Implementation of an enhanced recovery pathway for minimally invasive PECTUS surgery: a population-based cohort study evaluating short- and long-term outcomes using mobile health technology (Preprint)

BACKGROUND Pectus excavatum and pectus carinatum are the most common chest wall deformities. Although minimally invasive correction (MIPC) has become common practice, it remains associated with severe postoperative pain. Preoperative psychosocial factors such as anxiety and low self-esteem can increase postsurgical pain. Early detection of psychological symptoms, effective biopsychosocial perioperative management of patients and prevention of pain chronification using an enhanced recovery pathway (ERP) may improve outcomes. The incidence of the latter is poorly described in adolescents undergoing MIPC. OBJECTIVE To evaluate whether an ERP after surgery facilitated early recovery and to assess persistent postsurgical pain three months after surgery in pediatric patients undergoing MIPC using m-Health technology. METHODS A population-based cohort study was conducted with prospectively collected data from patients undergoing pectus surgery between June 2017 and December 2017. An ERP was initiated preoperatively and included patient education, eHealth-based psychological screening, multimodal preemptive analgesia, nausea prophylaxis as well as early Foley catheter removal and respiratory exercises. After hospital discharge, patients were assessed for up to ten weeks by evaluating pain and underwent rehabilitation using online diary and Bluetooth-connected telemonitoring devices. Retrospectively derived control patients in our hospital who were undergoing the same procedure without an ERP were matched by age (≤ 18 years). RESULTS Twenty-nine adolescents were enrolled using the developed ERP. Preemptive multimodal analgesia pain rating scores were low during hospital admission and were comparable between the groups. Optimal epidural placement occurred in 26 of the 29 participants (90%), hereby no motor block or Horner syndrome occurred. Bladder and epidural catheters were removed after 3.41 ± 1.50 and 5.76 ± 1.02 days, respectively. Low numeric pain rating scores (NRSs) and decreased incidence of nausea contributed to improved early rehabilitation. Telemonitoring at home was feasible in adolescents after hospital discharge despite adherence difficulties. Although pain scores at the final interview were low (0.81 ± 1.33), 9 out of 27 long-term follow up ERP patients (33%) still experienced frequent disturbing thoracic pain requiring analgesic administration, school absenteeism and multiple doctor (re)visits. CONCLUSIONS Allocating patients to the appropriate level of care preoperatively and immediately after surgery may improve long-term outcome variables. Using internet-based technologies and feasible, objective monitoring tools can help clinicians screen surgical patients for risk factors and initiate early treatment if necessary. Future research should focus on improving risk stratification and including a psychological assessment and evaluation of the effect of perioperative care pathways in children undergoing major surgery. CLINICALTRIAL ClinicalTrials.gov, NCT03100669, https://clinicaltrials.gov/ct2/show/NCT03100669