title: Is epidural anesthesia truly the best pain management strategy after minimally invasive pectus excavatum repair?
abstract: OBJECTIVE
  The repair of pectus excavatum with bar placement is associated with substantial postoperative pain. Optimal pain control strategy has not been addressed with level 1 or substantial level 2 evidence. Many institutions operate under the assumption that a thoracic epidural offers the best pain control for these patients. Therefore, we conducted a retrospective evaluation to examine the validity of this assumption.
  
  
  METHODS
  A retrospective review of patients undergoing pectus excavatum repair with bar placement from January 2000 to February 2006 was conducted. The demographic variables collected included age, sex, weight, and Haller's index scores. Outcome variables included total operating room time, number of calls to the anesthesiologist, hours of urinary catheterization, hours until complete transition to oral pain medication, length of hospitalization, and maximum pain scores for each of the first 5 postoperative days.
  
  
  RESULTS
  There were a total of 203 patients, of which 188 had an epidural, compared with 15 with intravenous narcotic therapy. Of the 188 patients committed to an epidural, 65 had a failed attempt in the operating room or a dysfunctional catheter removed within 24 hours. Patients without an epidural had a shorter operating room time, less time of urinary catheterization, decreased time to complete transition to oral medication, and decreased length of hospitalization with lower maximum scores.
  
  
  CONCLUSIONS
  Our data challenge the assumption that routine epidural catheter placement on all patients undergoing pectus excavatum repair with bar placement offers the best pain management strategy. There is clearly a role for a prospective randomized trial to clarify the best management for these patients.
authors.affiliation: Department of Surgery, The Children's Mercy Hospital, Kansas City, MO 64108, USA. sspeter@cmh.edu
authors.forename: Shawn D
authors.initials: SD
authors.lastname: St Peter
authors.forename: Kathryn A
authors.initials: KA
authors.lastname: Weesner
authors.forename: Ronald J
authors.initials: RJ
authors.lastname: Sharp
authors.forename: Susan W
authors.initials: SW
authors.lastname: Sharp
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Ostlie
authors.forename: George W
authors.initials: GW
authors.lastname: Holcomb
mesh_terms: D000293:Adolescent; D000767:Anesthesia, Epidural / Q000379:methods*; D000771:Anesthesia, Intravenous / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D005660:Funnel Chest / Q000175:diagnosis / Q000601:surgery*; D006801:Humans; D007902:Length of Stay; D008297:Male; D019060:Minimally Invasive Surgical Procedures / Q000379:methods; D010147:Pain Measurement; D010149:Postoperative Pain / Q000188:drug therapy* / Q000503:physiopathology; D017060:Patient Satisfaction; D011336:Probability; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D013906:Thoracoscopy / Q000379:methods; D013997:Time Factors; D016896:Treatment Outcome