Introduction: Conventional postoperative pain management, with an intravenous patient-controlled approach or thoracic epidural analgesia, has proved suboptimal following a minimally invasive repair of pectus excavatum (MIRPE). Considering its postulated mechanism of action, we encouraged cryoanalgesia as an effective method for post-repair pain management and a possibly superior alternative. Methods: A randomized, single-blind clinical trial was tested on patients undergoing PE repair in March and December 2022. Among 101 patients, consenting study participants were randomly assigned to one of two groups: cryoanalgesia (group C, n=24) or non-cryoanalgesia (group N, n=24). Group N received conventional pain management. Comparing the results, pain levels were measured using the Visual Analog Scale (VAS-R for resting and VAS-D for dynamic) and the total rescue analgesic consumption was determined. Intrathoracic cryoablation was performed bilaterally on the fourth and seventh intercostal nerves using a cryoprobe at -80°C for 2 min. Results: The two groups had similar baseline-patient characteristics however; group C had a longer mean operative time (159 min vs. 125 min, p<0.01) and experienced significantly less pain throughout the postoperative course, with VAS at 6 h (5.38 vs 7.04, p<0.01) and 48 h (3.17 vs. 5.67, p<0.01). Conclusion: Cryoanalgesia improved postoperative pain control at rest and during movement following PE repair. However, the outcome was less favorable than expected because, the VAS was greater than 4 (moderate pain), although after a day or two, it decreased to lower levels (VAS<4) in the cyro group. Considering its extra invasiveness and instrumentation, a routine cryoanalgesia procedure for pectus surgery is yet to be determined.
Background Pre-lifting of the sternum marked a major turning point in pectus excavatum repair. The author developed the crane technique in 2002 and successfully applied it to more than 2,000 cases using sternal wire stitching. However, blind sternal suturing limited the use of the wire-stitch crane. We propose a novel screw for sternal lifting as a new tool for the crane technique. Methods We developed a screw system strong enough to withstand the pressure needed for sternum lifting. The screw was designed to have a broader thread to hold the bony tissue securely. The screw’s sustaining power was tested using the torsion, driving torque, and axial pull-out tests in a polyurethane block and ex-vivo porcine sternum. Results The screws were easily driven into the sternum, and the head of the screw was connectable to the table-mounted retractor. In the torsion test, the 2° offset torsional yield was 4.53 N·m (reference value, 1 N·m). In the polyurethane block driving torque test, the maximum torque was 0.98 N·m (reference value, 0.70 N·m). The axial pull-out test was 446 N (reference value, 100 N). The maximum pull-out resistance in the ex-vivo porcine sternum model was 1,516 N. Conclusion The screw crane was strong enough to sustain the chest wall weight to be lifted. Thus, the screws could effectively replace the sternal wire stitching in crane pre-lifting of the sternum. We expect that application of the screw-crane will be easy and that it will improve the safety and success rate of pectus repair surgery.
Recurrent pectus excavatum (PE) after a Ravitch operation is not uncommon. Extensive costal cartilage resection from the previous Ravitch procedure can lead to an irregular, unstable chest wall depressions with a varying degree of deformity. The optimal approach to cover the chest wall defect and remodel the deformity, remains unknown. We report the case of a 27-year-old woman seeking surgery for the third time for recurrent PE. The patient presented with 2-time recurrent pectus excavatum following a failed Ravitch procedure and subsequent pectus bar repair. The entire chest wall reconstruction and remodeling entailed covering the chest wall defect with 2 titanium plates across both sides of the rib cage, and lifting and fixing the depressed chest wall with 2 parallel pectus bars.
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