Anesthetic and Analgesic Management of Pediatric Patients for Staged Repeat Same-Day Surgery

Dermatofibrosarcoma protuberans (DFSP) is a rare dermatologic malignancy in children requiring a multidisciplinary approach for surgical excision and postoperative care. The modified "slow Mohs" repeat staged excision and the associated anesthetic technique are not well described in the pediatric literature.

We describe three pediatric patients whose staged excision procedures were completed using general anesthesia plus systemic multimodal analgesia (all patients), including tunneled epidural catheters (two patients with truncal tumors) or a scheduled long-acting opioid (one patient with a forehead lesion). Complete dermatologic excision and excellent surgical analgesia were achieved in all patients. Specific interventions to verify epidural catheter position and allow potential prolonged catheter use were of particular utility in perioperative management.

Children with DFSP present a unique challenge to provide optimal surgical and cosmetic results with serial staged Mohs excision while ensuring adequate ongoing analgesia. Close interdisciplinary communication and advance planning are essential. Multimodal analgesia, including tunneled epidural catheters if anatomically appropriate, or scheduled long-acting opioid, is a key component of successful management. Confirmation of epidural catheter position likely improves analgesic efficacy and reduces the need for catheter replacement. We suggest that the care of pediatric patients undergoing slow Mohs staged repeat excision is best undertaken in a tertiary care setting with adequate multidisciplinary subspecialist support.