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Eldredge RS, Ochoa B, Carmichael J, Ostlie DJ, Lee J, McMahon L, Notrica DM, Padilla BE. Opioid Prescriptions at Discharge After Minimally Invasive Repair of Pectus Excavatum Are Reduced With Cryoablation. J Pediatr Surg 2024; 59:1291-1296. [PMID: 38584007 DOI: 10.1016/j.jpedsurg.2024.03.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 03/04/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND The minimally invasive repair of pectus excavatum (MIRPE) is associated with significant postoperative pain and opioid use. The objective of this study was to determine the effect of intercostal nerve cryoablation (Cryo) on inpatient and post-hospital opioid prescription practices following MIPRE. METHODS A retrospective review at a single pediatric center was conducted of patients ≤21 years old who underwent MIRPE. Oral morphine equivalents (OME) of inpatient and discharge opioids were compared between Cryo and no-Cryo cohorts. RESULTS 579 patients were identified (82.8% male, mean age 15.4 ± 2.0 years). Cryo was performed in 73.5% of patients. The total inpatient OME use was less in the Cryo group (0.89 ± 0.68 vs. 1.6 ± 0.5 OME/kg/day; p < 0.001). Patients who underwent Cryo were prescribed significantly less OME at discharge compared to the no-Cryo group (3.9 ± 1.7 vs. 10.0 ± 4.1 OME mg/kg, p < 0.001). There was no statistically significant difference in the proportion of patients who required an opioid prescription refill (Cryo 12.4% vs. no-Cryo 11.5%, p = 0.884) or were readmitted (Cryo 5.3% vs. no-Cryo 4.6%, p = 0.833). CONCLUSION Patients who underwent cryoablation during MIRPE were prescribed significantly less opioid at the time of discharge without increasing the need for opioid refills or hospital readmissions. LEVEL OF EVIDENCE Treatment study; Level III evidence.
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Affiliation(s)
- R Scott Eldredge
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's, Phoenix, AZ, USA; Department of Surgery, Mayo Clinic School of Medicine and Science, Phoenix, AZ, USA
| | - Brielle Ochoa
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's, Phoenix, AZ, USA
| | - Jared Carmichael
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's, Phoenix, AZ, USA
| | - Daniel J Ostlie
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's, Phoenix, AZ, USA; Department of Surgery, Mayo Clinic School of Medicine and Science, Phoenix, AZ, USA; Department of Child Health and Development, University of Arizona, School of Medicine, Phoenix, AZ, USA
| | - Justin Lee
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's, Phoenix, AZ, USA; Department of Child Health and Development, University of Arizona, School of Medicine, Phoenix, AZ, USA
| | - Lisa McMahon
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's, Phoenix, AZ, USA; Department of Surgery, Mayo Clinic School of Medicine and Science, Phoenix, AZ, USA; Department of Child Health and Development, University of Arizona, School of Medicine, Phoenix, AZ, USA
| | - David M Notrica
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's, Phoenix, AZ, USA; Department of Surgery, Mayo Clinic School of Medicine and Science, Phoenix, AZ, USA; Department of Child Health and Development, University of Arizona, School of Medicine, Phoenix, AZ, USA
| | - Benjamin E Padilla
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's, Phoenix, AZ, USA; Department of Child Health and Development, University of Arizona, School of Medicine, Phoenix, AZ, USA.
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Eldredge RS, Ochoa B, Khoury E, Mihalcin K, Ostlie D, Lee J, McMahon L, Notrica D, Padilla BE. Long-Term Sensory Function 3 years after Minimally Invasive Repair of Pectus Excavatum with Cryoablation. J Pediatr Surg 2024; 59:379-384. [PMID: 37973420 DOI: 10.1016/j.jpedsurg.2023.10.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 10/20/2023] [Indexed: 11/19/2023]
Abstract
INTRODUCTION Minimally invasive repair of pectus excavatum (MIRPE) with intercostal nerve cryoablation (Cryo) decreases length of hospitalization and opioid use, but long-term recovery of sensation has been poorly described. The purpose of this study was to quantify long-term hypoesthesia and neuropathic pain after MIRPE with Cryo. METHODS A prospective cohort study was conducted single-institution of patients ≤21 years who presented for bar removal. Consented patients underwent chest wall sensory testing and completed neuropathic pain screening. Chest wall hypoesthesia to cold, soft touch, and pinprick were measured as the percent of the treated anterior chest wall surface area (TACWSA); neuropathic pain was evaluated by questionnaire. RESULTS The study enrolled 47 patients; 87% male; median age 18.4 years. The median bar dwell time was 2.9 years. A median of 2 bars were placed; 80.9% were secured with pericostal sutures. At enrollment, 46.8% of patients had identifiable chest wall hypoesthesia. The mean percentage of TACWSA with hypoesthesia was 4.7 ± 9.3% (cold), 3.9 ± 7.7% (soft touch), and 5.9 ± 11.8% (pinprick). Hypoesthesia to cold was found in 0 dermatomes in 62%, 1 dermatome in 11%, 2 dermatomes in 17% and ≥3 dermatomes in 11%. T5 was the most common dermatome with hypoesthesia. Neuropathic symptoms were identified by 13% of patients; none required treatment. CONCLUSION In long-term follow up after MIRPE with Cryo, 46.8% of patients experienced some chest wall hypoesthesia; the average TACWSA with hypoesthesia was 4-6%. Hypoesthesia was mostly limited to 1-2 dermatomes, most commonly T5. Chronic symptomatic neuropathic pain was rare. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- R Scott Eldredge
- Division of Pediatric Surgery, Phoenix Children's, Phoenix, AZ, USA; Division of General Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Brielle Ochoa
- Division of Pediatric Surgery, Phoenix Children's, Phoenix, AZ, USA
| | - Emily Khoury
- Division of Pediatric Surgery, Phoenix Children's, Phoenix, AZ, USA
| | - Kristin Mihalcin
- Division of Pediatric Surgery, Phoenix Children's, Phoenix, AZ, USA
| | - Daniel Ostlie
- Division of Pediatric Surgery, Phoenix Children's, Phoenix, AZ, USA; University of Arizona School of Medicine, Phoenix, AZ, USA
| | - Justin Lee
- Division of Pediatric Surgery, Phoenix Children's, Phoenix, AZ, USA; University of Arizona School of Medicine, Phoenix, AZ, USA
| | - Lisa McMahon
- Division of Pediatric Surgery, Phoenix Children's, Phoenix, AZ, USA; University of Arizona School of Medicine, Phoenix, AZ, USA
| | - David Notrica
- Division of Pediatric Surgery, Phoenix Children's, Phoenix, AZ, USA; University of Arizona School of Medicine, Phoenix, AZ, USA
| | - Benjamin E Padilla
- Division of Pediatric Surgery, Phoenix Children's, Phoenix, AZ, USA; University of Arizona School of Medicine, Phoenix, AZ, USA.
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Perez MN, Ferrantella A, Johnson KN, Goldstein SD. Intercostal spinal nerve cryoablation for analgesia following pectus excavatum repair. Semin Pediatr Surg 2024; 33:151382. [PMID: 38190771 DOI: 10.1016/j.sempedsurg.2024.151382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
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.
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Affiliation(s)
- Mallory N Perez
- Department of Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
| | - Anthony Ferrantella
- Department of Surgery, Phoenix Children's Hospital, Mayo Clinic College of Medicine and Science, Phoenix, AZ, USA
| | - Kevin N Johnson
- Department of Pediatric Surgery, Vanderbilt University School of Medicine, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - Seth D Goldstein
- Department of Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
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Lai K, Eldredge RS, Zobel M, Hargis-Villanueva A, Ostlie A, Padilla BE. Intercostal Nerve Cryoablation for Postoperative Pain Control in Pediatric Thoracic Surgery: A Scoping Review. J Laparoendosc Adv Surg Tech A 2023; 33:994-1004. [PMID: 37462727 DOI: 10.1089/lap.2023.0070] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023] Open
Abstract
Background: Cryoanalgesia uses the application of cold temperatures to temporarily disrupt peripheral sensory nerve function for pain control. This review outlines the principles of cryoablation, clinical applications, and clinical data for its use in pediatric thoracic surgery. Methods: A comprehensive PubMed search was performed using the principal terms and combinations of cryoablation, cryoanalgesia, Nuss, Nuss repair, pectus, pectus excavatum, thoracic surgery, thoracotomy, and chest wall. Pediatric articles were reviewed and included if relevant. Adult articles were reviewed for supporting information as needed. Reference lists of included articles were reviewed for possible additional sources. Discussion: The scientific and clinical principles of cryoablation are outlined, followed by a focused review of current clinical application and outcome data. Conclusion: Postoperative pain is a major challenge following thoracic surgery. Cryoanalgesia is emerging as an adjunct in pediatric thoracic surgery, particularly for the Nuss procedure or minimally invasive repair of pectus excavatum. It effectively controls pain, decreasing postoperative opioid use and hospital length of stay with few short-term complications. Although more long-term studies are needed, early evidence suggests there is reliable return of sensation to the chest wall and long-term neuropathic pain is rare.
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Affiliation(s)
- Krista Lai
- Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, Arizona, USA
| | - R Scott Eldredge
- Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, Arizona, USA
| | - Michael Zobel
- Division of Pediatric Surgery, University of California San Francisco, San Francisco, USA
| | | | - Andrew Ostlie
- Department of Child Health, University of Arizona School of Medicine, Tucson, Arizona, USA
| | - Benjamin E Padilla
- Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, Arizona, USA
- Department of Child Health, University of Arizona School of Medicine, Tucson, Arizona, USA
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Eldredge RS, McMahon L. Intercostal nerve cryoablation therapy for the repair of pectus excavatum: a systematic review. Front Surg 2023; 10:1235120. [PMID: 37693640 PMCID: PMC10484532 DOI: 10.3389/fsurg.2023.1235120] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 08/10/2023] [Indexed: 09/12/2023] Open
Abstract
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.
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Affiliation(s)
| | - Lisa McMahon
- Department of Surgery, Division of Pediatric Surgery, Phoenix Children’s Hospital, Phoenix, AZ, United States
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