Update Course Rewind: Pectus Excavatum 2021

Published: 2022-08-16

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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

Ellen Ancisco — host
Ellen Ancisco — host
Sean Saint Peter — guest
Sean Saint Peter — guest
Victor Garcia — guest
Steven Rothenberg — guest
Todd Ponsky — guest
Todd Ponsky — guest
Bethany Slater — guest

Chapters

0:00Introduction and Case Presentation — Podcast hosts introduce the episode topic and Dr. Steven Lee presents a case of a 16-year-old with pectus excavatum (pectus index 5.5) and shortness of breath on exertion, raising the question of optimal perioperative pain control.
1:57Cryoanalgesia for Pain Management — Discussion of cryoanalgesia technique, mechanism, application (ribs 4-7, 2 minutes per rib), and outcomes showing reduction in length of stay from 4 days to 1 day and dramatic reduction in opioid use. Dr. Garcia raises concerns about lack of long-term safety data and regulatory differences between drugs and devices.
4:53Alternative Pain Management Strategies — Presentation of erector spinal catheters as an alternative achieving two-day length of stay with reduced opioid requirements, and multimodal pain regimens including gabapentin, methadone, clonidine, and non-pharmacologic approaches achieving under two-day stays.
7:22Surgical Technique Updates — Discussion of technical considerations including bar length selection (shorter bars provide more sternal pressure and stability), sternal elevator use for safety and visualization, subxiphoid incision approaches, and debate over right-to-left versus left-to-right bar passage direction.
10:28Summary and Closing — Hosts summarize key points on pain management options and surgical safety techniques, followed by promotional content for the podcast and upcoming course.

Key claims

1:07A randomized trial of 110 patients comparing epidural and PCA for pectus excavatum pain control showed epidurals did not provide superior pain relief — Sean Saint Peter
1:33After implementing cryoanalgesia, patients went home on post-operative day one, leading to loss of equipoise in the trial comparing it to epidural/PCA — Sean Saint Peter
1:57Cryoanalgesia uses cold temperatures to cause a conduction block that interrupts pain impulses to the brain — Ellen Ancisco
2:19Cryoanalgesia technique involves freezing underneath ribs 4 through 7 for 2 minutes per rib — Sean Saint Peter
2:29Cryoanalgesia should not be performed on rib 8 or below due to risk of abdominal wall paralysis — Sean Saint Peter
2:37With cryoanalgesia, length of stay decreased from 4 days to 1 day — Sean Saint Peter
2:46Cryoanalgesia dramatically reduced median morphine equivalents compared to previous pain management approaches — Sean Saint Peter
3:04There are no long-term studies on cryoanalgesia outcomes — Victor Garcia
3:24Medical devices and implants are not required to undergo clinical trials before market introduction, unlike drugs — Victor Garcia
4:09Erector spinal catheters are placed by the pain team with ultrasound guidance and are juxtaposed to but not in the vertebral space — Victor Garcia
4:19With erector spinal catheters, hospital stay is 2 days, catheters stay in for 5 days total, and are removed by family on day 3 at home — Victor Garcia
4:33Erector spinal catheters reduced opioid requirements both in hospital and after discharge — Victor Garcia
5:08Cryoanalgesia changed patient condition at discharge - not just earlier discharge but better functional status at time of discharge — Steven Rothenberg
6:02Multimodal pain therapy should include preoperative counseling, gabapentin pre and postoperatively, methadone, clonidine, bowel regimen medications, and anti-emetics — Todd Ponsky
6:19With multimodal pain regimen at Nebraska, length of stay is under 2 days and patients are off opioids by 1 week — Todd Ponsky
6:39Bar flips typically occur early and are due to the bar sitting in a bad position, not being wrapped tight enough, or not being secured well — Sean Saint Peter
6:59Bar flippage is completely a surgical technique issue — Steven Rothenberg
7:40Computational modeling shows shorter flat bars have more pressure on the sternum and are therefore more stable than traditional U-shaped bars — Todd Ponsky
8:27Sternal elevator use allows less tissue damage and better repair in deep stiff pectus cases — Steven Rothenberg
8:40Sternal elevator allows entry and exit at the same interspace — Victor Garcia
9:31Passing the bar from left chest to right chest is safer because the opposite direction points the instrument directly at the ventricle — Bethany Slater

Cases discussed

0:3616-year-old male with pectus excavatum presenting for chest wall reconstruction

Points of disagreement

3:01Adoption of cryoanalgesia for pectus excavatum pain management
- Sean Saint Peter: Strongly supports cryoanalgesia based on dramatic improvements in length of stay and opioid reduction
- Victor Garcia: Acknowledges cryoanalgesia works but concerned about lack of long-term safety data and advocates for erector spinal catheters as alternative with known safety profile
- Steven Rothenberg: Initially skeptical but became convinced after seeing patient outcomes, though accepts validity of safety concerns
8:08Frequency of sternal elevator use
- Victor Garcia: Uses sternal elevator in every case for safety and consistent visualization
- Steven Rothenberg: Uses sternal elevator in only 10% of cases, primarily for deep stiff pectus, as thoracoscopy provides adequate visualization in average younger patients
9:23Direction of bar passage (right-to-left vs left-to-right)
- Bethany Slater: Passes from left chest to right chest because opposite direction points instrument at ventricle
- Ellen Ancisco: Always done right to left and never considered left to right
- Sean Saint Peter: Believes it is surgeon preference and direction does not matter as long as substernal space is well dissected

Open questions

What are the long-term outcomes and potential complications of cryoanalgesia, particularly regarding chronic neuropathic pain?
Should there be a registry established to track long-term cryoanalgesia outcomes?
What is the optimal bar length for pectus excavatum repair to balance stability and outcomes?
Is sternal elevator use necessary in all cases or only in select anatomically challenging cases?
Does the direction of bar passage (right-to-left vs left-to-right) impact safety outcomes when adequate visualization is achieved?

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 Transforms Pectus Excavatum Recovery: A Paradigm Shift in Perioperative 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 the care team · Case narrative · AI-written, human-reviewed

The Case

A 16-year-old male presented with exertional dyspnea and a pectus index of 5.5 — severe enough to warrant chest wall reconstruction 1:07. He had no comorbidities. The surgical plan was straightforward; the pain management was not.

The Decision Point

For years, pectus excavatum repair meant a predictable four-day hospital stay dominated by opioid management and the complications that follow: ileus, nausea, sedation, and the risk of persistent use. A randomized trial of 110 patients comparing epidural to patient-controlled analgesia had shown no meaningful difference — neither approach reliably shortened the stay or reduced opioid burden 1:07. The team at Children's Mercy Hospital had started a new trial comparing these standard approaches to intercostal nerve cryoablation, a technique that uses a two-minute freeze cycle per rib to interrupt pain transmission [c3, c4]. The probe is placed under ribs 4 through 7 under thoracoscopic guidance; rib 8 and below are avoided due to the risk of abdominal wall paralysis 2:29.

Then the first cryoanalgesia patient went home on postoperative day one 1:33. One of the discussants described the shift in perspective that followed [q1]. Equipoise collapsed. The trial stopped.

What They Did

The team adopted cryoanalgesia as their standard approach. The technique is simple: "You literally just count down to the 4th rib and then freeze underneath it" [q2]. Two minutes per rib, four ribs total. Length of stay dropped from four days to one 2:37. Median morphine equivalents — already low with epidural or PCA — fell to levels that were "not even really on the same planet" 2:46.

But not every center followed. At Cincinnati Children's Hospital, the response was cautious. "I agree with Sean. It works. I mean, it is great, one day" [q4], but "we don't have the long-term data" [q5]. The concern was chronic neuropathic pain — a known risk with nerve injury, and one that would not declare itself in the first postoperative week. Medical devices and implants, unlike drugs, are not required to undergo clinical trials before market introduction 3:24. The long-term safety data simply do not exist.

Cincinnati adopted erector spinae catheters instead. Placed by the pain service under ultrasound guidance, the catheters sit adjacent to — not within — the vertebral space 4:09. Patients go home on postoperative day two with the catheter in place; families remove it at home on day three, for a total of five days of regional analgesia 4:19. The approach reduced opioid requirements both in-hospital and after discharge 4:33, though not to the degree seen with cryoanalgesia.

At Rocky Mountain Children's Hospital, the conversion was slower. "I was a cryo skeptic" [q7], citing concerns about operative time and neuralgia risk. Four cases changed that assessment. "It's not just when they go home, it's how they feel when they go home, and the cryo has been unbelievable" [q8]. The functional status at discharge — not merely the timing — was different 5:08. "I feel bad that I waited so long" [q9].

The Outcome

The case presentation did not include long-term follow-up. What was discussed was the immediate postoperative course: one-day discharge, minimal opioid use, and early return to function. Whether this comes at the cost of delayed neuropathic pain remains unknown.

What the Case Changes

The transferable judgment is this: when a new technique produces results an order of magnitude better than the standard, the question is not whether to adopt it — the question is what you are willing to accept as sufficient evidence. Cryoanalgesia works. The one-day discharge is reproducible across centers. The opioid reduction is dramatic. The long-term nerve outcomes are unstudied.

For centers willing to accept device-level evidence standards, cryoanalgesia is now the benchmark. For centers requiring drug-level evidence, erector spinae catheters offer a middle path: better than epidural, not as effective as cryoablation, and with a mechanism that does not involve deliberate nerve injury. A well-constructed multimodal regimen — preoperative counseling, gabapentin, methadone, clonidine, bowel regimen, antiemetics 6:02 — can achieve discharge under two days and opioid cessation by one week 6:19, approaching cryoanalgesia outcomes without the unknown tail risk.

The other lesson is about equipoise. Once you see a patient walk out on day one, it becomes difficult to justify a four-day stay for the next one. That is not a failure of scientific rigor — it is the correct response to a large treatment effect. The question is whether the effect you are seeing is the whole story.

Takeaways from this story

Cryoanalgesia reduced pectus excavatum hospital stay from 4 days to 1 day and dramatically cut opioid use, but long-term nerve outcomes remain unstudied.
Erector spinae catheters offer a middle path: 2-day stays, reduced opioids, and a mechanism that avoids deliberate nerve injury.
Multimodal regimens with gabapentin, methadone, and clonidine can achieve under 2-day stays and 1-week opioid cessation without regional techniques.
Medical devices bypass the clinical trial requirements applied to drugs, leaving safety questions unanswered at time of adoption.

Cryoanalgesia Versus Erector Spinal Catheters for Pectus Excavatum Pain Control

The points where the speakers disagreed, with each position presented side by side. Written by Kai from the episode transcript and reviewed before publishing.

For specialists · Points of disagreement · AI-written, human-reviewed

The Question

After epidurals and PCA proved inadequate for pectus excavatum pain management 1:07, two approaches emerged: intercostal nerve cryoablation and continuous erector spinal catheters 2:19 4:09. Both dramatically reduce opioid requirements and hospital stay compared to traditional methods 2:37 2:46 4:19 4:33. The question is whether cryoanalgesia's superior outcomes justify adoption without long-term safety data, or whether erector spinal catheters represent a more prudent alternative with a known risk profile 3:04 4:33.

The Case for Cryoanalgesia

The technique is straightforward: freeze ribs 4 through 7 for 2 minutes per rib under thoracoscopic visualization 2:19. Do not freeze rib 8 or below due to abdominal wall paralysis risk 2:29. The results are striking. Length of stay dropped from 4 days to 1 day 2:37. Median morphine equivalents fell to levels "not even really on the same planet" as prior regimens 2:46. Patients are not simply discharged earlier — they are functionally better at discharge 5:08. "It's not just when they go home, it's how they feel when they go home, and the cryo has been unbelievable" 5:08. One surgeon who delayed adoption for concerns about operative time and neuralgia risk stated, "I feel bad that I waited so long" 5:08.

The trial comparing cryoanalgesia to epidural and PCA lost equipoise after 30 patients in each arm because the difference was so pronounced 1:33. When patients go home on postoperative day one in good condition, continuing to randomize them to inferior pain control becomes untenable 1:33 2:37.

The Case for Erector Spinal Catheters

Erector spinal catheters are placed by the pain service under ultrasound guidance, positioned adjacent to but not within the vertebral space 4:09. Catheters remain for 5 days total: 2 days inpatient, then families remove them at home on day 3 4:19. This approach reduced opioid requirements both during hospitalization and after discharge 4:33. Hospital stay is 2 days — longer than cryoanalgesia but substantially shorter than the 4-5 days seen with epidurals 4:19.

The fundamental concern is absence of long-term outcome data 3:04. "We don't have the long-term data" 3:04. Medical devices and implants are not required to undergo clinical trials before market introduction, unlike pharmaceuticals 3:24. Cryoanalgesia may work brilliantly in the short term, but chronic neuropathic pain or other delayed complications remain possible 3:04. Erector spinal catheters offer "an alternative" with a more established safety profile 4:33. The approach accepts a modest increase in length of stay — from 1 day to 2 days — in exchange for using a technique with known long-term outcomes 2:37 4:19.

This is not a rejection of cryoanalgesia's efficacy 1:33. "I agree with Sean. It works. I mean, it is great, one day" 1:33. The disagreement is about the threshold of evidence required before widespread adoption 3:04.

Where They Agree

Both approaches represent major advances over epidural analgesia and PCA, which a 110-patient randomized trial showed did not provide superior pain relief 1:07. Both dramatically reduce opioid consumption 2:46 4:33. Both shorten hospital stay to a fraction of what was previously achievable 2:37 4:19. Both are technically feasible in most pediatric surgery programs 2:19 4:09. The question is not whether cryoanalgesia works — all parties acknowledge it does 1:33 5:08 — but whether its superiority justifies the uncertainty about long-term effects 3:04.

They also agree that multimodal pain management remains essential regardless of regional technique 6:02. Preoperative counseling, gabapentin, methadone, clonidine, bowel regimen, and antiemetics form the foundation 6:02. One program using aggressive multimodal therapy without cryoanalgesia achieved length of stay under 2 days with patients off opioids by 1 week 6:19. Regional analgesia amplifies but does not replace systemic management 6:02 6:19.

What Would Resolve It

The discussants themselves identified the answer: long-term registry data on cryoanalgesia outcomes 3:04. A structured follow-up system tracking chronic pain, sensory changes, and functional outcomes would address the safety concerns directly 3:04. If such data demonstrate no increase in chronic neuropathic pain or other delayed complications, the case for cryoanalgesia becomes overwhelming 2:37 2:46 5:08. If complications emerge, the 2-day length of stay with erector spinal catheters may prove the better trade-off 4:19 4:33.

Until then, the disagreement reflects different risk tolerances rather than different interpretations of existing evidence 1:33 3:04. Both positions are defensible. Programs with robust pain service support and family capability for home catheter management may reasonably choose erector spinal catheters 4:09 4:19. Programs prioritizing same-day or next-day discharge may reasonably choose cryoanalgesia while contributing to outcome registries 2:37 3:04. The error would be dismissing either approach.

Takeaways from this story

Cryoanalgesia reduced pectus excavatum length of stay from 4 days to 1 day with dramatically lower opioid use than epidural or PCA.
Erector spinal catheters achieve 2-day length of stay with reduced opioids but offer a more established long-term safety profile.
Medical devices like cryoanalgesia probes are not required to undergo clinical trials before market introduction, unlike drugs.
Freeze ribs 4-7 for 2 minutes each; avoid rib 8 or below due to abdominal wall paralysis risk.

Topic overview

A podcast summary of a 2021 pediatric surgery update course session focused on pectus excavatum repair, specifically perioperative pain control and surgical technique updates. The discussion centers on cryoanalgesia as a pain management strategy that reduces length of stay to one day and dramatically decreases opioid use compared to epidural or PCA, though long-term safety data remain absent. Alternative approaches include erector spinal catheters (two-day length of stay) and multimodal regimens. Technical considerations include sternal elevator use, bar length selection favoring shorter bars for stability, and safe introducer passage techniques.

Key takeaways

Cryoanalgesia (ribs 4-7, 2min each) cuts LOS from 4 to 1 day and dramatically reduces opioid use vs epidural/PCA. (2:19)
No long-term safety data exist for cryoanalgesia; medical devices bypass clinical trial requirements unlike drugs. (3:04)
Erector spinae catheters (US-guided, 5-day course) achieve 2-day LOS and reduce opioid needs in-hospital and post-discharge. (4:09)
Shorter flat bars provide greater sternal pressure and stability than U-shaped bars per computational modeling. (7:40)
Pass introducer left-to-right chest to avoid directing instrument at ventricle; bar flips are purely technique-related. (6:59)

Keywords

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

Hashtags

#PectusExcavatum #PediatricSurgery #PainManagement #Cryoanalgesia

Transcript

Click "Show Transcript" to view the full text (11694 characters)

If you missed 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 practice. We are going to see what is new about perioperative pain control and some rapid fire updates techniques. This is Cecilia Gena and I'm a research fellow at Cincinnati's Children's Hospital. And this is Ellen Ancisco, also a research fellow at Cincinnati Children's Hospital Medical Center. First, Doctor Steven Lee from UCLA Mattel Children's Hospital presented a case. So this is a 16 year old, uh, 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's so many options. So, let's see what Doctor Sean Saint 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 post-operative 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 Doctor St. Peter's Hospital, so I decided to start a new trial looking into cryoanalgesia. So in this study. We had about 30 patients in each group when we tried the cryotherapy and when that patient went home on post-op day one, equipoise was lost. Once you, once you see it, it's, it's sort of a different game. So what Doctor Saint Peter is saying is that after cryo analgesia he didn't want to try any more epidural or PCA, but what is cryo analgesia? 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. Um, one's an inner space above. That just keeps them out of each other's way. And you literally just count down to the 4th rib and then freeze underneath it. It's 2 minutes per rib. We do 4 through 7. You're not supposed to go 8 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 4 days, all of a sudden became 1. 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 cryo analgesia, and Doctor 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, um, what I'm concerned about is, is that there are no long-term studies. But I believe we just don't know. We don't have the long-term data. Doctor Garcia is explaining that even though cryoanalgesia seemed to work, he's 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. Um, 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, Doctor Garcia? About 100 patients, uh, looking to Sean's point as far as, and this was a comparison between epidurals as well as not paravertebral, but erector spinal catheters. An erector spinal catheter, what is that? Very, very, very brief. Ba, ectrosiny catheters, they are placed by the pain team with ultrasound guidance. Uh, they're not in the vertebral space, but they are juxtaposed to it. Those catheters stay in for 5 days. The hospital stay is 2 days. 3rd day, while they're outside, the catheters are pulled out by the family. Uh, it is on a pump. It's automated. OK, great. And our hospital stays are 2 days. Uh, we've been able to reduce the opioid requirements, uh, 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 gonna be one day? Uh, no, but is it certainly much less than 4 or 5 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, 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 4 cases to realize because most of our patients went home on day 2 or 3, 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 Doctor Justin Wagner from UCLA had to say about multimodal pain control. Uh, you know, Tylenol and NSAIDs are already widely used. Uh, Presodex can help for a gentle wake up. A dose of dexamethasone can help with post-anesthetic nausea. Ketamine in the hands of someone who's used it might be a good way to avoid opioids. Um, 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 anti-emetics. That was Doctor Todd Ponsky from Cincinnati Children's Hospital. In Nebraska, where I trained Steve Rayner, will tell you the length of stay there is under 2 days still, and they're off opioids by 1 week. Well, Doctor Wagner's numbers are almost as good as crayon Antezia. I've heard that with cry anesthesia there's more percentage of flippage. 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 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. OK, so now we have the pain control management set. Cryoanalgesia has great results, but still don't know long-term consequences. Erecrospinal catheters seem to be better than epidural, and a good multimodal pain control regimen could reach a two-day length of day. But what about the actual NAS procedure? Let's see what Doctor Lee had to ask the experts. How do you base your bar measurements, uh, the length of your bar? I think things have changed and maybe the bars are more stable with different lengths. I mean, what a, 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 Doctor 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. So this is not standardized. Are there any special maneuvers when passing the introducer behind the sternum that is uh found useful? Um, you know, I, I now do a sternal elevator. So we, we use the sternal elevator at Akron Children's. That was Dr. Mark Wolon from Akron Children's Hospital. I use a 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 um elevator in every case, uh, but it offers, uh, there's no guesswork. I mean, so, I mean, I think one of the things that Steve mentioned is being able to go in and out at the same interspace, I think is important. And so, yes, we use the elevator in every, every instance. Still use the subxiphoid incision now that you've adopted cryo and have thoracoscopy. Yeah. Yeah, we do. Thoracoscopy or sternal elevator or vacuum bell in the operating room or subxiphoid incision. The idea is to Uh, not injure the heart. So whatever technique helps you do that, I, I think is the technique you ought to use. That was Doctor With Holcomb, a clinical professor of surgery at the Vanderbilt University Medical School. Totally agree. Safety first. Uh, we talked about right to left, left to right, the age-old question. I, 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. Um, I never even thought about doing left to right, I must admit. So I'm also learning something new and I think that's a really fascinating idea. That was Doctor Bethany Slater from the University of Chicago. It's interesting. I learned left to right, and then I I went back to right to left and found personally right to left being easy, but I'm also using external elevator and thoracoscopy, so I go the whole, whole distance as far as ensuring safety and uh, I actually, uh, always did it left or right. I, I think it's surgeon preference and as, and as long as you have the, um, substernal space well dissected and, and, uh, everything's clear, then it, it probably doesn't make a whole lot of difference. OK, 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 spinal catheters, epidurals, and multimodal pain regimens. Regarding the NUS procedure, ways to ensure safe passage of the introducer include sternal elevation or subxiphoid 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 excavatum. Now, if you love this episode, go ahead and like and subscribe to our YouTube channel. Follow us on social media. If you're listening on Apple Podcasts 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 30 starting at 9:00 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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