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Eur J Pediatr Surg 2022; 32(01): 073-079
DOI: 10.1055/s-0041-1740555
Original Article

Percutaneous Cryoanalgesia: A New Strategy for Pain Management in Pectus Excavatum Surgery

María Velayos 
1   Pediatric Surgery Department, La Paz University Hospital, Madrid, Spain
,
Mercedes Alonso
2   Children's Anesthesia and Resuscitation Department, La Paz University Hospital, Madrid, Spain
,
Carlos Delgado-Miguel 
1   Pediatric Surgery Department, La Paz University Hospital, Madrid, Spain
,
Karla Estefanía-Fernández
1   Pediatric Surgery Department, La Paz University Hospital, Madrid, Spain
,
Antonio J. Muñoz-Serrano 
1   Pediatric Surgery Department, La Paz University Hospital, Madrid, Spain
,
Manuel V. López Santamaría
1   Pediatric Surgery Department, La Paz University Hospital, Madrid, Spain
,
Francisco Reinoso-Barbero
2   Children's Anesthesia and Resuscitation Department, La Paz University Hospital, Madrid, Spain
,
Carlos A. De La Torre
1   Pediatric Surgery Department, La Paz University Hospital, Madrid, Spain
› Author Affiliations Funding Dr. María Velayos reports support for the present manuscript (e.g., funding, provision of study materials, medical writing, article processing charges, etc.) and receipt of equipment, materials, drugs, medical writing, gifts, or other services from MedXpert Universal System and Metrum Cryoflex.
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Abstract

Introduction In recent years, pain protocols for pectus excavatum (PE) have incorporated cryoanalgesia through thoracoscopic approach. Since 2019, ultrasound-guided percutaneous cryoanalgesia (PCr) has been applied at our institution, either on the same day as the Nuss procedure or 48 hours before surgery. We carried out a preliminary retrospective review of patients with PE in whom PCr prior to surgery was performed at our institution between 2019 and 2021.

Materials and Methods Two groups were evaluated: PCr on the same day (PCrSD) and PCr 48 hours before surgery (PCr48). Despite PCr, patients were treated with “patient-controlled analgesia” (PCA) with opioids for at least 24 hours, switching to conventional intravenous analgesia and oral analgesia in the following days. Demographic, clinical-radiological variables, PCA opioid use, pain grade according to the visual analog scale (VAS), and length of stay (LOS) were compared between the groups. A total of 20 patients were included (12 with PCrSD and 8 with PCr48), without significant differences in demographics or clinical-radiological variables. The overall median time of PCr was 65 minutes (55–127), with no differences between the groups.

Results PCr48 group presented with significantly lower median number of hours of continuous PCA (24 vs. 32 hours; p = 0.031), lower median number of rescue boluses (11 vs. 18; p = 0.042), lower median VAS in the early postoperative hours (2 vs. 5.5; p = 0.043), and lower median LOS (3.5 vs. 5 days).

Conclusion PCr performed 48 hours prior to surgery is more effective in terms of PCA requirements, VAS, and LOS when compared with cryoanalgesia on the same day.

Keywords

pectus excavatum - cryoanalgesia - percutaneous - ultrasonography - pain


Publication History

Received: 17 July 2021

Accepted: 21 October 2021

Article published online:
23 December 2021

© 2021. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 de Oliveira Carvalho PE, da Silva MVM, Rodrigues OR, Cataneo AJM. Surgical interventions for treating pectus excavatum. Cochrane Database Syst Rev 2014; 2014 (10) CD008889
    PubMedGoogle Scholar
  • 2 Morikawa N, Laferriere N, Koo S, Johnson S, Woo R, Puapong D. Cryoanalgesia in patients undergoing Nuss repair of pectus excavatum: technique modification and early results. J Laparoendosc Adv Surg Tech A 2018; 28 (09) 1148-1151
    CrossrefPubMedGoogle Scholar
  • 3 Nuss D, Kelly Jr RE, Croitoru DP, Katz ME. A 10-year review of a minimally invasive technique for the correction of pectus excavatum. J Pediatr Surg 1998; 33 (04) 545-552
    CrossrefPubMedGoogle Scholar
  • 4 Kelly RE, Goretsky MJ, Obermeyer R. et al. Twenty-one years of experience with minimally invasive repair of pectus excavatum by the Nuss procedure in 1215 patients. Ann Surg 2010; 252 (06) 1072-1081
    CrossrefPubMedGoogle Scholar
  • 5 Mao YZ, Tang S, Li S. Comparison of the Nuss versus Ravitch procedure for pectus excavatum repair: an updated meta-analysis. J Pediatr Surg 2017; 52 (10) 1545-1552
    CrossrefPubMedGoogle Scholar
  • 6 Graves C, Idowu O, Lee S, Padilla B, Kim S. Intraoperative cryoanalgesia for managing pain after the Nuss procedure. J Pediatr Surg 2017; 52 (06) 920-924
    CrossrefPubMedGoogle Scholar
  • 7 Kelly Jr RE, Shamberger RC, Mellins RB. et al. Prospective multicenter study of surgical correction of pectus excavatum: design, perioperative complications, pain, and baseline pulmonary function facilitated by internet-based data collection. J Am Coll Surg 2007; 205 (02) 205-216
    CrossrefPubMedGoogle Scholar
  • 8 Densmore JC, Peterson DB, Stahovic LL. et al. Initial surgical and pain management outcomes after Nuss procedure. J Pediatr Surg 2010; 45 (09) 1767-1771
    CrossrefPubMedGoogle Scholar
  • 9 Ghionzoli M, Brandigi E, Messineo A, Messeri A. Pain and anxiety management in minimally invasive repair of pectus excavatum. Korean J Pain 2012; 25 (04) 267-271
    CrossrefPubMedGoogle Scholar
  • 10 Papic JC, Finnell SME, Howenstein AM, Breckler F, Leys CM. Postoperative opioid analgesic use after Nuss versus Ravitch pectus excavatum repair. J Pediatr Surg 2014; 49 (06) 919-923 , discussion 923
    CrossrefPubMedGoogle Scholar
  • 11 Parrado R, Lee J, McMahon LE. et al. The use of cryoanalgesia in minimally invasive repair of pectus excavatum: lessons learned. J Laparoendosc Adv Surg Tech A 2019; 29 (10) 1244-1251
    CrossrefPubMedGoogle Scholar
  • 12 Dekonenko C, Dorman RM, Duran Y. et al. Postoperative 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. J Pediatr Surg 2020; 55 (08) 1444-1447
    CrossrefPubMedGoogle Scholar
  • 13 Protopapas AD, Athanasiou T. Peri-operative data on the Nuss procedure in children with pectus excavatum: independent survey of the first 20 years' data. J Cardiothorac Surg 2008; 3 (01) 40
    CrossrefPubMedGoogle Scholar
  • 14 Reinoso-Barbero F, Fernández A, Durán P, Castro LE, Campo G, Melo MM. Thoracic epidural analgesia vs patient-controlled analgesia with intravenous fentanyl in children treated for pectus excavatum with the Nuss procedure [in Spanish]. Rev Esp Anestesiol Reanim 2010; 57 (04) 214-219
    CrossrefPubMedGoogle Scholar
  • 15 Parrado RH, Thornburg D, Kang P, McMahon LE. Elastomeric pain pumps as an adjunct for postoperative pain control after minimally invasive repair of pectus excavatum. J Laparoendosc Adv Surg Tech A 2021; 31 (03) 331-335
    CrossrefPubMedGoogle Scholar
  • 16 Ahiskalioglu A, Kucun T, Yayik AM, Ulas AB, Ates İ. Ultrasound-guided transversus thoracis muscle plane block provides effective postoperative analgesia for pediatric open pectus carinatum surgery: first report. Pain Med 2021; 22 (05) 1233-1235
    CrossrefPubMedGoogle Scholar
  • 17 Graves CE, Moyer J, Zobel MJ. et al. Intraoperative intercostal nerve cryoablation during the Nuss procedure reduces length of stay and opioid requirement: a randomized clinical trial. J Pediatr Surg 2019; 54 (11) 2250-2256
    CrossrefPubMedGoogle Scholar
  • 18 Keller BA, Kabagambe SK, Becker JC. et al. Intercostal nerve cryoablation versus thoracic epidural catheters for postoperative analgesia following pectus excavatum repair: preliminary outcomes in twenty-six cryoablation patients. J Pediatr Surg 2016; 51 (12) 2033-2038
    CrossrefPubMedGoogle Scholar
  • 19 Keppler-Noreuil KM, Rios JJ, Parker VER. et al. PIK3CA-Related Overgrowth Spectrum (PROS): diagnostic and testing eligibility criteria, differential diagnosis, and evaluation. Am J Med Genet A 2015; 167A (02) 287-295
    CrossrefPubMedGoogle Scholar
  • 20 Arshad SA, Hatton GE, Ferguson DM, Li LT, Austin MT, Tsao K. PAPS SPONSOR. Cryoanalgesia enhances recovery from minimally invasive repair of pectus excavatum resulting in reduced length of stay: a case-matched analysis of NSQIP-Pediatric patients. J Pediatr Surg 2021; 56 (07) 1099-1102
    CrossrefPubMedGoogle Scholar
  • 21 Gallardo CC, Martínez J, Bellía-Munzon G. et al. Thoracoscopic cryoanalgesia: a new strategy for postoperative pain control in minimally invasive pectus excavatum repair. Cir Pediatr 2020; 33 (01) 11-15
    PubMedGoogle Scholar
  • 22 Kim S, Idowu O, Palmer B, Lee SH. Use of transthoracic cryoanalgesia during the Nuss procedure. J Thorac Cardiovasc Surg 2016; 151 (03) 887-888
    CrossrefPubMedGoogle Scholar
  • 23 Cha PI, Min JG, Patil A, Choi J, Kothary NN, Forrester JD. Efficacy of intercostal cryoneurolysis as an analgesic adjunct for chest wall pain after surgery or trauma: systematic review. Trauma Surg Acute Care Open 2021; 6 (01) e000690
    CrossrefPubMedGoogle Scholar
  • 24 Aiken TJ, Stahl CC, Lemaster D. et al. Intercostal nerve cryoablation is associated with lower hospital cost during minimally invasive Nuss procedure for pectus excavatum. J Pediatr Surg 2021; 56 (10) 1841-1845
    CrossrefPubMedGoogle Scholar
  • 25 Sun RC, Mehl SC, Anbarasu CR. et al. Intercostal cryoablation during Nuss procedure: A large volume single surgeon's experience and outcomes. J Pediatr Surg 2021; 56 (12) 2229-2234
    CrossrefPubMedGoogle Scholar
  • 26 Torre M, Mameli L, Bonfiglio R. et al. A new device for thoracoscopic cryoanalgesia in pectus excavatum repair: preliminary single center experience. Front Pediatr 2021; 8: 614097
    CrossrefPubMedGoogle Scholar
  • 27 Ju H, Feng Y, Yang BX, Wang J. Comparison of epidural analgesia and intercostal nerve cryoanalgesia for post-thoracotomy pain control. Eur J Pain 2008; 12 (03) 378-384
    CrossrefPubMedGoogle Scholar
  • 28 Roxburgh JC, Markland CG, Ross BA, Kerr WF. Role of cryoanalgesia in the control of pain after thoracotomy. Thorax 1987; 42 (04) 292-295
    CrossrefPubMedGoogle Scholar
  • 29 Yang MK, Cho CH, Kim YC. The effects of cryoanalgesia combined with thoracic epidural analgesia in patients undergoing thoracotomy. Anaesthesia 2004; 59 (11) 1073-1077
    CrossrefPubMedGoogle Scholar
  • 30 Sujka J, Benedict LA, Fraser JD, Aguayo P, Millspaugh DL, St Peter SD. Outcomes using cryoablation for postoperative pain control in children following minimally invasive pectus excavatum repair. J Laparoendosc Adv Surg Tech A 2018; 28 (11) 1383-1386
    CrossrefPubMedGoogle Scholar
  • 31 Keller BA, Kabagambe SK, Becker JC. et al. Intercostal nerve cryoablation versus thoracic epidural catheters for postoperative analgesia following pectus excavatum repair: preliminary outcomes in twenty-six cryoablation patients. J Pediatr Surg 2016; 51 (12) 2033-2038 DOI: 10.1016/j.jpedsurg.2016.09.034.
    CrossrefPubMedGoogle Scholar
  • 32 Trescot AM. Cryoanalgesia in interventional pain management. Pain Physician 2003; 6 (03) 345-360
    CrossrefPubMedGoogle Scholar
  • 33 Filippiadis D, Efthymiou E, Tsochatzis A, Kelekis A, Prologo JD. Percutaneous cryoanalgesia for pain palliation: current status and future trends. Diagn Interv Imaging 2021; 102 (05) 273-278
    CrossrefPubMedGoogle Scholar
  • 34 Evans PJD, Lloyd JW, Jack TM. Cryoanalgesia for intractable perineal pain. J R Soc Med 1981; 74 (11) 804-809
    CrossrefPubMedGoogle Scholar
  • 35 Gabriel RA, Ilfeld BM. Novel methodologies in regional anesthesia for knee arthroplasty. Anesthesiol Clin 2018; 36 (03) 387-401
    CrossrefPubMedGoogle Scholar
  • 36 Green CR, de Rosayro AM, Tait AR. The role of cryoanalgesia for chronic thoracic pain: results of a long-term follow up. J Natl Med Assoc 2002; 94 (08) 716-720
    PubMedGoogle Scholar
  • 37 Gologorsky R, Ewbank C, Idowu O, Kim S. Use of cryoanalgesia as a postoperative pain management for open pectus carinatum repair. Pediatr Surg Int 2021; 37 (01) 179-181
    CrossrefPubMedGoogle Scholar
  • 38 Pilkington M, Harbaugh CM, Hirschl RB, Geiger JD, Gadepalli SK. Use of cryoanalgesia for pain management for the modified ravitch procedure in children. J Pediatr Surg 2020; 55 (07) 1381-1384
    CrossrefPubMedGoogle Scholar
  • 39 Gabriel RA, Finneran JJ, Swisher MW. et al. Ultrasound-guided percutaneous intercostal cryoanalgesia for multiple weeks of analgesia following mastectomy: a case series. Korean J Anesthesiol 2020; 73 (02) 163-168
    CrossrefPubMedGoogle Scholar