Impact of Cryoablation on Pectus Excavatum Repair in Pediatric Patients

Abstract

BACKGROUND: Minimally invasive repair of pectus excavatum (MIRPE) involves placement of a transthoracic, retrosternal support bar under thoracoscopic guidance. Despite its minimally invasive technical approach, postoperative pain is a significant morbidity that often results in increased length of stay. Multi-modal pain control strategies have been used in the past with limited success. Recently, the use of intraoperative intercostal nerve cryoablation (CA) has been added. In the present study, we aim to evaluate the effects of CA on postoperative pain control, opioid requirements, and perioperative outcomes. STUDY DESIGN: A single-center, retrospective chart review of all patients (less than 18 years old) who underwent MIRPE from 2009 to 2020 was performed. CA was started in June 2018. Data collection included demographics, preoperative characteristics, intraoperative findings, and postoperative outcomes. We hypothesized that CA would be associated with improved pain scores, lower doses of total inpatient opioid requirement, and shorter length of stay (LOS). RESULTS: One hundred sixty-one patients met inclusion criteria: 75 underwent intraoperative CA and 86 underwent MIRPE without CA (NCA group). CA significantly decreased median LOS from 4 days in NCA to 2 days; the use of CA was the only significant predictor of LOS on linear regression. CA was also associated with decreased total PCA, intravenous opioid, and oral opioid dosages. There was no difference in inpatient pain scores and a slight increase in mean procedure time. However, CA was associated with significantly decreased postoperative complications. CONCLUSIONS: The use of cryoablation during MIRPE significantly decreases LOS, perioperative opioid requirements, and postoperative complications, with a minimal increase in operative time. Cryoablation is an effective pain control modality in the surgical management of chest wall deformities in children.

Ultrasound-Guided Percutaneous Cryoanalgesia for Pectus Excavatum: When Should It be Applied?

“…8 Several studies based on the application of thoracoscopic cryoanalgesia in MIRPE conclude a shorter hospital stay, reduced opioid consumption, and less pain compared with conventional techniques. 3,[9][10][11][12][17][18][19][20] As already described in the literature, the effect of cryoanalgesia can vary between 6 and 48 hours after application. In 2021, we conducted a study comparing patients in whom PCr was applied on the same day of PE surgery and those in whom it was applied 48 hours before surgery.…”

Pediatric regional anesthesiology: a narrative review and update on outcome-based advances

“…Because demyelination is a time-dependent process, cryoablation is often combined with another immediate-acting analgesic technique, such as LA nerve blocks 91–93 . Core neural structures (epineurium, perineurium, and endoneurium) are left intact, and over time, reinnervation of the nerve through axonal regeneration occurs 93,94 . The time required for recovery is proportional to the cryoablation exposure time, 93 and recent studies suggest that reinnervation may occur more rapidly in younger patients than in adults 95 .…”

“…The time required for recovery is proportional to the cryoablation exposure time, 93 and recent studies suggest that reinnervation may occur more rapidly in younger patients than in adults 95 . Although this mechanism has been known for decades, cryoanalgesia probes became commercially available and approved by the FDA in 2015, sparking a relatively recent increase in use for procedures with increased intercostal mediated pain, such as thoracotomy and chest wall procedures 92,94–97 . These studies have generally shown significant decreases in-hospital length of stay and opioid consumption without affecting pain scores 92,94,95,97 .…”

“…[91][92][93] Core neural structures (epineurium, perineurium, and endoneurium) are left intact, and over time, reinnervation of the nerve through axonal regeneration occurs. 93,94 The time required for recovery is proportional to the cryoablation exposure time, 93 and recent studies suggest that reinnervation may occur more rapidly in younger patients than in adults. 95 Although this mechanism has been known for decades, cryoanalgesia probes became commercially available and approved by the FDA in 2015, sparking a relatively recent increase in use for procedures with increased intercostal mediated pain, such as thoracotomy and chest wall procedures.…”

“…95 Although this mechanism has been known for decades, cryoanalgesia probes became commercially available and approved by the FDA in 2015, sparking a relatively recent increase in use for procedures with increased intercostal mediated pain, such as thoracotomy and chest wall procedures. 92,[94][95][96][97] These studies have generally shown significant decreases in-hospital length of stay and opioid consumption without affecting pain scores. 92,94,95,97 However, long-term outcomes, such as neuropathic pain and effectiveness, on other nerves need more investigation.…”