Update Course Rewind: Cryoanalgesia in Pectus Cases 2024
With Dr. John De Fiori · hosted by Dr. Lizzie Lee · StayCurrentMD
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What the experts said
Doctor De Fiori performs cryoanalgesia from T3 to T8, although most of the literature is just to T7.
The new probe tip gets down to temperature about 20 seconds faster, the freeze cycle is 90 seconds instead of 2 minutes, and it's 15 seconds less to thaw back to temperature.
A new 10 millimeter probe with a 60-second freeze cycle that gets down quicker is coming out on October 1st.
Doctor De Fiori uses double lumen tube in all cases because the exposure of the intercostal nerves is exceptional and it ensures that the block is applied posterior enough to get the lateral cutaneous branch.
Doctor De Fiori has gotten multiple calls from other surgeons saying sometimes their blocks don't work, and invariably it's a surgeon using a single lumen tube doing the block too far anteriorly because they can't get posterior to the anterior axillary line.
If you don't get posterior enough with the cryoprobe, that's when you get blocks that are ineffective.
Doctor De Fiori has done the double freeze technique (main nerve and collateral branch) in 20 patients, and peak pain scores have dropped from about 5 to about 3.
The double freeze technique hasn't affected Doctor De Fiori's length of stay because 98% of his patients go home the next day anyway.
The new probe takes half the amount of time, and Doctor De Fiori is now doing double the number of blocks.
Cryoanalgesia is a minimally invasive procedure to repair pectus excavatum or alleviate pain during surgery on the chest wall that temporarily blocks nerve conduction along peripheral nerve pathways and relieves pain by freezing the affected nerve.
The freeze point is in the posterior axillary line, 4 centimeters from the vertebral column.
With the original cryoprobe, it's a 2-minute freeze cycle.
Subpleural injection with 0.25% marcaine with epinephrine works immediately, as opposed to the 8 to 10 hour delay with the cryo nerve block.
Subpleural injection takes only 15 seconds per interspace.
50% of the update course audience has never used cryoanalgesia.
About 40% of the update course responders answered that cost is the main reason they don't use cryoanalgesia.
Doing T3 to T8 bilaterally with the new probe saves almost 30 minutes.
The new probe has improved shaft insulation so that it can actually touch the lung, since it only reaches room temperature.
A Chicago paper showed that a 1 minute freeze cycle instead of a 2 minute freeze cycle had nerve blocks that were just as effective.
The Chicago study was limited because they did not measure pain scores or compare the 1 minute freeze cycle directly to 2-minute freeze cycles.
There is a risk of pneumothorax from the lung tearing after inadvertent adhesion to the cryoprobe.
The double lumen endotracheal tube helps minimize pneumothorax risk by deflating the lung and maximizing working space so that the cryoprobe does not touch the lung.
A major advantage of the double lumen tube over the single lumen tube is that it helps prevent the nerve block from being done too far anteriorly, which will make the nerve block ineffective.
Doctor Sung Kim did a cadaver study at UCSF showing that 18% of the lateral cutaneous branch nerves are posterior to the mid axillary line.
Some surgeons have success with using a single lumen tube doing a mediastinal dissection, going across from the right to the left side.
Doctor Kim showed in the study that there is a large collateral branch of the intercostal nerve that runs along the top of the nerve, separate from the main intercostal branch on the bottom of the nerve.
In a small group of patients, Doctor Kim cryoablated the main intercostal nerve at the bottom of the rib and the collateral branch at the top of the rib below it.
As you move down toward T7 and T8, the interspace will widen enough to freeze both the main nerve and collateral branch.
In the UCSF study, when they did 2 freeze points per interspace on 22 patients, the length of stay decreased from 2 days to 1 day.
In the UCSF study, 9 out of the 22 patients reported pain scores of 0.
Cryoanalgesia controls pain and decreases hospital length of stay with few short-term complications.