Implementation of an Enhanced Recovery Pathway for Minimally Invasive Pectus Surgery: A Population-Based Cohort Study Evaluating Short- and Long-Term Outcomes Using eHealth Technology

Abstract

Background Pectus excavatum and pectus carinatum are the most common chest wall deformities. Although minimally invasive correction (minimally invasive repair of pectus, MIRP) 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. However, the incidence of the latter is poorly described in adolescents undergoing MIRP. Objective The objective of our study was to evaluate the implementation of an ERP containing early recovery goals and to assess persistent postsurgical pain 3 months postoperatively in pediatric patients undergoing MIRP. The ERP consists of a Web-based platform containing psychological screening questionnaires and extensive telemonitoring for follow-up of patients at home. 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; it included patient education, electronic health-based psychological screening, multimodal pre-emptive analgesia, nausea prophylaxis as well as early Foley catheter removal and respiratory exercises. After hospital discharge, patients were followed up to 10 weeks using a Web-based diary evaluating pain and sleep quality, while their rehabilitation progress was monitored via Bluetooth-connected telemonitoring devices. Results We enrolled 29 adolescents using the developed ERP. Pre-emptive multimodal analgesia pain rating scores were low at hospital admission. Optimal epidural placement, defined by T8-9 or T9-10, occurred in 90% (26/29) of the participants; thus, no motor block or Horner syndrome occurred. Mean bladder catheterization duration was 3.41 (SD 1.50) days in ERP patients. Numeric rating scale (NRS) scores for pain and the incidence of nausea were low, contributing to a fluent rehabilitation. Mean NRS scores were 2.58 (SD 1.77) on postoperative day (POD) 1, 2.48 (SD 1.66) on POD 2, and 3.14 (SD 1.98) on POD 3 in ERP-treated patients. Telemonitoring at home was feasible in adolescents after hospital discharge despite adherence difficulties. Although the pain scores at the final interview were low (0.81 [SD 1.33]), 33% (9/27) long-term follow-up ERP patients 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 postoperatively may improve long-term outcome variables. Internet-based technologies and feasible, objective monitoring tools can help clinicians screen surgical patients for ri...

Motivational Design Techniques to Increase Adherence to a Telemonitoring Therapy A Study with Adolescent Pectus Patients

“…The full medical procedure, that contextualizes this study, is described in [1] and follows Werner and Kongsgaard's [52] working definition. Pectus patients were followed up by the multidisciplinary pain center for maladaptive coping strategies and pain-rehabilitation interference using their individual Appi@Home platform 1 , a web-based diary evaluating pain and sleep quality app.…”

“…Hence, eight pectus patients, aged 13-18 years (M = 15.3, SD = 1.7) completed the study. As pectus excavatum affects four times more males than females [1] and pectus carinatum has an even more pronounced male predominance [2], we only had one female participant. In all but one interview, there was always a parent present.…”

“…Funnel chest, a condition with a sunken appearance of the sternum, or pectus excavatum, occurs in one out of 400-1000 live births and is the most common chest wall deformity with an 80% to 90% incidence rate [1]. Pigeon chest, a raised appearance of the sternum, or pectus carinatum, is the second most common anterior chest deformity (15%) [2].…”

“…However, "[d]espite the increased scientific interest in pain management after pectus surgery [6], [7], the provision of adequate pain management and the necessary antiemetic and psychological treatments during the whole perioperative period remain a challenge for health care providers." [1] Both preoperative psychological screening and long-term postoperative patient follow-up are needed.…”

A Smarter Health through the Internet of Surgical Things

“…Within the surgical patient subgroup, there have been a few clinical studies looking into the applicability of telemonitoring, usually in the postoperative period [3,[65][66][67][68][69][70][71][72][73][74][75][76][77][78][79][80] (Supplemental Table S3). Patients enrolled in an at-home monitoring program after chest wall surgery were also monitored effectively by utilizing the Internet to input certain parameters in an online platform [65,67] Cardiac surgery patients were also studied in an IoST rehabilitation program that included wearable biomedical and motion tracking sensors [68]. The physician was therefore able to monitor the patients' activity levels and their performance in rehabilitation exercises.…”