A Randomized Controlled Trial of Cryoanalgesia for Pain Management following Pectus Excavatum Repair: A Single-Center, Single-Blind, Parallel Design Study

Abstract

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.

Serratus Anterior Plane Block: A Better Modality of Pain Control after Pectus Excavatum Repair

“…Cryoanalgesia has been the subject of recent investigation at numerous facilities due to its superior efficacy and reduced hospital stay when compared to traditional pain management techniques [ 9 - 11 ]. However, it necessitates single-lung ventilation via double-lumen intubation, video-assisted intrathoracic procedures, and the use of additional cryoequipment, all of which are invasive and increase both time and cost [ 11 ]. In contrast, our SAPB procedures are moderately timed, averaging about 17 minutes, and do not require one-lung ventilation or thoracoscopy.…”

“…Patients were positioned supine, with both arms freely suspended in overhead slings to avoid arm stretching. Bilateral chest wall incisions were made at the mid-axillary line, each approximately 1 cm in length, to accommodate the insertion of a pectus bar [ 11 ].…”

“…The catheters were typically removed 2 to 3 days after surgery. Further details regarding our pain management protocol, which includes general anesthesia, IV-PCA, subcutaneous local anesthetic infusion, and postoperative analgesics, are documented in a previous publication [ 11 ].…”

“…Recent studies have shown that cryoanalgesia enhances postoperative pain management after PE repair compared to traditional methods [ 9 - 11 ]. However, the application of cryoanalgesia necessitates a thoracoscopic approach, single-lung ventilation, and additional instrumentation, factors that restrict its widespread adoption following PE repair [ 11 ].…”

Serratus anterior plane block for acute pain management after pectus excavatum repair

“…Cryoanalgesia has recently gained popularity owing to its superior pain control outcomes compared to those associated with conventional methods ( 10 – 12 ). However, cryoanalgesia requires a thoracoscopic approach, single-lung ventilation, intrathoracic procedures, and additional instrumentation, which are invasive and require more time and cost ( 13 ). As a better alternative, we adopted serratus anterior (SA) plane block (SAPB), a technique involving local anesthetic infusion through an extrathoracic catheter ( 14 , 15 ).…”