Surg 43:79-82, 2008

9. The Kansas City Experience Retrospective Study On Pain Management J Pediatr Surg 43:79-82, 2008

10. Prospective Randomized Trial On Pain Management Sept 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 patients (16%)PCA required after epidural removal in 7 patients (16%) APSA 2011 Accepted, J Pediatr Surg The Kansas City Experience

11. EpiduralPCAP Value Operation Time (Mins)53 ± 1853 ± 160.92 Total OR Time (Hrs:Mins)1:58 ± :211:35 ± :20< 0.001 EpiduralPCAP Value Calls to Anesthesia1.6 ± 2.00.4 ± 0.7< 0.001 Hrs to Foley Removal64.6 ± 14.552.3 ± 27.10.004 Hours to Regular Diet18.5 ± 14.219.9 ± 16.20.63 Hours to Oral Medications67.1 ± 21.260.8 ± 20.70.12 Post-operative Length of Stay (Days) 4.54 ± 1.014.25 ± 1.00.13 Operation Times – Epidural vs PCA

12. The Kansas City Experience Hospital Charges – Epidural vs PCA EpiduralPCAP 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

13. QUESTIONS www.cmhpectus.com www.cmhmis.com