Regional Anesthesia and Surgical Volume in Children Undergoing Nuss Repair: A Multicenter Review

Regional anesthetic approach and surgical volume have been shown to outcomes in patients undergoing Nuss procedure for pectus excavatum. However, their independent relationship is not described. We investigated how regional anesthesia and surgical volume are associated with length of stay (LOS), postoperative opioid use, operating room utilization, and complications.

This is a 9-center retrospective review of patients ≤21 ys after Nuss procedure for pectus excavatum (2016-2020). High-volume centers and surgeons defined as the upper-quartile for annual procedures. Outcomes were compared with mixed effects linear/logistic regression models with random intercepts by institution as appropriate. A single-center unadjusted analysis was performed of erector spinae catheter (ESC) utilization (due to nonuniform use; high-volume only at 1-center).

780 patients were included. Significant variation existed in anesthetic approach and volume. Cryoablation was independently associated with shorter LOS (-2.1 d; 95% confidence interval [CI]: -2.6,-1.7) and lower postoperative opioid utilization (-120 morphine milligram equivalents, 95% CI: -181, -58.1) but increased surgical time (+45 min; 95% CI: 30.3, 59.8). Individual surgeon volume was associated with decreased LOS (-0.3 d; 95% CI: -0.5, -0.01), though high-volume centers had increased complications (odds ratio 2.2; 95% CI: 1.1, 4.2). There was no association between anesthetic approach and surgical complications. Within the single center utilizing ESCs (n = 138), a shorter LOS (2 versus 3 d, P < 0.01) was observed compared to those not receiving an ESC (n = 19).

Analgesic approaches varied significantly across institutions and limited our ability to directly compare cryoablation and ESCs. On multivariate analysis, cryoablation was associated with decreased LOS and postoperative opioid use, irrespective of center and surgeon volume. ESCs were similarly associated with improved outcomes. Rigorous prospective comparison of ESCs and cryoablation is warranted.