O3312: Bridging the Gap in Pain Control after Minimally Invasive Repair of Pectus Excavatum: A 15-year Evolution

Background: Pectus excavatum is a common congenital chest wall abnormality characterized by concavity of the anterior chest. Minimally invasive repair of pectus excavatum (MIRPE) is the surgical treatment of choice. While minimally invasive, the procedure is associated with significant pain. Effective pain management is crucial for improving patient comfort, shortening hospital length of stay (LOS), and reducing complications. The introduction of intercostal nerve cryoablation has become increasingly common, but techniques to mitigate the delay of onset of analgesia from cryoablation vary. Our aim was to evaluate the efficacy of our institution's perioperative pain control protocol over multiple iterations.

Methods: An IRB-approved retrospective cohort study was conducted evaluating all patients at our institution who underwent MIRPE from 2010-2024. Comparative analysis was conducted between different pain management modalities: group 1 - thoracic epidural analgesia, paravertebral nerve block, or patient-controlled analgesia alone, group 2 - cryoablation, and group 3 - cryoablation with thoracoscopic intercostal nerve blocks (TINBs). Univariate and multivariable regression models were analyzed.

Results: We included 146 patients (91% male) who underwent MIRPE with an average age of 17 years (SD: 2.6) and an average Haller index of 4.6 (SD: 1.9) (Table 1). On regression analysis, there was no difference in pain scores among the groups on postoperative day (POD) 1-3. However, cryoablation alone was associated with increased opioid use on POD 1 by 1.38 MME/kg (95% CI: 1.06, 1.71) and on POD2 by 0.75 MME/kg (95% CI: 0.33, 1.17), with a significant decrease in LOS of 1.3 days (95% CI: -2.08, -0.58) compared to group 1. The addition of TINB showed significant decrease of opioid use on POD 1 by 1.25 MME/kg (95% CI: -1.58, -0.93), on POD2 by 0.77 MME/kg (95% CI: -1.20, -0.34), and total in-hospital use by 3.19 MME/kg (95% CI: -4.83, -1.55) (Figure 1), with significant decrease in LOS of 0.92 days (95% CI: -1.69, -0.15) compared to cryoablation alone. Overall, in the cryoablation with TINB group compared to group 1, there was a significant decrease of opioid use on POD 3 by 0.61 MME/kg (95% CI: -0.95, -0.27) and total inhopsital use by 1.79 MME/kg (95% CI: -2.79, -0.78) (Figure 1) with a significant decrease in LOS of 2.25 days (95% CI: -2.72, -1.78).

Conclusion: As our perioperative pain protocol has evolved, the introduction of cryoablation alone increased inpatient postoperative opioid use and decreased length of stay, while maintaining mild pain scores. However, the addition of thoracoscopic intercostal nerve blocks to cryoablation effectively bridged the gap to cryoablation onset, resulting in decreased total in-hospital opioid use, lower than historical pain modalities, and decreased length of stay.