Short and long term outcomes of using cryoablation for postoperative pain control in patients after pectus excavatum repair

The implementation of a pectus bar insertion enhanced recovery after surgery pathway: A quality improvement initiative

BACKGROUND

Pectus excavatum repair is associated with significant discomfort, and pain is a primary contributor to postoperative hospital length of stay. Recent advances in postoperative pain control include the use of intercostal cryoablation techniques that may now make it possible to discharge patients on the day of surgery. Unnecessary variation in patient care and noncompliance with care bundles may be a factor in extended length of stay. The global aim of this quality improvement initiative was to successfully implement an enhanced recovery after surgery (ERAS) pathway on patients undergoing pectus excavatum repair. The SMART aim was to have a greater than 70% compliance for the perioperative bundle elements within 1 year of the pathway implementation.

METHODS

Multiple Plan-Do-Study-Act (PDSA) cycles were designed to create and implement an ERAS pathway for patients undergoing a pectus bar insertion procedure. This multidisciplinary pathway was designed, managed, and implemented with key stakeholders from the Departments of Evidence Based Practice, Surgery, Anesthesiology, and Perioperative Nursing. Patient characteristics, outcomes, and compliance with elements of the pathway were measured for analysis for both the baseline and post-intervention groups with monthly automated reports.

RESULTS

After implementation of the ERAS pathway, data on the first 50 patients showed a 90% compliance with the perioperative bundle elements. Mean length of stay was significantly decreased from 33 h (95% CI [28.76, 37.31]) to 18 h (95% CI [14.54, 21.70]). There were zero readmissions within 24 hours for patients who were discharged on the day of surgery.

CONCLUSION

Employing a multidisciplinary approach in both planning and execution that standardized clinician practices and minimized unnecessary variation in patient care, an ERAS pathway for pectus bar insertion has been successfully established at our institution.

Cryoanalgesia as the Essential Element of Enhanced Recovery after Surgery (ERAS) in Children Undergoing Thoracic Surgery-Scoping Review

This article aims to present cryoanalgesia as an inventive strategy for pain alleviation among pediatric patients. It underlines the tremendous need to align pain management with the principles of the enhanced recovery after surgery (ERAS) approach. The aim of the study was to review the patient outcomes of nerve cryoanalgesia during surgery reported with regard to ERAS in the literature. The literature search was performed using PubMed and Embase to identify articles on the use of cryoanalgesia in children. It excluded editorials, reviews, meta-analyses, and non-English articles. The analysis focused on the study methods, data analysis, patient selection, and patient follow-up. This review includes a total of 25 articles. Three of the articles report the results of cryoanalgesia implemented in ERAS protocol in children. The research outcome indicates shortened hospital stay, potential reduction in opioid dosage, and significant progress in physical rehabilitation. This paper also describes the first intraoperative utilization of intercostal nerve cryoanalgesia during the Nuss procedure in Poland, highlighting its effectiveness in pain management. Adding the cryoanalgesia procedure to multimodal analgesia protocol may facilitate the implementation of the ERAS protocol in pediatric patients.

Lessons Learned after 176 Patients Treated with a Standardized Procedure of Thoracoscopic Cryoanalgesia during Minimally Invasive Repair of Pectus Excavatum

BACKGROUND

Intrathoracic intercostal cryoanalgesia (Cryo) during minimally invasive repair of pectus excavatum (MIRPE) reports have been related to improved pain management, although its extent differs amongst studies. We aimed to report our experience using a standardized perioperative approach including Cryo during MIRPE, and compare our actual results with those of a previous thoracic epidural analgesia (TE) cohort. Lessons learned are summarized.

METHODS

Retrospective study including patients undergoing Cryo during MIRPE between October 2018 and May 2023. Results with a standardized perioperative approach were analyzed. We then compared our Cryo cohort with a previous cohort of 62 patients who underwent TE and MIRPE between 2013 and 2018. Continuous variables were reported as mean and standard deviation, and as median (interquartile range) for variables with non-uniform distribution.

RESULTS

We performed 176 Cryo during MIRPE (16.8 ± 4.6 years), with a mean postoperative length of stay (LOS) of 1.4 ± 0.8 days and a median total requirement of 7.5 (0.0; 15.0) oral morphine equivalents (OME) (mg). Patients with Cryo had a significantly lower mean LOS (1.4 ± 0.8 vs. 3.6 ± 1.0 days, p < 0.0001), and median total opioid requirement [7.5 (0.0; 15.0) vs. 77.4 (27.0; 115.5 OME (mg), p < 0.0001) compared to TE patients. Lessons learned included ensuring adequate contact of the cryoprobe with the target, proper exposition, and specialized multidisciplinary perioperative patient and family support, including psychology and physical therapy.

CONCLUSIONS

In this study, we reported lessons learned after performing a standardized protocol of perioperative care in patients undergoing Cryo during MIRPE. This protocol enabled the achievement of a short LOS and low postoperative opioid requirement.

TYPE OF STUDY

Retrospective comparative study.

LEVEL OF EVIDENCE

III.

Chest Wall Dermatitis Patterns Following Thoracoscopic Intercostal Nerve Cryoablation for Surgical Correction of Pectus Excavatum

BACKGROUND

Intercostal nerve cryoablation (INC) has been shown to reduce postoperative pain and length of stay following surgical correction of pectus excavatum (SCOPE). Some patients have developed chest wall dermatological symptoms after INC that can be mistaken for metal allergy or infection. The purpose of this study is to report the symptoms, severity, incidence, and treatment of post-cryoablation dermatitis.

METHODS

A retrospective single institution review was performed for patients who underwent SCOPE with and without INC between June 2016 and March 2023 to assess for incidence of postoperative dermatological findings. Characteristics associated with these findings were evaluated.

RESULTS

During study period, 383 patients underwent SCOPE, 165 (43.1%) without INC and 218 (56.9%) with. Twenty-three (10.6%) patients who received INC developed exanthems characteristic of post-cryoablation dermatitis with two distinct phenotypes identified. No patients who underwent SCOPE without INC developed similar manifestations. Early dermatitis, characterized by a painless, erythematous, and blanching rash across the anterior thorax, was observed in 16 patients, presenting on median postoperative day 6.0 [IQR 6.0-8.5], with median time to resolution of 23.0 [IQR 12-71.0] days after symptom onset. Late dermatitis, characterized by hyperpigmentation spanning the anterior thorax, was observed in 7 patients, presenting on median postoperative day 129.0 [IQR 84.5-240.0], with median time to resolution of 114.0 [IQR 48.0-314.3] days.

CONCLUSION

This is the first report of dermatological manifestations following SCOPE with INC, a phenomenon of unknown etiology and no known long-term sequela. In our experience, it is self-resolving and lacks systemic symptoms suggesting observation alone is sufficient for resolution.

LEVEL OF EVIDENCE

IV.

Intercostal spinal nerve cryoablation for analgesia following pectus excavatum repair

Pectus excavatum is a common chest wall deformity, most often treated during adolescence, that presents a significant postoperative pain control challenge for pediatric surgeons following surgical correction. The purpose of this article is to review the technique and outcomes of intercostal spinal nerve cryoablation for postoperative analgesia following surgical correction of pectus excavatum. Contemporary and historic literature were reviewed. Findings are summarized to provide a concise synopsis of the benefits of intercostal spinal nerve cryoablation relative to alternative analgesic modalities, as well as advocate for more widespread inclusion of this technique into multimodal pain regimens.

A Prospective Study of Sensory Changes in Pediatric Patients After Minimally Invasive Repair of Pectus Excavatum With Cryoablation

BACKGROUND

Cryoablation during minimally invasive repair for pectus excavatum (MIRPE) reduces opioid use and hospital length of stay. Skin hypoesthesia of the chest wall also occurs. This study sought to determine the frequency, onset, duration, and location of sensory changes and neuropathic pain after cryoablation.

METHODS

A prospective study was conducted on patients aged ≤21 years undergoing MIRPE with cryoablation of T3 to T7 dermatomes bilaterally for 120 s at a single institution between March 2021 to December 2022. Patients underwent sensory testing of the chest wall and neuropathic pain surveys (S-LANSS) preoperatively and then postoperatively for 6 months. Incidence and duration of hypoesthesia and neuropathic pain were evaluated.

RESULTS

Of 61 patients enrolled in the study, 45 completed evaluations at six months postoperatively. All patients had skin hypoesthesia on postoperative day (POD)1. The mean percentage of the treated anterior chest wall surface area (TACWSA) with hypoesthesia to cold stimulus was 52% (±29.3) on POD 0 and 55% (±19.7) on POD 1. Sensation returned over time, with hypoesthesia affecting 11.1% (±15.5) TACWSA at 6 months. At study completion 58% of patients (26/45) had complete return of sensation; hypoesthesia was found at: 1 dermatome 13% (2/45), 2 dermatomes 22% (11/45), and 3 dermatomes 4% (2/45). Neuropathic pain (S-LANSS ≥12) was documented in 16% (9/55) of patients at hospital discharge but decreased to 6.7% of patients at 6 months.

CONCLUSION

Onset of skin hypoesthesia after cryoablation occurred on POD0 and affected 52% of the TACWSA. All patients experienced return of sensation to varying degrees, with 58% experiencing normal sensation in all dermatomes by 6 months. The etiology of persistent hypoesthesia to select dermatomes is unknown but may be related to operative technique or cryoablation. Chronic neuropathic pain is uncommon.

LEVEL OF EVIDENCE

II.

TYPE OF STUDY

Prognosis Study.

Benefits of the Erector Spinae Plane Block before Cryoanalgesia in Children Undergoing Surgery for Funnel Chest Deformity

Thoracic surgery causes significant pain despite standard multimodal analgesia. Intraoperative cryoanalgesia may be a solution. The onset of the clinical effect of cryoanalgesia can take 12-36 h. The addition of a regional anaesthesia before the cryoanalgesia procedure can enable analgesic protection for the patient during this period. The main aim of the study was to evaluate the benefits of the erector spinae plane (ESP) block prior to Nuss surgery. The 'control' group consisted of 10 teenagers who underwent cryoablation together with intravenous multimodal analgesia according to the standard protocol. The 'intervention' group included 26 teenage patients who additionally received an erector spinae plane block before operation. Pain relief (p = 0.015), opioid use (p = 0.009), independent physical activity and rehabilitation (p = 0.020) were faster in the intervention group. No features of local anaesthetic drug toxicity or complications of the ESP block were observed. The bilateral ESP block together with intraoperative intercostal nerve cryoablation performed prior to Nuss correction of funnel chest were more effective in terms of pain control.

Evaluation of Analgesic Practice Changes Following the Nuss Procedure in Pediatric Patients

INTRODUCTION

Pectus excavatum repair by the Nuss procedure results in severe postoperative pain. Regional blocks and intercostal nerve cryoablation (INC) have emerged as potential strategies to manage analgesia. This study compares pain-related outcomes following these perioperative interventions.

METHODS

We reviewed charts of patients <18 y who underwent the Nuss procedure at Duke Children's Hospital from July 2018 to June 2022. Patients were divided into three groups by analgesic strategy: no block, regional catheters, or INC, representing the chronologic change in our practice. The primary outcome was total and daily in-hospital opioid utilization measured by oral morphine equivalents (OMEs). Secondary outcomes included average daily pain scores, length of stay, opioid refills after discharge, and complications.

RESULTS

Twenty-one patients were included and analyzed: no block (n = 6), regional catheters (n = 7), and INC (n = 8). INC-treated patients required significantly lower total postoperative, in-hospital OMEs (64 ± 47 [mean ± standard deviation]) than those with no block (270 ± 217, P = 0.04) or those with regional catheters (273 ± 176, P = 0.03). INC was associated with longer average operative times (161 ± 36 min) than no block (105 ± 21 min, P = 0.005) or regional catheters (90 ± 11 min, P < 0.001). INC-treated patients had shorter hospital length of stays (median 68 h) than those with regional catheters (median 74 h, P = 0.006).

CONCLUSIONS

INC was associated with longer operative times but decreased in-hospital OMEs when compared to bilateral regional block catheters and multimodal analgesia alone.

Intercostal nerve cryoablation therapy for the repair of pectus excavatum: a systematic review

Introduction

The minimally invasive repair of pectus excavatum (PE) is a painful procedure that can result in long-term hospitalization and opioid use. To mitigate the length of stay and opioid consumption, many different analgesia strategies have been implemented. The aim of this study is to review the use and patient outcomes of intercostal nerve cryoablation (INC) during PE repair reported in the literature.

Methods

An unfunded literature search using PubMed identifying articles discussing INC during PE repair from 1946 to 1 July 2023 was performed. Articles were included if they discussed patient outcomes with INC use during PE repair. Articles were excluded if they were reviews/meta-analyses, editorials, or not available in English. Each article was reviewed for bias by analyzing the study methods, data analysis, patient selection, and patient follow-up. Articles comparing outcomes of INC were considered significant if p-value was <0.05.

Results

A total of 34 articles were included in this review that described INC use during pectus repair. Most supported a decreased hospital length of stay and opioid use with INC. Overall, INC was associated with fewer short-term and long-term complications. However, the researchers reported varied results of total hospital costs with the use of INC.

Conclusion

The review was limited by a paucity of prospective studies and low number of patients who received INC. Despite this, the present data support INC as a safe and effective analgesic strategy during the repair of PE.

Cost and outcomes of intercostal nerve cryoablation versus thoracic epidural following the Nuss procedure

BACKGROUND

Pectus excavatum is the most common congenital chest wall abnormality, with the Nuss procedure being the most commonly performed repair. Pain control is the predominant factor in the postoperative treatment of these patients. This study aims to compare the cost and outcomes of intercostal nerve cryoablation (INC) and thoracic epidural (TE) in patients undergoing the Nuss procedure.

METHODS

A retrospective chart review was conducted at our institution for all patients who underwent the Nuss procedure for pectus excavatum from 2002 to 2020. Patients were stratified by pain management strategy, INC vs. TE. Chi-square and Fisher's exact were used to compare categorical variables. Wilcoxon tests were used to evaluate continuous variables and costs.

RESULTS

A total of 158 patients were identified. Of these, 80.4% (N = 127) were treated with epidural, while 19.6% (N = 31) were treated with intercostal nerve cryoablation. The INC group had lower rates of PCA use (35.5% vs. 93.7%, p < 0.001), lower total morphine milligram equivalent requirement (27.0 vs. 290.8, p < 0.001), and shorter length of stay (3.2 days vs. 5.3 days, p < 0.001) compared to the TE group. INC was also associated with longer operative times (153.0 min vs. 89.0 min, p < 0.001). The total hospitalization cost for the INC group was higher compared to the TE group ($24,742.5 vs $21,621.9, p = 0.001).

CONCLUSIONS

In patients undergoing the Nuss procedure, compared to thoracic epidural, INC was associated with lower opioid use and shorter length of stay but at the cost of longer operative time and increased hospitalization cost.

LEVEL OF EVIDENCE

Treatment Study, Level III.

Implementation of a Cryoablation-based Pain Management Protocol for Pectus Excavatum

INTRODUCTION

The Nuss repair for pectus excavatum is associated with significant postoperative pain. Our institution developed protocols to standardize pain management for pectus excavatum patients in the immediate postoperative period. We present our experience with protocol implementation and patient outcomes.

METHODS

We standardized regional anesthesia with a 0.25% bupivacaine incisional soaker catheter (post-implementation 1, PI1) before transitioning to intercostal nerve cryoablation (INC) (post-implementation 2, PI2). Patient outcomes were tracked using statistical process control charts in AdaptX™ OR Advisor and run charts in Tableau. Chi-squared tests assessed demographic differences between cohorts.

RESULTS

244 patients were included: 78 pre-implementation, 108 PI1, and 58 PI2. Average age was 15.9-16.5 years. Patients were majority male, non-Hispanic white, and English speaking. Hospital length of stay decreased 4.1-2.4 days. INC increased surgery time (99-125 min) but decreased PACU time (112-78 min). Maximum pain scores improved in PACU (7.7-6.0) and 0-24 h postoperatively (8.3-6.8) but were not different 24-48 h postoperatively (5.4-5.8). Average opioid dosing decreased 0-48 h from 1.9 to 0.8 mg/kg morphine milliequivalents and was associated with reduction in post-operative nausea and constipation. There were no 30-day readmissions.

CONCLUSION

An institution-wide pain management protocol using INC for pectus excavatum patients was implemented. Intercostal nerve cryoablation was found to be superior to bupivacaine incisional soaker catheters and reduced hospital length of stay, immediate postoperative pain scores, morphine milliequivalent opioid dosing, postoperative nausea, and constipation.

LEVEL OF EVIDENCE

Level IV.

A Retrospective Study Comparing Outcomes of Paravertebral Clonidine Infusion for Pediatric Patients Undergoing Nuss Procedure

INTRODUCTION

The continuous paravertebral blockade as part of the multimodal pain protocol is an effective regional technique to control pain after the Nuss procedure. We investigated the effectiveness of clonidine as an adjunct to paravertebral ropivacaine infusion.

METHODS

We conducted a retrospective study of 63 patients who underwent Nuss procedures and received bilateral paravertebral catheters. Data on demographics, surgical, anesthesia, and block characteristics, numeric rating pain scores (NRS), opioids consumption, hospital length of stay, complications, and side effects from medication administration were collected in children who received paravertebral ropivacaine 0.2% infusion without (N = 45) and with clonidine (1 mcg/mL) (N = 18).

RESULTS

The two groups had similar demographics, although the clonidine group had higher Haller indices (6.5 (4.8, 9.4) vs. 4.8 (4.1, 6.6), p = 0.013). The clonidine group required less morphine equivalent/kg on postoperative day 2 (median, interquartile range 0.24 (0.22, 0.31) vs. 0.47 (0.29, 0.61) p = 0.002). There was no difference in median NRS pain scores. Both groups had similar catheter infusion durations, hospital length of stay, and complication rates.

CONCLUSION

A postoperative pain management plan that includes paravertebral analgesia, including clonidine as an adjunct, may be considered to minimize opioid administration for patients undergoing primary Nuss repair.

Making a Painless Drain: Proof of Concept

Chest tubes account for a large proportion of postoperative pain after cardiothoracic operations. The objective of this study was to develop a novel, cost-effective, easy-to-use, lidocaine-eluting coating to reduce pain associated with postoperative chest tubes. A lidocaine-eluting hydrogel was developed by dispersing lidocaine-loaded nanoparticles in an aqueous solution containing gelatin (5%). Glutaraldehyde (1%) was added to crosslink the gelatin into a hydrogel. The hydrogel was dehydrated, resulting in a thin, stable polymer. Sterile lidocaine hydrogel-coated silicone discs and control discs were prepared and surgically implanted in the subcutaneous space of C57B6 mice. Using von Frey filaments, mice underwent preoperative baseline pain testing, followed by pain testing on post-procedure day 1 and 3. On post-procedure day 1, mice implanted with control discs demonstrated no change in pain tolerance compared to baseline, while mice implanted with 20 mg and 80 mg lidocaine-loaded discs demonstrated a 2.4-fold (P = 0.36) and 4.7-fold (P = 0.01) increase in pain tolerance, respectively. On post-procedure day 3, mice implanted with control discs demonstrated a 0.7-fold decrease in pain tolerance compared to baseline, while mice implanted with 20 mg and 80 mg lidocaine-loaded discs demonstrated a 1.8-fold (P = 0.88) and 8.4-fold (P = 0.02) increase in pain tolerance, respectively. Our results demonstrate successful development of a lidocaine-eluting chest tube with hydrogel coating, leading to improved pain tolerance in vivo. The concept of a drug-eluting drain coating has significant importance due to its potential universal application in a variety of drain types and insertion locations.