Chest Wall Deformities


Welcome to the APSA Quality and Safety Committee Pectus toolkit. This toolkit is intended to help anyone who is interested in quality improvement on the management of chest wall deformities.

Available toolkit projects are listed below. Many of the approaches described are evidence-based - some are not. These approaches have not been approved by APSA.

Pectus Early Recovery after Surgery Pathway

In 2013, the Johns Hopkins All Children’s Hospital began the use of a standardized perioperative practice plan for patients undergoing minimally invasive repair of pectus excavatum (MIRPE) which has resulted in a decrease in resource utilization, narcotic use, and length of stay. The use of epidural anesthesia has been abandoned and replaced with a multimodal analgesic approach (see below).


ERAS pathway after MIRPE
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Pain medication protocol
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Stakeholders: surgeons, anesthesiologists, perioperative staff, patients/parents, administration, community

Challenges and solutions: The standardized perioperative practice plan required a collaborative effort amongst services (surgery, anesthesia) as well buy-in from perioperative services.

Published data: Enhancing recovery after minimally invasive repair of pectus excavatum [1]

Submitted by: Raquel Gonzalez

Additional implementers: Nicole Chandler

ERAS Pathway for Nuss, use of Gabapentin and Cryoablation

Johns Hopkins Children’s Center uses an early recovery after surgery (ERAS protocol) for the Nuss procedure which includes the use of gabapentin and multimodal analgesia. Implementation of ERAS for the Nuss procedure led to a significant reduction in length of stay, early pain scores and urinary catheter usage without an increase in post-operative emergency department visits and hospital readmissions. Moreover, cryoablation is being offered for more durable pain control and less need for postoperative narcotics.


Stakeholders: pectus excavatum patients, general pediatric surgeons/nurse practitioners, pediatric pain physicians/nurse practitioners

Challenges and solutions: Implementing ERAS protocol and medication regimen both pre and postsurgery due to many providers among the surgery and pain teams. Educating floor nursing regarding pain control and use of nonpharmacologic interventions. Family buy in regarding steps needed both pre and postsurgery. Held meetings with both general surgery and pain teams to go over protocol and wrote up a protocol to be distributed to team members. Distributed and sat down with floor nursing to explain pectus protocol. Talk to families over the phone and email counseling families and giving them realistic expectations regarding surgery and recovery from the Nuss procedure. Beyond the success of ERAS we sought to further minimize the need for opioid analgesia and decrease hospital length of stay. Other institutions have had success with intraoperative cryoablation of intercostal nerves T3 throughT8. This provides a more durable and predictable pattern of analgesia than surgeon administered intercostal nerve blocks. The biggest hurdle to making this part of our routine management of pectus excavatum has been processing the need for this product and obtaining approval from our value analysis committee. Anyone undertaking this should be prepared with a cost analysis and anticipated savings from the decreased length of stay and reduced opioid use.

Published data: Successful use of an enhanced recovery after surgery (ERAS) pathway to improve outcomes following the Nuss procedure for pectus excavatum[2]

Submitted by: Kristin Wharton

Additional implementers: Clint Cappiello, Alejandro Garcia, Joann Hunsberger, and Jessica George

Postoperative and Discharge Protocol

The Medical University of South Carolina uses the following standard discharge and postoperative care protocol for patients following pectus repair. There were reduced complications and length of stay following the implementation of a standard postoperative physical therapy, discharge criteria and follow-up care protocols.


Stakeholders: surgery, nursing, anesthesia, radiology, rehab/physical therapists

Submitted by: Rob Cina

Additional implementers: Jenny Waterhouse

Postoperative Pain Management

In 2018, the Chest Wall Program at Riley Hospital for Children implemented a multimodal postoperative pain control regimen coupled with a standardized postoperative management bundle for all patients who underwent surgical correction pectus excavatum by either Nuss or Ravitch procedure. The purpose of this program was to decrease narcotic use while providing equivalent or improved postoperative pain control.


Stakeholders: pediatric surgery, pediatric anesthesia, pediatric acute pain service, physical therapy

Challenges and solutions: Surgeon buy-in. Solutions were two-fold. The first was education. The second was seeing early successes with the use of the protocol (improved length of stay, equal or better daily pain control and decreased opioid use overall).

Abstract: Early results after the implementation of the multimodal analgesia protocol for pectus repair

Submitted by: Matt Landman

Recent Research

In addition to the references stated above, please feel free to refer to the additional publication pertaining to quality improvement initiatives in pectus excavatum patients [3].


  1. Litz CN, Farach SM, Fernandez AM, et al. Enhancing recovery after minimally invasive repair of pectus excavatum. Pediatr Surg Int. 2017;33(10):1123-1129.  [PMID:28852843]
  2. Wharton K, Chun Y, Hunsberger J, et al. Successful use of an enhanced recovery after surgery (ERAS) pathway to improve outcomes following the Nuss procedure for pectus excavatum. J Pediatr Surg. 2020;55(6):1065-1071.  [PMID:32197827]
  3. Zuidema WP, Oosterhuis JWA, van der Heide SM, et al. Early cost-utility estimation of the surgical correction of pectus excavatum with the Nuss bar. Eur J Cardiothorac Surg. 2019;55(4):699-703.  [PMID:30380039]
Last updated: March 22, 2021