Cryoablation for Postoperative Pain Control after the Nuss Procedure for Pectus Excavatum
Jonathan Bucan, MD and Nathan M Novotny, MD
Beaumont Health, Royal Oak
A rare few pediatric surgeons have impacted the field to the extent that deserves a paradigm shift and naming of a procedure after the surgeon. Donald Nuss is one of those rare few. Nuss’ development of a minimally invasive approach revolutionized the treatment of pectus excavatum and the procedure was rapidly adopted. One major challenge of the treatment of pectus excavatum however is the postoperative pain. Cryoablation for postoperative pain control after the Nuss procedure is the newest attempt at controlling one of the Nuss procedure’s biggest challenges.
Due to significant post-operative pain following the Nuss Procedure, common methods of pain control include patient-controlled analgesia (PCA) and thoracic epidurals. These methods often include continuous flow of narcotics, weaned over the course of the hospital stay, and transitioned to oral analgesia for home use. However, these types of analgesia do not come without risk. Epidurals can be misplaced and malfunction, while PCAs have conflicting data on whether they adequately control early post-operative pain, and the risk for opioid dependence continues to linger in the background.1 While PCAs have been shown to be beneficial over epidurals, hospital length of stays and pain scores are unacceptably high(Is there a reference for this?). Enter cryoablation. Intraoperative cryoablation of intercostal nerves is the next best thing to happen to pediatric surgery since the development of electrocautery surgery! (Maybe a little over the top, but you get the point) cryoanalgesia helps prevent pain following the Nuss Procedure by freezing affected peripheral nerves and producing pain relief that is long lasting and leads to decreased length of stay.2 According to one study, mean postoperative length of stay was significantly shorter in patients with cryoanalgesia (N = 10) than in a previous cohort treated with thoracic epidural (N = 15), and pain was well controlled.3 Another study which randomized 20 patients to receive either cryoablation (N = 10) or thoracic epidural (n = 10) suggested that median LOS decreased by 2 days in patients undergoing cryoablation, to 3 days from 5 days.4 Finally, one other study took 35 patients treated with cryoablation compared to 32 epidural and 33 PCA patients which resulted in less time to pain control with oral medication (21 h, versus 72 and 67 h, p < 0.01), and decreased LOS (1 day, versus 4.3 and 4.2 days, p < 0.01).5 Pause for a moment. Read that again. Cryoablation patients stayed a single day in the hospital versus 4+ days for our conventional methods of pain control. And yet, there is no free lunch. Astute clinicians will ask, ‘what is it going to cost me?’ Across the three studies mentioned above, mean operating time increased anywhere from 30 minutes –46.5 minutes.3,4,5Also, due to
immediate pain relief following the procedure from cryoablation, patients may ignore activity restrictions and require re-intervention due to a possible displaced Nuss bar.6(wonder if its worth re-wording slightly to make it clear that it’s a suggestion of potential increased bar displacement and that its not been shown …yet .. possibly 😉 )And yet still compelling.The Nuss Procedurewas a revolutionary approach to correct pectus excavatum. But it hurts like a bitch-unsure. Agree with the sentiment, would very much use it myself and possibly worse -( i spent most of yesterday with every sentance including twat) But wonder whether for the sake of a sentance, it’s worth not offending. I dont feel strongly though. Cryoablation of intercostal nerves takes a little time in the operating room but is a potential solution to days and weeks of pain postoperatively for patient and surgeon. Cryoablation provides instantaneous pain relief, decreased length of stay, and better overall pain control than previous conventional methods. Cryoablation may be that revolutionary approach to pain control that Dr. Nuss’s revolutionary procedure needs.References1.Shawn D St Peter, Kathryn A Weesner, Eric E Weissend, et al, “Epidural vs patient-controlled analgesia for postoperative pain after pectus excavatum repair: a prospective, randomized trial”, Journal of Pediatric Surgery. 2012 Jan;47(1):148-53. Doi: 10.1016/j.jpedsurg.2011.10.0402.Sunghoon Kim, Olajire Idowu, Barnard Palmer, Sang H. Lee, “Use of transthoracic cryoanalgesia during the Nuss Procedure”, Journal of Thoracic Cardiovascular Surgery. 2016 Mar;151(3):887-888. Doi: 10.1016/j.jtcvs.2015.09.1103.Claire Graves, Olarjire Idowu, Sang Lee, et al, “Intraoperative cryoanalgesia for managing pain after the Nuss procedure”, Journal of Pediatric Surgery. 2017 Jan;52(6):920-924. Doi: 10.1016/j.jpedsurg.2017.03.0064.Claire E Graves, Jarrett Moyer, Michael J. Zobel, et al, “Intraoperative intercostal nerve cryoablation during the Nuss procedurereduces length of stay and opioid requirement: A randomized clinical trial”, Journal of Pediatric Surgery. 2019;54(11):2250. Doi: 10.1016/j.jpedsurg.2019.02.0575.Dekonenko C, Dorman RM, Duran Y, et al, “Post operative pain control modalities for pectus excavatum repair: A prospective observational study of cryoablation compared to results of a randomized trial of epidural vs patient-controlled analgesia”, Journal of Pediatric Surgery. 2019 Oct 26;S0022-3468 Doi: 10.1016/j.jpedsurg.2019.09.0216.Benjamin Keller, Sandra Kabagambe, James Becker, et al, “Intercostal nerve cryoablation versus thoracic epidural catheters for postoperative analgesia following pectus excavatum repair: Preliminary outcomes in twenty-six cryoablation patients”, Journal of Pediatric Surgery. 2016 Dec;51(12):2033-2038 Doi: 10.1016/j.jpedsurg.2016.09.034