Enhancing recovery after minimal invasive surgery of the pectus. A review of the literature

Abstract

Background: Pectus excavatum (PE) and pectus carinatum (PC) are the most frequent chest wall deformities presenting for a minimal invasive repair of pectus (MIRP). Enhanced recovery protocols (ERP) could improve postoperative recovery and reduce complications, however there is little uniformity in the management of patients undergoing MIRP. The aim of this review is to present an overview of the different ERPs. Our primary outcome is the effect of these ERPs on length of hospital stay (LOS), secondary outcomes include, but are not limited to, the effect on pain scores, urinary catheter requirement and duration, post-operative opioid usage and its side effects.

Method: Data were collected through a Pubmed/MEDLINE literature search. The main inclusion criterium for each study was the implementation of a clearly defined ERP consisting of a multimodal approach in a population requiring MIRP.

Results: In total six articles were included, each of them containing a cohort study population before and after implementing an ERP. All control groups were historical cohorts with data extracted from medical files, prior to implementation of an ERP. Thus, all articles were retrospective comparative cohort studies, with a level IV of evidence. Most studies suggest that the implementation of an ERP could reduce LOS and reduce the incidence of urinary catheter requirement and duration, without an increase in complications. A reduction in opioid usage and the incidence of its side effects and a reduction in pain scores could not be uniformly achieved.

Conclusion: There is promising evidence that implementing an ERP may improve short-term outcome in a young population undergoing minimal invasive repair of pectus. Large prospective multicentred trials are needed, using proper controls and implementing multiple aspects of the ERP (pre-, peri- and postoperatively).