Update Course Rewind: Pectus Excavatum 2021

Published: 2022-08-16

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Dr. Lee Ponsky

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Inside this episode

Kai, the Library's AI content creator, listened to this episode and mapped who's speaking, the chapters, key claims, and cases. Every item links to the exact moment in the recording.

AI-enriched

Who's speaking

Cecilia Higiena — host
Speaker 2 — host
Ellen Ncisco — host
Todd Ponsky — guest

Chapters

0:00Introduction and Cryoanalgesia for Pain Control — Introduction to the podcast episode reviewing a pectus excavatum session. Presentation of a case of a 16-year-old with pectus index 5.5 and discussion of cryoanalgesia as a pain control method that reduced length of stay to one day and dramatically reduced opioid use compared to epidural and PCA.
3:50Alternative Pain Management Approaches — Discussion of erector spinae catheters as an alternative to cryoanalgesia, achieving two-day length of stay with reduced opioid requirements. Presentation of multimodal pain control regimens and their effectiveness.
7:00Surgical Technique Updates — Discussion of technical aspects of the Nuss procedure including bar length selection (shorter bars providing more sternal pressure), use of sternal elevators for safe passage, subxiphoid incisions, and debate over left-to-right versus right-to-left bar passage direction.
10:25Summary and Closing — Recap of key points on pain management options and surgical techniques, with podcast closing remarks and promotion of upcoming events.

Key claims

1:02A randomized trial of 110 patients comparing epidural and PCA for pectus excavatum pain control showed that epidurals did not provide superior pain relief — Cecilia Higiena
1:21After implementing cryoanalgesia, a patient went home on post-operative day one, which was a dramatic improvement over previous pain control methods — Speaker 2
1:56Cryoanalgesia uses cold temperatures to cause a conduction block that interrupts pain impulses to the brain — Cecilia Higiena
2:09The cryoanalgesia technique involves freezing underneath ribs four through seven for two minutes per rib — Cecilia Higiena
2:09Cryoanalgesia should not be performed on rib eight or below because it can cause abdominal wall paralysis — Cecilia Higiena
2:33With cryoanalgesia, hospital length of stay decreased from four days to one day — Speaker 2
2:43Cryoanalgesia dramatically reduced median morphine equivalents compared to previous pain control methods — Cecilia Higiena
2:52There are no long-term studies on cryoanalgesia outcomes — Speaker 2
3:14Medical devices and techniques are not required to undergo clinical trials before introduction to market, unlike medications — Cecilia Higiena
4:08Erector spinae catheters are placed by the pain team with ultrasound guidance and are juxtaposed to but not in the vertebral space — Speaker 2
4:08Erector spinae catheters stay in for five days, with hospital stay of two days, and catheters are pulled out by the family on the third day while at home — Speaker 2
4:30Erector spinae catheters reduced opioid requirements both in the hospital and outside of the hospital — Cecilia Higiena
4:30With erector spinae catheters, hospital stay is two days, which is much less than the four or five days seen with epidurals — Cecilia Higiena
4:50Cryoanalgesia changed not just when patients go home but how they feel when they go home — Speaker 2
5:40For multimodal pain therapy, the best treatments are preoperative counseling, gabapentin both pre and postoperatively, methadone, clonidine, bowel regimen medications and antiemetics — Cecilia Higiena
6:20With multimodal pain control at one institution, length of stay is under two days and patients are off opioids by one week — Cecilia Higiena
6:40If bars are going to flip, they flip early because they were sitting in a bad spot, the bar was not wrapped tight enough, or it was not secured well — Speaker 2
6:40Bar flippage is completely a surgical issue related to bar positioning and securing technique — Speaker 2
7:00Computational modeling showed that shorter flat bars have more pressure on the sternum compared to traditionally U-shaped bars, making them more stable — Cecilia Higiena
7:40Sternal elevator is used in about 10% of cases at one institution — Cecilia Higiena
8:00In younger patients with average anatomy, thoracoscopy provides adequate visualization without needing a sternal elevator — Cecilia Higiena
8:20In really deep stiff pectus cases, sternal elevation allows less tissue damage and a better repair — Cecilia Higiena
8:40One surgeon uses the sternal elevator in every case to eliminate guesswork and enable passage in and out at the same intercostal space — Cecilia Higiena
9:00Thoracoscopy, sternal elevator, vacuum bell in the operating room, or subxiphoid incision all serve the purpose of avoiding cardiac injury — Cecilia Higiena
9:30Passing the bar from left chest to right chest is preferred by some surgeons because going right to left means the introducer points directly at the ventricle — Speaker 2
10:00Bar passage direction probably does not make a significant difference as long as the substernal space is well dissected and everything is clear — Speaker 2

Cases discussed

0:3116-year-old male with pectus excavatum presenting with shortness of breath on exertion

Points of disagreement

2:52Use of cryoanalgesia for pectus excavatum pain control
- Speaker 2: Cryoanalgesia works well but there are concerns about lack of long-term data and potential for chronic neuropathic pain
- Cecilia Higiena: Cryoanalgesia has dramatically improved outcomes with one-day length of stay and minimal opioid use, though acknowledges need for registry to track long-term outcomes
7:40Frequency of sternal elevator use
- Cecilia Higiena: Uses sternal elevator in about 10% of cases, primarily in deep stiff pectus cases, as thoracoscopy provides adequate visualization in average younger patients
- Cecilia Higiena: Uses the sternal elevator in every case to eliminate guesswork and ensure consistent intercostal space passage
9:30Direction of bar passage (left-to-right versus right-to-left)
- Speaker 2: Prefers left chest to right chest passage because right to left means the introducer points directly at the ventricle
- Speaker 2: Always performed right to left and found it easier, uses sternal elevator and thoracoscopy for safety
- Speaker 2: Always did left to right passage
- Speaker 2: Direction probably does not matter as long as substernal space is well dissected and clear

Open questions

What are the long-term outcomes and potential complications of cryoanalgesia for pectus excavatum pain control?
Is there an optimal bar length that balances stability with surgical outcomes?
Does the direction of bar passage (left-to-right versus right-to-left) affect clinical outcomes when adequate visualization is ensured?

This episode was analyzed and enriched by Kai, the Library's AI content creator. Every item links to the moment it comes from — click a timestamp to listen in context.

Written for:

Cryoanalgesia Versus Erector Spinae Catheters for Pectus Excavatum Pain Control

The patient case from this episode, retold from presentation to outcome with the decisions made along the way. Written by Kai from the episode transcript and reviewed before publishing.

For specialists · Case narrative · AI-written, human-reviewed

The Presentation

A 16-year-old male presented with shortness of breath on exertion. He had no comorbidities and a pectus index of 5.5. The plan was chest wall reconstruction, and the question facing the surgical team was which perioperative pain control strategy to employ 1:02.

The Decision Point

The traditional approach—epidural versus patient-controlled analgesia—had already been tested at one institution in a randomized trial of 110 patients, and epidurals had not demonstrated superior pain relief 1:02. The team was enrolling patients in a comparative study when they performed their first cryoanalgesia case. That patient went home on postoperative day one 1:21. As one discussant put it: "When that patient went home on post-op day one, equipoise was lost. Once you see it, it's sort of a different game" [q2].

The question became whether to abandon the ongoing trial and adopt cryoanalgesia universally, or whether to pursue alternative regional techniques that might offer comparable outcomes without the uncertainty of long-term cryoanalgesia effects.

Cryoanalgesia uses cold temperatures to create a conduction block that interrupts pain impulses 1:56. The technique involves freezing underneath ribs four through seven for two minutes per rib 2:09. Rib eight and below are avoided due to risk of abdominal wall paralysis 2:09. The results were dramatic: hospital length of stay dropped from four days to one day 2:33, and median morphine equivalents decreased substantially 2:43.

But the absence of long-term outcome data created hesitation 2:52. Unlike medications, medical devices and techniques are not required to undergo clinical trials before market introduction 3:14, and the concern centered on potential chronic neuropathic complications that might not manifest for years.

The alternative under consideration was erector spinae catheters. These are placed by the pain team with ultrasound guidance, positioned adjacent to but not within the vertebral space 4:08. The catheters remain in place for five days, with hospital discharge at two days and family-managed catheter removal on day three at home 4:08. This approach reduced opioid requirements both in-hospital and after discharge 4:30, with hospital stays of two days—substantially less than the four to five days seen with epidurals 4:30.

What the Team Did

Different institutions made different choices. One center adopted cryoanalgesia after initial skepticism, with a surgeon noting that "it's not just when they go home. It's how they feel when they go home. And the cryo has been unbelievable" [q8]. Another center continued with erector spinae catheters, accepting a two-day length of stay as a meaningful improvement over epidurals even if not matching cryoanalgesia's one-day discharge 4:30.

A third approach emphasized multimodal pain therapy without regional techniques: preoperative counseling, gabapentin pre- and postoperatively, methadone, clonidine, bowel regimen medications, and antiemetics 5:40. This regimen achieved length of stay under two days with patients off opioids by one week 6:20.

The Outcome

The case presentation did not include long-term follow-up data. The immediate perioperative outcomes were reported—length of stay, opioid consumption, patient comfort at discharge—but the discussants explicitly acknowledged that long-term safety data for cryoanalgesia do not exist 2:52. One surgeon stated: "I accept Vic's concerns and criticisms. And I agree, perhaps, you know, that we do need to have a registry for this. But it has totally changed the management of these patients" [q9].

What This Changes

The transferable judgment is not that one technique is definitively superior, but that the pain control landscape for pectus excavatum repair has fundamentally shifted. Epidurals no longer represent the ceiling of what is achievable. Cryoanalgesia offers the shortest length of stay and lowest opioid consumption, but requires acceptance of unknown long-term risk. Erector spinae catheters provide a middle path: better than epidurals, requiring family participation in catheter management, achieving two-day discharge. Aggressive multimodal protocols without regional techniques can approach similar outcomes in experienced hands.

The choice depends on institutional resources, family capability for home catheter management, surgeon comfort with cryoanalgesia technique, and tolerance for uncertainty regarding late complications. What is no longer defensible is routine four- to five-day hospitalization with epidural-based pain control when multiple alternatives have demonstrated superior results.

Takeaways from this story

Cryoanalgesia reduced hospital stay from four days to one day and dramatically decreased opioid use compared to epidurals
Erector spinae catheters achieve two-day discharge with reduced opioids, requiring family catheter removal at home on day three
Long-term safety data for cryoanalgesia do not exist, creating uncertainty about late neuropathic complications
Multimodal protocols with gabapentin, methadone, and clonidine can achieve under two-day stays without regional techniques

Pectus Excavatum Repair: Pain Control Revolution and Technical Refinements

The episode's main topic retold as a plain-language walkthrough — what it is, why it matters, and what the speakers concluded. Written by Kai from the episode transcript and reviewed before publishing.

For trainees · Explainer · AI-written, human-reviewed

Why This Subspecialty Exists

Pectus excavatum — the inward depression of the anterior chest wall — is the most common congenital chest wall deformity. While some cases are cosmetic, severe deformity compresses the heart and lungs, limiting cardiopulmonary function. The Nuss procedure, a minimally invasive repair placing a curved metal bar beneath the sternum to push it outward, transformed management. But the operation remained notorious for severe postoperative pain, often requiring days of hospitalization with epidural analgesia or patient-controlled analgesia. The subspecialty challenge has been making this effective operation tolerable.

The Core Clinical Problem

A randomized trial of 110 patients comparing epidural and PCA for pectus excavatum pain control showed that epidurals did not provide superior pain relief 1:02. Neither approach adequately controlled the intense intercostal pain from bar placement, and both kept patients hospitalized for days. The problem was not just duration of stay but quality of recovery — patients went home still in significant pain, requiring substantial opioid prescriptions.

How the Approach Works

Cryoanalgesia: The Disruptive Innovation

Cryoanalgesia uses cold temperatures to cause a conduction block that interrupts pain impulses to the brain 1:56. The technique involves freezing underneath ribs four through seven for two minutes per rib 2:09. Cryoanalgesia should not be performed on rib eight or below because it can cause abdominal wall paralysis 2:09.

The impact was immediate and dramatic. With cryoanalgesia, hospital length of stay decreased from four days to one day 2:33, and the procedure dramatically reduced median morphine equivalents compared to previous pain control methods 2:43. One discussant described the moment of conversion: "When that patient went home on post-op day one, equipoise was lost" [q2]. Another, initially skeptical, noted that "it's not just when they go home. It's how they feel when they go home" [q8].

The technique adds operative time — the cryoprobe is passed through a separate port, and each rib requires two minutes of freezing. But for many surgeons, the trade-off is worth it.

Alternative Approaches

Erector spinae catheters represent a middle path. These are placed by the pain team with ultrasound guidance and are juxtaposed to but not in the vertebral space 4:08. The catheters stay in for five days, with hospital stay of two days, and catheters are pulled out by the family on the third day while at home 4:08. Erector spinae catheters reduced opioid requirements both in the hospital and outside of the hospital 4:30, achieving hospital stays substantially shorter than traditional epidural approaches 4:30.

Multimodal pain therapy without regional techniques can also be effective. The best treatments are preoperative counseling, gabapentin both pre and postoperatively, methadone, clonidine, bowel regimen medications and antiemetics 5:40. With multimodal pain control at one institution, length of stay is under two days and patients are off opioids by one week 6:20.

Technical Refinements

Bar stability has improved through better understanding of mechanics. Computational modeling showed that shorter flat bars have more pressure on the sternum compared to traditionally U-shaped bars, making them more stable 7:00. If bars are going to flip, they flip early because they were sitting in a bad spot, the bar was not wrapped tight enough, or it was not secured well 6:40. Bar flippage is completely a surgical issue related to bar positioning and securing technique 6:40.

Safe passage of the introducer behind the sternum remains paramount. Sternal elevator is used in about 10% of cases at one institution 7:40. In younger patients with average anatomy, thoracoscopy provides adequate visualization without needing a sternal elevator 8:00. In really deep stiff pectus cases, sternal elevation allows less tissue damage and a better repair 8:20. One surgeon uses the sternal elevator in every case to eliminate guesswork and enable passage in and out at the same intercostal space 8:40. Thoracoscopy, sternal elevator, vacuum bell in the operating room, or subxiphoid incision all serve the purpose of avoiding cardiac injury 9:00.

Even the direction of bar passage is debated. Passing the bar from left chest to right chest is preferred by some surgeons because going right to left means the introducer points directly at the ventricle 9:30. Others have always passed right to left without incident. Bar passage direction probably does not make a significant difference as long as the substernal space is well dissected and everything is clear 10:00.

Where Practice Remains Contested

The enthusiasm for cryoanalgesia is not universal. There are no long-term studies on cryoanalgesia outcomes 2:52. Concerns about chronic neuropathic pain persist. Medical devices and techniques are not required to undergo clinical trials before introduction to market, unlike medications 3:14 — meaning the long-term safety data that would be mandatory for a new drug simply does not exist for cryoanalgesia. Some centers have adopted it widely; others remain cautious, preferring erector spinae catheters or optimized multimodal regimens.

When to Involve This Team

The discussion did not address specific referral criteria or timing. Pectus excavatum repair is typically performed in adolescence when the chest wall is still malleable but the patient can participate in the decision and postoperative care. Severe cases with documented cardiopulmonary compromise warrant earlier referral. The choice of pain management approach — and the institutional experience with each technique — should be part of the preoperative discussion with families.

Takeaways from this story

Cryoanalgesia reduced pectus repair hospital stay from four days to one day while dramatically cutting opioid use.
No long-term safety data exists for cryoanalgesia because devices bypass the clinical trial requirements mandatory for drugs.
Erector spinae catheters achieve two-day stays with reduced opioids, offering a middle path between epidurals and cryoanalgesia.
Shorter flat bars create more sternal pressure than U-shaped bars, improving stability and reducing bar flippage risk.
Multiple techniques prevent cardiac injury during bar passage; choose based on case complexity and what ensures clear visualization.

Topic overview

This podcast episode summarizes a 2021 pediatric surgery update course session on pectus excavatum repair, focusing on perioperative pain control and surgical technique refinements. The discussion centers on cryoanalgesia as a pain management approach that reduced hospital length of stay from four days to one day and dramatically decreased opioid requirements compared to epidural and PCA, though concerns about lack of long-term safety data remain. Alternative pain strategies including erector spinae catheters and multimodal regimens are presented as achieving two-day length of stay. Technical aspects covered include bar length selection (shorter bars may provide more sternal pressure and stability), use of sternal elevators to ensure safe passage of the introducer, and surgeon preference regarding left-to-right versus right-to-left bar passage direction.

Key takeaways

Cryoanalgesia reduced pectus excavatum hospital stay from 4 days to 1 day and dramatically cut opioid use vs epidural/PCA. (2:33)
Erector spinae catheters achieve 2-day hospital stays with reduced opioid needs; families remove catheters at home on day 3. (4:08)
Multimodal pain regimens (gabapentin, methadone, clonidine, counseling) yield <2-day stays and opioid-free by 1 week. (5:40)
Shorter flat bars generate more sternal pressure than U-shaped bars, improving stability and reducing bar flip risk. (7:00)
Sternal elevator use in deep/stiff pectus cases reduces tissue damage and ensures safe introducer passage. (8:20)

Keywords

pectus excavatum shortness of breath on exertion chronic neuropathic pain post-anesthetic nausea abdominal wall paralysis chest wall reconstruction Nuss procedure cryoanalgesia epidural PCA thoracoscopy erector spinae catheter placement sternal elevation subxiphoid incision cystoscopy

Hashtags

#PectusExcavatum #NussProcedure #PediatricSurgery #ChestWallDeformity

Transcript

Click "Show Transcript" to view the full text (11545 characters)

If you miss our Stay Current Pediatric Surgery Update course, don't worry, because we are going to summarize our favorite sessions right here on this podcast. Today's episode is all about PACT-Test. We are going to see what is new about perioperative pain control and some rapid-fire updates techniques. This is Cecilia Higiena and I'm a Research Fellow at Cincinnati Children's Hospital. And this is Ellen Ncisco, also a Research Fellow at Cincinnati Children's Hospital Medical Center. First, Dr. Steven Lee from UCLA Mattel Children's Hospital presented a case. So this is a 16-year-old young man with shortness of breath on exertion. He has no comorbidities and a pectus index of 5.5. The plan was to do a chest wall reconstruction. And the first question is, in addition to multimodal pain medication, what do you recommend for perioperative pain control? There are so many options. So let's see what Dr. Sean St. Peter had to tell us about this. He's a pediatric surgeon at Children's Mercy Hospital in Kansas City. We of course struggled with postoperative pain management as everybody did. And we had completed a randomized trial, 110 patients, to epidural and PCA. And in that study, the epidurals didn't really drop off. So neither epidural or PCA was doing the trick at Dr. St. Peter's Hospital. So they decided to start a new trial looking into cryoanalgesia. So we were enrolling in this study. We had about 30 patients in each group when we tried the first cryotherapy. And when that patient went home on post-op day one, equipoise was lost. Once you see it, it's sort of a different game. So what Dr. St. Peter is saying is that after cryoanalgesia, he didn't want to try any more epidural or PCA. But what is cryoanalgesia? Cryoanalgesia consists of the use of cold temperatures for analgesia. The low temperatures cause a conduction block resulting in an interruption of pain impulses to the brain. Awesome. And how do you do it? We currently put the camera on the top and the probe through the bottom. But you can see how they're separated. One's an inner space above. That just keeps them out of each other's way. And you literally just count down to the fourth rib and then freeze underneath it. It's two minutes per rib. We do four through seven. You're not supposed to go eight or below because you can get some abdominal wall paralysis. And what impact did you see in the patients? What we saw there is the length of stay where we just couldn't get below four days. All of a sudden became one. And what about the use of opioids? What impact we have on our median morphine equivalents? And they're not even really on the same planet. But not everyone is so excited about cryoanalgesia. And Dr. Victor Garcia, a pediatric surgeon from Cincinnati Children's Hospital, explained why. I agree with Sean. It works. I mean, it is great. One day. Yeah, no. So what I'm concerned about is that there are no long-term studies. But I believe we just don't know. We don't have the long-term data. Dr. Garcia is explaining that even though cryoanalgesia seemed to work, he is worried about future adverse effects, such as chronic neuropathic pain. You know, unlike drugs, medical devices and implants are not, are not required to undergo clinical trials before they're introduced into the market. What does that mean? For medications, the FDA requires clinical trials with long-term clinical results before approving them for use. For medical devices and techniques, this is not a requirement. And therefore, for things like cryoanalgesia, there are just not as many long-term results reported. And so, what do you use in your hospital, Dr. Garcia? About 100 patients. Looking to Sean's point, as far as, and this was a comparison between epidurals as well as, not perivertebral, but erector spinae catheter. An erector spinae catheter? What is that? Very, very briefly. Erectospinae catheters, they are placed by the pain team with ultrasound guidance. They're not in the vertebral space, but they are juxtaposed to it. Those catheters stay in for five days. The hospital stays two days. Third day, while they're outside, the catheters are pulled out by the family. It is on a pump. It's automated. Okay, great. Our hospital stays are two days. We've been able to reduce the opioid requirements, not only in the hospital, but also outside of the hospital. So, I'm, from the perspective, at least with our experience, that we do have an alternative. Is it going to be one day? No. But is it certainly much less than the four or five days that we saw with epidurals? Absolutely, yes. I was a cryo skeptic. That's Dr. Steven Rothenberg from Rocky Mountain Children's Hospital. My biggest issues with it were the added time. The other is concerned about the neuralgia and the complications that I'd heard about. And I will tell you that it took me about four cases to realize, because most of our patients went home on day two or three. But it's not just when they go home. It's how they feel when they go home. And the cryo has been unbelievable. I mean, I feel bad that I waited so long. I accept Vic's concerns and criticisms. And I agree, perhaps, you know, that we do need to have a registry for this. But it has totally changed the management of these patients. And let's see what Dr. Justin Wagner from UCLA had to say about multimodal pain control. You know, Tylenol and NSAIDs are already widely used. Prestidex can help for a gentle wake up. A dose of dexamethasone can help with post-anesthetic nausea. Ketamide in the hands of someone who's used it might be a good way to avoid opioids. And if you have child life specialists, mindfulness resources and a supportive group of physical therapists, they can be enormously helpful. So for multimodal therapy, the best treatments are preoperative counseling, gabapentin both pre and postoperatively, and then methadone, clonidine, bowel regimen medications and antiemetics. That was Dr. Todd Ponsky from Cincinnati Children's Hospital. In Nebraska, where I trained Steve Rayner, we'll tell you the length of stay there is under two days still. And they're off opioids by one week. Well, Dr. Wagner's numbers are almost as good as cryonotasia. I've heard that with cryonotasia, they are more percentage of flip it. Can you say what you think about that? So, typically if bars are going to flip, they're going to flip early and it's going to be because they were sitting in a funky inner space, they were sitting in a bad spot, the bar wasn't wrapped tight enough, or it wasn't secured well. And even then I would say, it's not the securing that does it. That bar's got to sit in a comfortable position before you start to secure it or it's probably not going to stay there. I do think that bar flippage is completely a surgical issue. Okay, so now we have the pain control management set. Cryoanalgesia has great results, but still don't know long term consequences. Erectospinal cathethos seem to be better than epidural. And a good multimodal pain control regimen could reach a two day length of stay. But what about the actual NAS procedure? Let's see what Dr. Lee had to ask the experts. How do you base your bar measurements, the length of your bar? I think things have changed and maybe the bars are more stable with different lengths of them. I mean, what a great transition from talking about bar flippage and technique. I just wanted to bring up that some physics minded surgeons did this really interesting computational model to show the sites of stress points with traditionally U-shaped bars in contrast to shorter flat bars. So what Dr. Wagner is explaining is that shorter bars have more pressure on the sternum. Therefore, they are more stable. So the tendency is to have shorter bars, though this is not standardized. Are there any special maneuvers when passing the introducer behind the sternum that is found useful? You know, I now do a sternal elevator. So we use the sternal elevator at Akron Children's. That was Dr. Mark Wolkine from Akron Children's Hospital. I use the sternal elevator in about 10% of the cases. I think in the average kid that we do that's younger, you see well enough with thoracoscopy, you don't need to do it. Having the sternum elevated in those really deep stiff pectuses allows you less tissue damage and have a better repair. Steve, we use the elevator in every case, but it offers, there's no guesswork. I mean, I think one of the things that Steve mentioned is being able to go in and out at the same inner space, I think is important. And so, yes, we use the elevator in every instance. Do you still use the sub-xiphoid incision now that you've adapted cryo and have thoracoscopy? Yeah. Yeah, we do. Thoracoscopy or sternal elevator or vacuum bell in the operating room or sub-xiphoid incision, the idea is to not injure the heart. So whatever technique helps you do that, I think is the technique you ought to use. That was Dr. Wythe Holcomb, a clinical professor of surgery at the Vanderbilt University Medical School. Totally agree. Safety first. We talked about right to left, left to right, the age-old question. I'm interested to see what the current thoughts are when you pass the bar. I go from the left chest to the right chest because if you go from the right chest to the left chest, you're coming down and whatever you're passing across is pointing right at the ventricle. I've always done right to left. I never even thought about doing left to right, I must admit. So I'm also learning something new and think that's a really fascinating idea. That was Dr. Bethany Slater from the University of Chicago. It's interesting. I learned left to right and then I went back to right to left and found personally right to left being easy, but I'm also using a sternal elevator and thoracoscopy, so I go the whole distance as far as ensuring safety. I actually always did it left to right. I think it's surgeon preference and as long as you have the sub-sternal space well dissected and everything's clear, then it probably doesn't make a whole lot of difference. Okay, great. So to sum up, remember that for pain management, cryoanalgesia has a lot of interest and support, but we still have to figure out long-term data. Other methods of analgesia include erector spinae catheters, epidurals, and multimodal pain regimens. Regarding this procedure, ways to ensure safe passage of the introducer include sternal elevation or sub-xiphoid incisions. Many people pass the bar from left to right, but whatever ensures good visualization and safety is the most important. And there you have it, our 2021 update course session on pain management and repair techniques for pectus ascivata. Now, if you loved this episode, go ahead and like and subscribe to our YouTube channel. Follow us on social media. If you're listening to an Apple podcast or on Spotify, please leave us a rating and a review and be sure to download the Stay Current and Pediatric Surgery app. It's in the Apple App Store and in the Google Play Store. And as a reminder, don't forget we have another virtual event coming up soon at the end of August. It's the 10th annual pediatric surgery update course. Todd has been doing this for 10 years and it's awesome. We'll have it in person in Cleveland and everyone can join us virtually. It's happening on Tuesday at 30 starting at 9 a.m. Eastern Time. Check out the link in the description below to join us. But until next time, I'm Cecilia. I'm Ellen. I'm Todd Ponsky. And remember, knowledge should be free.

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