Minimally Invasive Repair Of Pectus Excavatum Research Articles

Quality of life with minimally invasive repair of pectus excavatum: a systematic review and meta-analysis.

Minimally invasive repair of pectus excavatum (MIRPE) is a popular method for surgical correction of PE, and its impact on quality of life is a growing area of interest. We performed a systematic review and meta-analysis to evaluate the impact of MIRPE on the quality of life of patients. This study was registered with PROSPERO under reference number CRD42020222061. A literature search of PubMed, Cochrane Library, EMBASE and Scopus was conducted from the date of inception till November 23, 2020. We included studies which administered one or more questionnaires on patients up to 60 years old, parents or both, to assess the quality of life before and after MIRPE. Studies not written in English, abstracts, articles without primary data, reviews and studies which combined data on PE and other deformities were excluded. Risk of bias was assessed using the Risk of Bias in Non-randomised Studies of Interventions and the Cochrane risk of bias tool. A random-effects meta-analysis was performed to obtain mean differences for key themes of quality of life before and after MIRPE. Responses from the same questionnaires, as well as common themes across different questionnaires, were compared. Of the 20 studies identified for systematic review, 7 studies that reported the responses of 478 patients were included in the meta-analysis. Patients who underwent MIRPE experienced an increased self-esteem [standardized mean difference (SMD): 1.38, 95% confidence interval (CI): 0.95 to 1.81, P<0.00001] and a smaller degree of chest interference with their social activities (SMD: 0.84, 95% CI: 0.60 to 1.08, P<0.00001). These findings were consistent even after the implanted bar was removed. MIRPE may be associated with a better quality of life for patients with PE as self-esteem and extent of chest interference with social activities are improved after the procedure. The key limitations of this study are the lack of high-quality evidence due to paucity of randomized trials, and the significant heterogeneity in reported outcomes due to variations in the questionnaires and timepoints of administration.

Preoperative Metal Allergy Testing for Pectus Excavatum Repair Does Not Effectively Identify Patients Who Develop Metal bar Allergy

BackgroundMetal allergy following placement of a metal pectus bar for minimally invasive repair of pectus excavatum (MIRPE) is a rare complication with potentially significant morbidity. There is no consensus regarding preoperative metal allergy testing (MAT). This study aims to assess incidence of metal allergy and titanium bar use in tested and untested patients and trends in MAT with different approaches to MAT. MethodsA retrospective chart review was performed on patients who underwent MIRPE from July 2009 to June 2022 at a single institution. During this time, MAT was performed routinely (RT; routine testing) and selectively (ST; selective testing). ResultsThe cohort included 741 patients for analysis. Metal bar allergy was documented in 1.3 % of all patients; the incidence was 1.3 % in patients with MAT and 1.4 % without MAT. The incidence of bar allergy was 1.1 % in the RT group and 1.6 % in the ST group. In the RT group, bar allergy occurred in 1.4 % (3/216) of patients with a negative MAT. In the ST group, bar allergy occurred in 1.2 % (2/164) of patients with a negative MAT and in 1.9 % (3/162) of untested patients with a stainless-steel bar. Titanium bar use was not significantly different between the RT and ST groups (18.3 % vs 16.3 %, p > 0.05). ConclusionThe incidence of metal bar allergy after MIRPE was less than 2 %, and titanium bar use was not significantly different in routine and selective testing groups. MAT was not associated with a reduction in bar allergy, and its use remains unsupported. Level of EvidenceIII.

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

BackgroundIntrathoracic 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. MethodsRetrospective 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. ResultsWe 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. ConclusionsIn 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 studyRetrospective comparative study. Level of evidenceIII.

Titanium nitride coating of pectus bar increases metal contamination after minimally-invasive repair of pectus excavatum.

Previous studies demonstrated a release of toxic metals, e.g. nickel and chromium, from stainless steel bars used for minimally invasive repair of pectus excavatum (MIRPE). In the present study, we investigated the impact of titanium nitride coating on the metal release and exposure of MIRPE patients. We analyzed the courses of nickel and chromium levels in blood, urine and local tissue in patients undergoing MIRPE with a titanium nitride coated pectus bar between 03/2017 and 10/2018. Sample collection was scheduled prior to MIRPE, at defined postoperative time points and at bar removal. Additionally, we evaluated irritative symptoms. Results were compared to a control group who received uncoated stainless steel bars in a previous time period (03/2015-02/2017). 12 patients received coated pectus bars (mean age 15.7 years). The control group included 28 patients. After implantation of a titanium nitride coated bar, significant increase in systemic nickel and chromium levels after one, two and three years was noted. In an interim analysis one year after MIRPE, we observed patients with coated bars to have significantly elevated trace metal values compared to the control group. This elevation persisted throughout the observation period. Tissue metal values were also significantly increased. Irritative symptoms occurred significantly more often in study patients compared to controls (50.0% vs. 14.3%). Coating of pectus bars with titanium nitride failed to reduce metal contamination after MIRPE. Instead, it resulted in a significant increase of trace metal levels after MIRPE, compared to patients with stainless steel bars, which may be explained by wear of the coating and inter-component mobilization processes.

Minimalized Erlangen Correction Method by Hümmer (MEK) Compared with Conventional and Minimally Invasive Correction Methods for Pectus Excavatum Single Center Experience

Pectus excavatum (funnel chest) is the most common chest wall deformity in childhood and adolescence with a prevalence in the literature ranging from 1 in 3400 to 1 in 1000. In addition to conservative therapy with a suction cup and physiotherapy to improve posture, fitness, and muscle strength, there are several different surgical techniques, many of which have been improved over time. In evaluating the Minimalized Erlangen Correction Method (MEK), the main purpose of this retrospective analysis is to present the results and to compare them with reports on the Minimally Invasive Repair of Pectus Excavatum (MIRPE) technique, especially regarding long-term patient satisfaction, and with other open surgical methods in terms of operative trauma, as well as flexibility in its application, risk of complications, and patient safety.

A Randomized Controlled Trial of Cryoanalgesia for Pain Management following Pectus Excavatum Repair: A Single-Center, Single-Blind, Parallel Design Study.

Conventional postoperative pain management, with an intravenous patient-controlled approach or thoracic epidural analgesia, has proved suboptimal following a minimally invasive repair of pectus excavatum (MIRPE). Considering its postulated mechanism of action, we encouraged cryoanalgesia as an effective method for post-repair pain management and a possibly superior alternative. A randomized, single-blind clinical trial was tested on patients undergoing PE repair in March and December 2022. Among 101 patients, consenting study participants were randomly assigned to one of two groups: cryoanalgesia (group C, n=24) or non-cryoanalgesia (group N, n=24). Group N received conventional pain management. Comparing the results, pain levels were measured using the Visual Analog Scale (VAS-R for resting and VAS-D for dynamic) and the total rescue analgesic consumption was determined. Intrathoracic cryoablation was performed bilaterally on the fourth and seventh intercostal nerves using a cryoprobe at -80°C for 2 min. The two groups had similar baseline-patient characteristics however; group C had a longer mean operative time (159 min vs. 125 min, p<0.01) and experienced significantly less pain throughout the postoperative course, with VAS at 6 h (5.38 vs 7.04, p<0.01) and 48 h (3.17 vs. 5.67, p<0.01). Cryoanalgesia improved postoperative pain control at rest and during movement following PE repair. However, the outcome was less favorable than expected because, the VAS was greater than 4 (moderate pain), although after a day or two, it decreased to lower levels (VAS<4) in the cyro group. Considering its extra invasiveness and instrumentation, a routine cryoanalgesia procedure for pectus surgery is yet to be determined.

Analysis of Factors Affecting Postoperative Opioid Requirement in Pediatric Patients Undergoing Pectus Excavatum Repair with Multimodal Analgesic Management.

Children with pectus excavatum are treated with surgical repair in a procedure known as minimally invasive repair of pectus excavatum (MIRPE). MIRPE causes considerable postoperative pain, resulting in the administration of a substantial dose of opioids. This study aimed to identify perioperative factors that influence the requirement for opioids in children undergoing MIRPE. Retrospective data from children who underwent MIRPE were analyzed. A multimodal analgesic protocol was implemented with a continuous wound infiltration system and administration of non-opioid analgesics. Intravenous opioid analgesics were administered if the pain score was greater than 4. The cumulative opioid use was assessed by calculating the morphine equivalent dose at 6, 24, and 48 h after surgery. Perioperative factors affecting the postoperative opioid use were identified with multiple linear regression analyses. This study included 527 children aged 3-6 years, with a mean age of 3.9 years. Symmetrically depressed chest walls, a lower Haller index, and a lower revised depression index were found to be associated with decreased postoperative opioids. Boys required higher opioid doses than girls. Longer pectus bars (10 inches versus 9 inches) were associated with increased opioid use. Severity indices, gender, and the length of pectus bars influence postoperative opioid requirement in children undergoing MIRPE surgery with multimodal analgesia.

Pectus repair after prior sternotomy: clinical practice review and practice recommendations based on a 2,200-patient database.

The minimally invasive repair of pectus excavatum (MIRPE) is widely accepted as a method of pectus excavatum (PE) repair. Repair is rarely performed in patients with a history of median sternotomy. A feared complication of this procedure is iatrogenic cardiac injury; the risk of injury in patients with prior sternotomy is especially high due to the development of post-surgical retrosternal adhesions, which obscures the "critical view" during MIRPE. A 14-center review reported the incidence to be as high as 7% after analyzing 75 patients with history of sternotomy who underwent MIRPE. Little literature exists on how to best prepare for MIRPE in patients with prior sternotomy. A review of the literature and a retrospective review of over 2,200 patients who underwent MIRPE at our institution was performed to analyze 9 patients who underwent MIRPE after prior sternotomy. Iatrogenic cardiac injury occurred in 2 patients. Given the infrequency in our experience and the low numbers reported in the literature, statistical conclusions cannot be drawn. However, prudent strategies based on this experience include thoracoscopy, routine sternal elevation, direct sub-xiphoid retrosternal dissection, coordination with cardio-thoracic surgeons, preparation for cardio-pulmonary bypass, and massive transfusion protocol availability to optimize surgical outcomes in patients undergoing MIRPE with a history of sternotomy.

Evolution of Pain Control for Adult Pectus Excavatum Repair

BackgroundPain control after minimally invasive repair of pectus excavatum (MIRPE) can be challenging, especially in adult patients undergoing surgical repair. This study reviewed different analgesic modalities used over ≥10 years after pectus repair. MethodsA retrospective analysis was performed of adult patients (≥18 years) who underwent uncomplicated primary MIRPE at a single institution from October 2010 to December 2021. Patients were classified by analgesic modality used: epidural, elastomeric continuous infusion subcutaneous catheters (SC-Caths), and intercostal nerve cryoablation. Comparisons among the 3 groups were performed. ResultsIn total, 729 patients were included (mean age, 30.9 ±10.3 years; 67% male; mean Haller index, 4.9 ±3.0). Patients in the cryoablation group required significantly lower doses of morphine equivalents (P < .001) and had overall the shortest hospital stay (mean, 1.9 ±1.5 days; P < .001) with <17% staying >2 days (vs epidural at 94% and SC-Cath at 48%; P < .001). The cryoablation group had a lower incidence of ileus and constipation (P < .001) but a higher incidence of pleural effusion requiring thoracentesis (P = .024). Mean pain scores among groups were minor (<3), and differences were insignificant. ConclusionsThe use of cryoablation in conjunction with enhanced recovery pathways provided significant benefit to our patients undergoing MIRPE compared with previous analgesic modalities. These benefits included a decrease in length of hospital stay, a reduction of in-hospital opioid use, and a lower incidence of opioid-related complications associated with constipation and ileus. Further studies to assess additional potential benefits with long-term follow-up after discharge are warranted.

Expedited Recovery Pain Management Pathway for Minimally Invasive Repair of Pectus Excavatum (MIRPE)

Expedited Recovery Pain Management Pathway for Minimally Invasive Repair of Pectus Excavatum (MIRPE)

A pilot study of multi-modal pain management for same-day discharge after minimally invasive repair of pectus excavatum (Nuss procedure) in children

BackgroundDespite advancements in minimally invasive repair of pectus excavatum (MIRPE), Nuss procedure, postoperative pain control remains challenging. This report covers a multimodal regimen using bilateral single-shot paravertebral block (PVB) and bilateral thoracoscopic intercostal nerve (T3–T7) cryoablation, leading to significant reduction in length of stay (LOS) and high rate of same-day discharge.Methods This is a comparative study of pain management protocols for patients undergoing the Nuss procedure at a single center from 2016 through 2020. All patients underwent the the same surgical technique for the treatment of pectus excavatum at a single center. Patients received bilateral PVB with continuous infusion (Group 1, n = 12), bilateral PVB with infusion and right-side cryoablation (Group 2, n = 9), or bilateral single-shot PVB and bilateral cryoablation (Group 3, n = 17). The primary outcome was LOS with focus on same-day discharge, and the secondary outcome was decreased opioid usage.ResultsEleven of 17 patients in Group 3 (65%) (bilateral single-shot PVB and bilateral cryoablation) were discharged the same day as surgery. The remaining Group 3 patients were discharged the following day with no complications or interventions. Compared to Group 1 (no cryoablation), Group 3 had shorter LOS (median 4.4 days vs. 0.7 days, respectively, p < 0.001) and significantly decreased median opioid use on the day of surgery (0.92 mg/kg vs. 0.47 mg/kg, p = 0.006).Conclusion Findings demonstrate the feasibility of multimodal pain management for same-day discharge after the Nuss procedure. Future multisite studies are needed to investigate the superiority of this approach to established methods.Level of EvidenceIII.

Automatic implant shape design for minimally invasive repair of pectus excavatum using deep learning and shape registration

Minimally invasive repair of pectus excavatum (MIRPE) is an effective method for correcting pectus excavatum (PE), a congenital chest wall deformity characterized by concave depression of the sternum. In MIRPE, a long, thin, curved stainless plate (implant) is placed across the thoracic cage to correct the deformity. However, the implant curvature is difficult to accurately determine during the procedure. This implant depends on the surgeon’s expert knowledge and experience and lacks objective criteria. Moreover, tedious manual input by surgeons is required to estimate the implant shape. In this study, a novel three-step end-to-end automatic framework is proposed to determine the implant shape during preoperative planning: (1) The deepest depression point (DDP) in the sagittal plane of the patient’s CT volume is automatically determined using Sparse R-CNN-R101, and the axial slice containing the point is extracted. (2) Cascade Mask R-CNN-X101 segments the anterior intercostal gristle of the pectus, sternum and rib in the axial slice, and the contour is extracted to generate the PE point set. (3) Robust shape registration is performed to match the PE shape with a healthy thoracic cage, which is then utilized to generate the implant shape. The framework was evaluated on a CT dataset of 90 PE patients and 30 healthy children. The experimental results show that the average error of the DDP extraction was 5.83 mm. The end-to-end output of our framework was compared with surgical outcomes of professional surgeons to clinically validate the effectiveness of our method. The results indicate that the root mean square error (RMSE) between the midline of the real implant and our framework output was less than 2 mm.

Management of Internal Mammary Artery Injuries Associated With the Nuss Procedure.

The minimally invasive repair of pectus excavatum (MIRPE), or Nuss procedure, is regarded as the gold standard technique for the treatment of symptomatic pectus excavatum. Minimally invasive repair of pectus excavatum is regarded as a low-risk operation with a reported life-threatening complication rate estimated at around 0.1%. Presented are three cases of right internal mammary artery injury (RIMA) after MIRPE resulting in massive hemorrhage in both the acute and chronic postoperative setting and subsequent management strategies. Exploratory thoracoscopy and angioembolization were utilized which achieved prompt hemostasis and allowed for complete patient recovery.

Impact of Cryoanalgesia Use During Minimally Invasive Pectus Excavatum Repair on Hospital Days and Total Hospital Costs Among Pediatric Patients

IntroductionSurgical repair of pectus excavatum is a painful procedure requiring multimodal pain control with historically prolonged hospital stay. This study aimed to evaluate the impact of cryoanalgesia during minimally invasive repair of pectus excavatum (MIRPE) on hospital days (HDs), total hospital costs (HCs), and complications. We hypothesized that cryoanalgesia would be associated with reduced HDs and total HCs with no increase in post-operative complications. MethodsWe conducted a retrospective review of pediatric patients who underwent MIRPE from 2011 to 2021. MIRPE details and post-operative outcomes within 90 days were abstracted. Total HDs included the index MIRPE admission and readmissions within 90 days. HCs were obtained from the hospital accounting system, retroactively adjusting for medical inflation. Bayesian generalized linear models with neutral prior assuming no effect were used. Differences between treatment groups were assessed using gamma distribution (HDs and HCs) and poisson (post-operative complications). All models used log link and controlled for age, gender, race, and Haller index. ResultsForty-four patients underwent MIRPE during the study period. Cryoanalgesia was utilized in 29 (66%) patients. The probability of a reduction with cryoanalgesia vs. no cryoanalgesia was 99% for HDs (3.0 vs. 5.4 days; Bayesian RR: 0.6, 95% CrI: 0.5–0.8), 89% for HCs ($18,787 vs. $19,667; RR: 0.9, 95% CrI: 0.8–1.1), and 70% for postoperative complications (17% vs 33%; RR: 0.8, 95% CrI: 0.3–1.9). ConclusionCryoanalgesia use in MIRPE likely reduced HDs, HCs, and post-operative complications. Further research is warranted to confirm these findings in large prospective studies. Level of EvidenceLevel III.

Changes in Pulmonary Functions of Adolescents with Pectus Excavatum Throughout the Nuss Procedure

BackgroundWe aimed to determine the longitudinal changes in pulmonary functions of adolescents with Pectus Excavatum who underwent the Nuss procedure, the minimally invasive repair of pectus excavatum (MIRPE). MethodsLung function measurements were performed before bar implantation (T0), at least six weeks to ten months after implantation (T1a), at least eleven months to sixty-one months after bar implantation (T1b) and at least two weeks after bar explantation (T2). ResultsData of 114 patients (83.3% male) whose median age at implantation was 15.6 years and at explantation 18.7 years were analyzed. Shortly after implantation at T1a a significant decline of vital capacity (VC; n = 82), forced vital capacity (FVC; n = 78) and forced expiratory volume in 1 second (FEV1; n = 80) compared to T0 was seen. At T1b a significant decline for the residual volume (RV; n = 83), the residual volume/total lung capacity ratio (RV/TLC; n = 81), the total specific airway resistance (sRaw; n = 80) and the total airway resistance (Raw; n = 84) also compared to T0 was measured. In the comparison of T1b to T2 a significant increase of VC, FVC (n = 67), FEV1 (n = 69), TLC (n = 67) and a significant decrease of Raw (n = 66), sRaw, RV (n = 65) and the RV/TLC (n = 64) ratio could be observed. In the direct analysis between T0 and T2, after the explantation of the bar a significant increase in VC (n = 54), FVC (n = 52), and TLC (n = 55) and a significant decrease of RV (n = 51) and the RV/TLC index (n = 50), and in airway resistance parameters like Raw (n = 52) and sRaw (n = 51) could be detected. ConclusionsLung function values along with markers of airway resistance improve in patients after the complete procedure of MIRPE. Level of EvidenceLevel II.

Novel index to estimate the cephalocaudal extent of the excavation in pectus excavatum: The Titanic index

Quantification of the severity of pectus excavatum deformities is currently performed using the Haller index (HI) and the Correction index (CI), amongst others. However, most indexes characterize the severity at the point of maximum excavation. We present a new index, the Titanic index (TI), aimed at the appraisal of the cephalocaudal extent of the excavation and its potential clinical use. Retrospective analysis of a cohort of patients who underwent a minimally invasive repair of pectus excavatum (MIRPE) between July 2020 and April 2022at a single center. We defined TI as the percentage of the sternum that lied behind the anterior costal line observed in the CT. Demographics, HI, CI, and TI calculated based on computed tomography images (CT) were analyzed. Also, we compared the severity indexes of two groups of patients divided by the number of implants introduced per patient (group A: two implants, and group B: more than two). Seventy-eight patients (92% male) were included, with a mean age of 17.2±4.8 years. The mean TI was 37%. Albeit weak, we identified significant correlations between the TI and the HI and, more closely, to the CI. Two implants were introduced in 37 (47%) patients, and more than two in 41 (53%) patients. Compared to patients with two implants, the group of patients who received more than two implants were older and showed worse thoracic indexes. Using receiver operating characteristic curve analysis, we identified the TI as a better predictor of the need for more than two implants than HI and CI. In this regard, a TI larger than 66.5% had a sensitivity of 93% and a specificity of 92%. We propose a novel index for the categorization of the severity of pectus excavatum. This index might be useful in planning the number of implants required for complete thoracic remodeling during MIRPE. Level III. Retrospective Comparative Study.

A Novel Method of Minimally Invasive Repair of Pectus Excavatum (MIRPE) in Patients with Bilateral Breast Prostheses: a Report of Two Patients

The literature on minimally invasive repair of pectus excavatum in patients with breast prostheses is very scarce, with only one report to date. We present two cases treated in our center in which this technique was performed without prior removal of the breast prostheses. In one of the patients, a sternal zenithal traction system was additionally used to facilitate retrosternal dissection. In this work, we present the technical details of the procedure. One of the patients presented with postoperative Dressler’s syndrome which resolved with conservative measures. We found no correlation between this complication and the presence of breast prostheses. After 4 and 2 years respectively, both patients are asymptomatic, with an adequate correction of the defect, and being followed up. Minimally invasive repair of pectus excavatum technique is safe and feasible in patients with bilateral breast prostheses. The placement of breast prostheses prior to the correction of rib cage deformities leads to an unpredictable aesthetic result in certain aspects, such as the exact positioning of the nipple areola complex. The approach to this pathology by a pediatric surgeon, who considers not only the aesthetic aspect but also the rib cage involvement and the potential presence of additional malformations (for example, a Poland sequence), is, in the authors’ opinion, beneficial to the overall outcome of these patients.

Intercostal Nerve Cryoablation in Minimally Invasive Repair of Pectus Excavatum: Effect on Pulmonary Function.

Introduction: Cryoablation of intercostal nerves is performed for pain control after minimally invasive repair of pectus excavatum (MIRPE). Cryoablation affects both sensory and motor neurons, resulting in temporary anesthesia to the chest wall and loss of intercostal motor function. The study objective is to determine the effect of cryoablation on incentive spirometry (IS) volumes, as a measure of pulmonary function, after MIRPE. Materials and Methods: A single-institution retrospective review of pediatric patients undergoing MIRPE was performed. All patients received a multimodal regimen (MMR) of analgesics postoperatively. Three groups were compared-cryoablation (CRYO), elastomeric pain pump (EPP), and MMR alone. The primary outcomes were postoperative IS volumes and IS volumes as a ratio of preoperative forced vital capacity (FVC). Secondary outcomes included pain scores, opioid use, length of stay (LOS), and infectious complications. Results: MIRPE was performed in 115 patients: 50 CRYO, 50 EPP, and 15 MMR alone. Groups were similar for demographics and pectus excavatum severity. Postoperative spirometry measurements were similar across groups: IS (CRYO 750 mL [500,961] versus EPP 750 mL [590,1019] versus MMR 696 mL [500,1037], P = .77); IS/FVC (CRYO 0.19 [0.14,0.26] versus EPP 0.20 [0.16,0.26] versus MMR 0.16 [0.15,0.24], P = .69). Although pain scores were also similar across groups, CRYO patients used less opioid (P < .05) and had shorter LOS (P < .05). Postoperative pneumonia was rare and similar across groups (P = 1.00). Conclusion: Intercostal nerve cryoablation during MIRPE does not adversely affect postoperative IS volumes or increase pneumonia rate, despite the temporary loss of motor innervation to intercostal muscles. Cryoablation provides effective pain control with less opioid use.

Nickel contamination after minimally-invasive repair of pectus excavatum persists after bar removal.

BackgroundMinimally-invasive repair of pectus excavatum (MIRPE) has been shown to be associated with high release of trace metals into patient’s body. The aim of our study was to analyze the kinetics of metal contamination after MIRPE and after bar removal.MethodsWe prospectively assessed nickel and chromium changes in blood, urine, and local tissue in patients undergoing MIRPE with stainless-steel bar(s). Baseline samples were taken prior to surgery, further samples were taken at six defined time points until 30 months after bar removal. Clinical symptoms were evaluated at the time of every sample collection.Results28 patients were included (mean age 16.4 years). At four weeks after MIRPE and persisting up to bar removal, we found significantly elevated trace metal levels in blood and urine. Tissue nickel and chromium levels were significantly elevated at the time of bar removal. After bar removal, the concentration of trace metal in urine and the concentration of chromium in plasma decreased gradually. In contrast, nickel levels in blood further increased. Five patients showed irritative symptoms after MIRPE, all symptomatic patients had elevated metal levels.ConclusionsFollowing MIRPE, we found a rapid systemic increase of nickel and chromium. Our data indicate that trace metal release could cause irritative symptoms. The prolonged elevated systemic nickel levels beyond bar removal necessitate further investigations of the long-term side effects of MIRPE.

Limited cryoablation reduces hospital stay and opioid consumption compared to thoracic epidural analgesia after minimally invasive repair of pectus excavatum.

pain following minimally invasive repair of pectus excavatum (MIRPE) is a critical concern that leads to a prolonged hospital stay and high doses of opiates administered to the patients. This study aimed to evaluate the efficacy of intraoperative cryoanalgesia (cryoablation of the intercostal nerves) during MIRPE. We retrospectively analyzed the data of 64 patients who underwent MIRPE and received cryoanalgesia or epidural analgesia between January 2019 and January 2021. The oral morphine milligram equivalent (MME) was used to calculate the dosage of opioid agents. The median age was 15 years (range, 4–33 years). The median postoperative hospital stay was 4 days (range, 2–6 days), with a median oral MME consumption of 45 mg (ranging from 0 to 1360 mg). Cryoanalgesia was performed in 38 patients, and epidural analgesia was administered to the remaining 26 patients. The cryoanalgesia group had a significantly lesser pain score, shorter postoperative hospital stay and lower oral MME consumption than the epidural analgesia group (5 vs 2; P < .001, 3 days vs 5 days; P < .001, 19 mg vs 634 mg; P < .001). Cryoanalgesia appears to reduce postoperative hospital stay and opioid consumption compared with epidural analgesia. The outcomes of this study indicate that cryoanalgesia might be a safe and effective method for pain control following MIRPE.