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

Todd Ponsky — host
Cecilia Higiena — host
Ellen Ncisco — host

Chapters

0:00Cryoanalgesia for Pain Control — Introduction of a case and discussion of cryoanalgesia as a pain management technique that reduced hospital stay from four days to one day and dramatically decreased opioid use, with concerns raised about lack of long-term safety data.
3:50Alternative Pain Management Strategies — Discussion of erector spinae catheters achieving two-day hospital stays and multimodal pain regimens including gabapentin, methadone, clonidine, and non-opioid adjuncts.
6:15Bar Stability and Measurement — Discussion of bar flippage as a surgical technique issue and computational modeling showing shorter flat bars create more sternal pressure and improved stability compared to traditional U-shaped bars.
8:01Surgical Technique Updates — Rapid-fire discussion of techniques to ensure safe introducer passage including sternal elevator use, sub-xiphoid incisions, thoracoscopy, and surgeon preferences for bar passage direction.

Key claims

0:31A 16-year-old male with shortness of breath on exertion, no comorbidities, and pectus index of 5.5 was planned for chest wall reconstruction — Todd Ponsky
1:02A randomized trial of 110 patients comparing epidural and PCA showed epidurals did not provide adequate pain control — Todd Ponsky
1:21After implementing cryoanalgesia, a patient went home on post-operative day one, ending equipoise in the trial — Cecilia Higiena
1:56Cryoanalgesia uses cold temperatures to cause a conduction block that interrupts pain impulses to the brain — Todd Ponsky
2:09Cryoanalgesia technique involves freezing ribs four through seven for two minutes per rib; ribs eight and below should not be treated due to risk of abdominal wall paralysis — Todd Ponsky
2:33Cryoanalgesia reduced hospital length of stay from four days to one day — Cecilia Higiena
2:43Cryoanalgesia dramatically reduced median morphine equivalents compared to previous pain management approaches — Todd Ponsky
2:52There are no long-term studies on cryoanalgesia outcomes, raising concerns about potential chronic neuropathic pain — Cecilia Higiena
3:14Medical devices and techniques are not required to undergo clinical trials before market introduction, unlike medications — Todd Ponsky
3:50Erector spinae catheters are placed by the pain team with ultrasound guidance, stay in for five days, and allow hospital discharge at two days with family removal of catheters on day three — Cecilia Higiena
4:30Erector spinae catheters reduced opioid requirements both in-hospital and post-discharge, achieving two-day hospital stays — Todd Ponsky
4:52Cryoanalgesia changed not just discharge timing but how patients feel at discharge — Cecilia Higiena
5:34Multimodal pain control includes Tylenol, NSAIDs, precedex for gentle wake-up, dexamethasone for nausea, ketamine to avoid opioids, child life specialists, mindfulness resources, and physical therapy — Todd Ponsky
6:15Best multimodal treatments are preoperative counseling, gabapentin pre and postoperatively, methadone, clonidine, bowel regimen medications, and antiemetics — Cecilia Higiena
6:15A multimodal pain regimen achieved hospital length of stay under two days with patients off opioids by one week — Cecilia Higiena
6:26Bar flippage typically occurs early due to bars sitting in incorrect intercostal space, poor positioning, inadequate wrapping, or insufficient securing — Todd Ponsky
6:26Bar flippage is completely a surgical technique issue, not related to the securing method — Todd Ponsky
7:35Computational modeling shows shorter flat bars create more pressure on the sternum compared to traditional U-shaped bars, making them more stable — Cecilia Higiena
8:01Sternal elevator is used in approximately 10% of cases, primarily in younger patients where thoracoscopy provides adequate visualization — Todd Ponsky
8:01Sternal elevation in deep, stiff pectus cases allows less tissue damage and better repair — Todd Ponsky
8:01Sternal elevator enables consistent entry and exit at the same intercostal space — Todd Ponsky
8:58Thoracoscopy, sternal elevator, vacuum bell, and sub-xiphoid incision are all techniques aimed at preventing cardiac injury — Cecilia Higiena
9:20Passing the bar from left to right avoids pointing the introducer directly at the ventricle — Todd Ponsky
9:20Bar passage direction is surgeon preference and does not make significant difference if sub-sternal space is well dissected and clear — Todd Ponsky

Cases discussed

0:3116-year-old male with pectus excavatum presenting for chest wall reconstruction

Points of disagreement

2:52Use of cryoanalgesia for pectus repair pain management
- Cecilia Higiena: Cryoanalgesia is effective but lacks long-term safety data, raising concerns about chronic neuropathic pain; prefers erector spinae catheters as a safer alternative with two-day hospital stays
- Todd Ponsky: Cryoanalgesia has transformed patient outcomes with one-day stays and dramatically reduced opioid use; acknowledges need for registry but believes benefits outweigh theoretical long-term risks
8:01Frequency of sternal elevator use
- Todd Ponsky: Uses sternal elevator in approximately 10% of cases, primarily for deep stiff pectus; thoracoscopy provides adequate visualization in most younger patients
- Cecilia Higiena: Uses sternal elevator in every case to eliminate guesswork and ensure consistent intercostal space entry and exit
9:20Direction of bar passage (left-to-right vs right-to-left)
- Todd Ponsky: Passes bar from left chest to right chest to avoid pointing introducer at the ventricle; switched from right-to-left after initially learning left-to-right
- Cecilia Higiena: Always performed right-to-left passage and found it easier; later switched back to left-to-right; considers it surgeon preference if sub-sternal space is well dissected

Open questions

What are the long-term outcomes and potential complications of cryoanalgesia, particularly regarding chronic neuropathic pain?
What is the optimal bar length and shape for maximizing stability while minimizing complications?
Does bar passage direction (left-to-right vs right-to-left) affect outcomes when proper visualization is maintained?

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:

Pectus Excavatum Pain Control: From Epidurals to Cryoanalgesia and Beyond

The episode's teaching points arranged as a structured lesson, building from the basics up to the finer points. Written by Kai from the episode transcript and reviewed before publishing.

For trainees · Teaching arc · AI-written, human-reviewed

The Failure of Traditional Approaches

Pain control after pectus excavatum repair has been the limiting factor in hospital discharge for decades. A randomized trial of 110 patients comparing epidural analgesia to patient-controlled analgesia demonstrated that neither approach provided adequate pain control — hospital stays remained stubbornly at four days despite these interventions 1:02. The problem was not that epidurals failed to work in principle; they simply could not deliver the level of analgesia these patients needed to mobilize and recover quickly.

Cryoanalgesia Changes the Calculation

Cryoanalgesia uses cold temperatures to create a conduction block that interrupts pain impulses to the brain 1:56. The technique is straightforward: freeze ribs four through seven for two minutes per rib, avoiding ribs eight and below due to risk of abdominal wall paralysis 2:09. When the first patient treated with cryoanalgesia went home on postoperative day one, equipoise in the ongoing trial was lost 1:21. "Once you see it, it's sort of a different game" [q1]. Hospital length of stay dropped from four days to one day 2:33, and median morphine equivalents fell dramatically compared to previous approaches 2:43. But the shift was not just about discharge timing — as one initially skeptical surgeon noted, "It's not just when they go home. It's how they feel when they go home" [q5].

The catch: there are no long-term studies on cryoanalgesia outcomes, raising legitimate concerns about potential chronic neuropathic pain 2:52. This gap exists because medical devices and techniques are not required to undergo clinical trials before market introduction, unlike medications 3:14. The absence of long-term data is not evidence of harm, but it is also not evidence of safety.

Alternative Pathways to Two-Day Stays

Erector spinae catheters offer a middle path. Placed by the pain team with ultrasound guidance, these catheters stay in for five days but allow hospital discharge at two days, with families removing the catheters at home on day three 3:50. This approach reduced opioid requirements both in-hospital and post-discharge, achieving two-day hospital stays without the unknowns of nerve ablation 4:30. The trade-off is clear: one extra day in hospital compared to cryoanalgesia, but with a more established safety profile.

Multimodal pain control forms the foundation regardless of which regional technique is chosen. The essentials include Tylenol, NSAIDs, precedex for gentle emergence, dexamethasone for nausea, ketamine to reduce opioid requirements, and non-pharmacologic support from child life specialists and physical therapists 5:34. The most effective multimodal regimens add preoperative counseling, gabapentin pre and postoperatively, methadone, clonidine, bowel regimen medications, and antiemetics — achieving hospital stays under two days with patients off opioids by one week 6:15 6:15.

Technical Precision Prevents Bar Complications

Bar flippage is entirely a surgical technique issue 6:26. Bars flip early because they sit in the wrong intercostal space, in poor position, are inadequately wrapped, or insufficiently secured 6:26. But securing alone will not save a poorly positioned bar — the bar must sit comfortably before any fixation is attempted. Computational modeling has shown that shorter flat bars create more pressure on the sternum than traditional U-shaped bars, making them more stable 7:35.

Sternal elevation is used in approximately 10% of cases, primarily in younger patients where thoracoscopy provides adequate visualization 8:01. In deep, stiff pectus cases, elevation allows less tissue damage and enables consistent entry and exit at the same intercostal space 8:01 8:01. Thoracoscopy, sternal elevator, vacuum bell, and sub-xiphoid incision are all techniques aimed at the same goal: preventing cardiac injury 8:58. "Whatever technique helps you do that, I think is the technique you ought to use" [q7].

The Direction Question

Some surgeons pass the bar from left to right to avoid pointing the introducer directly at the ventricle 9:20. Others have always worked right to left and find the left-to-right approach a "fascinating idea" they had never considered [q9]. The consensus: bar passage direction is surgeon preference and does not make significant difference if the sub-sternal space is well dissected and clear 9:20.

Takeaways from this story

Cryoanalgesia reduced hospital stay from four days to one day, but long-term safety data remain absent.
Erector spinae catheters achieve two-day discharge with established safety, offering a middle path between traditional and ablative approaches.
Bar flippage is a surgical technique issue: bars must sit comfortably before securing, not be forced into position by fixation.
Shorter flat bars create more sternal pressure than U-shaped bars, improving stability through physics rather than fixation method.
Multimodal regimens including gabapentin, methadone, and clonidine can achieve discharge under two days with opioid cessation by one week.

Cryoanalgesia Versus Erector Spinae Catheters for Pectus Repair 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

What is the optimal regional analgesia technique for minimally invasive pectus excavatum repair: intercostal nerve cryoablation or erector spinae plane catheters?

The Case for Cryoanalgesia

Cryoanalgesia reduced hospital length of stay from four days to one day 2:33 and dramatically reduced median morphine equivalents compared to previous approaches 2:43. The technique involves freezing ribs four through seven for two minutes per rib; ribs eight and below should not be treated due to risk of abdominal wall paralysis 2:09. One discussant who initially resisted the technique acknowledged, "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" [q5]. The impact was so dramatic that when a patient went home on post-operative day one during a randomized trial comparing epidural and PCA, equipoise was lost 1:21. "Once you see it, it's sort of a different game" [q1].

The proponents accept the need for long-term registry data but argue the clinical benefits — one-day discharge with minimal opioid requirements — justify adoption while that evidence accumulates.

The Case for Erector Spinae Catheters

Erector spinae catheters are placed by the pain team with ultrasound guidance, stay in for five days, and allow hospital discharge at two days with family removal of catheters on day three 3:50. This approach reduced opioid requirements both in-hospital and post-discharge, achieving two-day hospital stays 4:30. The critical concern is that there are no long-term studies on cryoanalgesia outcomes, raising concerns about potential chronic neuropathic pain 2:52. "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" [q3].

Medical devices and techniques are not required to undergo clinical trials before market introduction, unlike medications 3:14. This regulatory gap means cryoanalgesia lacks the long-term safety data that would be mandatory for a pharmaceutical intervention producing similar neural effects. Erector spinae catheters offer a proven alternative that achieves two-day stays — not one day, but substantially better than the four to five days seen with epidurals, and without the theoretical risk of permanent nerve injury.

Where They Agree

Both approaches represent dramatic improvements over epidural analgesia. A randomized trial of 110 patients comparing epidural and PCA showed epidurals did not provide adequate pain control 1:02. Both cryoanalgesia and erector spinae catheters are embedded in multimodal pain regimens that include Tylenol, NSAIDs, precedex for gentle wake-up, dexamethasone for nausea, ketamine to avoid opioids, child life specialists, mindfulness resources, and physical therapy 5:34. The best multimodal treatments include preoperative counseling, gabapentin pre and postoperatively, methadone, clonidine, bowel regimen medications, and antiemetics 6:15. One multimodal pain regimen achieved hospital length of stay under two days with patients off opioids by one week 6:15.

Both discussants acknowledge that their techniques work and that the choice reflects institutional resources, pain team expertise, and individual risk tolerance rather than a clear evidence-based superiority of one approach.

What Would Resolve It

The discussants agreed that a registry tracking long-term outcomes after cryoanalgesia would address the safety concerns. Specifically, data on the incidence of chronic neuropathic pain, sensory deficits, and functional outcomes at one year and beyond would allow direct comparison with erector spinae catheters and other regional techniques. Until those data exist, the choice between one-day discharge with theoretical long-term risk versus two-day discharge with established safety profiles remains a judgment call rather than an evidence-based decision.

Takeaways from this story

Cryoanalgesia reduced hospital stay from four days to one day but lacks long-term safety data on chronic neuropathic pain risk.
Erector spinae catheters achieve two-day discharge with reduced opioid use and established safety profile.
Medical devices bypass the clinical trial requirements mandatory for drugs, creating evidence gaps for techniques like cryoanalgesia.
Both approaches dramatically outperform epidural analgesia, which failed to provide adequate pain control in randomized trials.

Topic overview

A podcast summary of a 2021 pediatric surgery update course session on pectus excavatum repair, focusing on perioperative pain control and surgical techniques. The discussion centers on cryoanalgesia as a transformative pain management approach that reduces hospital stay to one day and dramatically lowers opioid use, though long-term safety data remain absent. Alternative pain strategies include erector spinae catheters (two-day stays) and multimodal regimens. Technical updates cover bar length optimization (shorter bars provide more sternal pressure and stability), safe introducer passage methods (sternal elevator, sub-xiphoid incision, thoracoscopy), and surgeon preference regarding bar passage direction.

Key takeaways

Cryoanalgesia (ribs 4-7, 2min each) cuts hospital stay from 4 days to 1 day and slashes opioid use vs epidural/PCA. (1:21)
Erector spinae catheters achieve 2-day discharge with reduced opioids; family removes catheter at home on day 3. (3:50)
Shorter flat bars generate more sternal pressure than U-shaped bars, improving stability and reducing bar flippage risk. (6:26)
Multimodal regimen (gabapentin, methadone, clonidine, preop counseling) achieves <2-day stay, opioid-free by 1 week. (6:15)
Long-term cryoanalgesia safety data absent; no trials required for device/technique approval unlike medications. (2:52)

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 erector spinae catheter thoracoscopy sternal elevation sub-xiphoid incision bar passage

Hashtags

#PectusExcavatum #PediatricSurgery #ChestWallDeformity #NussProcedure #PainManagement #Cryoanalgesia

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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