Decreasing length of stay for pectus excavatum repair by implementing an ERAS protocol

Enhanced recovery after surgery (ERAS) protocols are multi-disciplinary approaches aimed at expediting recovery while minimizing complications. Intercostal nerve cryoablation has markedly improved pain control during minimally invasive pectus excavatum repair (Nuss procedure). To further enhance recovery, we implemented an ERAS pathway focused on decreasing length of stay (LOS) from 3.0 to 1.4 days by the end of 2024 and maintaining for one year.

Stakeholder meetings determined the key components of patient education, pain management, intercostal nerve blocks with cryoablation, and post-operative physical therapy. All patients undergoing Nuss procedure were included. ERAS was initiated in March 2024. Patients were compared to pre-cryoablation cohorts prior to cryoablation use (2014-2020) and after cryoablation introduction but without other ERAS components (2018-2023). Balancing measures included 30-day complications and readmissions.

Ninety-seven patients were included: 33 in the pre-cryoablation cohort, 31 in the cryoablation-only group, and 33 in the ERAS group. When comparing the pre-cryoablation cohort, the cryoablation-only cohort, and the ERAS-cohort respectively, ERAS patients had significantly decreased operating time (hours) (2:17 vs. 2:47 vs. 1:35, p < 0.0001), opioid usage (MME/kg) (10.39 vs. 3.33 vs. 0.000, p < 0.0001), LOS (days) (4.39 vs. 3.00 vs. 1.17, p < 0.0001), and inpatient encounter charges ($64,961.06 vs. $59,071.10 vs. $46,839.45, p < 0.0001). ERAS initiation resulted in a center line shift for LOS beyond that seen after cryoablation introduction. No bar migrations and only one readmission occurred following implementation.

Implementation of a standardized ERAS protocol for pectus excavatum repair was associated with a significant decrease in LOS and opioid use without an increase in readmissions or bar migrations.