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_expert
Sean Saint Peter — guest_expert
Victor Garcia — guest_expert
Steven Rothenberg — guest_expert
Todd Ponsky — guest_expert
Todd Ponsky — guest_expert
Speaker 9 — guest_expert

Chapters

0:00Introduction and Case Presentation — Hosts introduce the episode topic and present a 16-year-old male case with pectus excavatum (pectus index 5.5) and shortness of breath on exertion, setting up the discussion of perioperative pain control options.
1:57Cryoanalgesia for Pain Management — Discussion of cryoanalgesia technique, mechanism, and outcomes including one-day length of stay and dramatic reduction in opioid use. Concerns raised about lack of long-term safety data and FDA device approval requirements.
3:51Alternative Pain Management Approaches — Erector spinal catheters described as alternative achieving 2-day length of stay with reduced opioid requirements. Multimodal pain regimens discussed including gabapentin, methadone, clonidine, and non-pharmacologic approaches.
6:16Pain Management Summary — Hosts summarize the pain management options presented: cryoanalgesia with excellent results but unknown long-term effects, erector spinal catheters superior to epidurals, and multimodal regimens achieving 2-day stays.
7:22Nuss Procedure Technical Considerations — Discussion of bar length selection (shorter bars may be more stable), use of sternal elevators for safety, thoracoscopy, subxiphoid incisions, and surgeon preference regarding left-to-right versus right-to-left bar passage.
10:28Summary and Closing — Final summary of key points on pain management and surgical technique, followed by promotional content for the podcast and upcoming course.

Key claims

1:07In a randomized trial of 110 patients comparing epidural and PCA for pectus excavatum pain control, epidurals did not show superior efficacy. — Sean Saint Peter
1:32In a trial of cryotherapy for pectus excavatum with approximately 30 patients per group, patients went home on post-operative day one, leading to loss of equipoise. — Sean Saint Peter
1:57Cryoanalgesia uses cold temperatures to cause a conduction block, interrupting pain impulses to the brain. — Ellen Ancisco
2:10Cryoanalgesia technique involves placing camera on top and probe through bottom, counting down to the 4th rib and freezing underneath it for 2 minutes per rib, treating ribs 4 through 7. — Sean Saint Peter
2:29Cryoanalgesia should not be performed on rib 8 or below because it can cause 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 of cryoanalgesia outcomes in pectus excavatum repair. — Victor Garcia
3:24Medical devices and implants are not required to undergo clinical trials before market introduction, unlike drugs. — Victor Garcia
3:36FDA requires clinical trials with long-term results for medications before approval, but not for medical devices and techniques. — Ellen Ancisco
3:55A study of approximately 100 patients compared epidurals with erector spinal catheters for pectus excavatum pain control. — Victor Garcia
4:09Erector spinal catheters are placed by the pain team with ultrasound guidance, positioned adjacent to but not in the vertebral space. — Victor Garcia
4:19Erector spinal catheters remain in place for 5 days, with hospital stay of 2 days; catheters are removed by family on day 3 at home. — Victor Garcia
4:33Erector spinal catheters reduced opioid requirements both in-hospital and post-discharge, with 2-day hospital stays compared to 4-5 days with epidurals. — Victor Garcia
5:08After implementing cryoanalgesia, patients not only went home on day 2 or 3 but felt significantly better at discharge compared to previous pain management methods. — Steven Rothenberg
5:40Multimodal pain therapy components include Tylenol, NSAIDs, precedex for gentle wake-up, dexamethasone for post-anesthetic nausea, and ketamine to avoid opioids. — Todd Ponsky
5:55Non-pharmacologic pain management resources include child life specialists, mindfulness resources, and physical therapists. — Todd Ponsky
6:02Best multimodal therapy treatments include preoperative counseling, gabapentin pre- and post-operatively, methadone, clonidine, bowel regimen medications, and anti-emetics. — Todd Ponsky
6:19At Nebraska where Steve Rayner practices, length of stay is under 2 days and patients are off opioids by 1 week using multimodal pain management. — Todd Ponsky
6:39Bar flippage typically occurs early and is due to the bar sitting in an incorrect interspace, poor positioning, inadequate wrapping, or insufficient securing. — Sean Saint Peter
6:54The bar must sit in a comfortable position before securing or it will not remain stable; securing alone does not prevent flippage. — Sean Saint Peter
6:59Bar flippage is completely a surgical technique issue, not related to pain management method. — Steven Rothenberg
7:40Computational modeling by physics-minded surgeons showed that shorter flat bars have different stress point distribution compared to traditional U-shaped bars, with more pressure on the sternum making them more stable. — Todd Ponsky
8:19Sternal elevator is used in approximately 10% of cases, primarily in younger patients with really deep stiff pectuses to allow less tissue damage and better repair. — Steven Rothenberg
8:35Some surgeons use sternal elevator in every pectus excavatum case to eliminate guesswork and enable entry and exit at the same interspace. — Victor Garcia
8:59Safety techniques to avoid cardiac injury during bar passage include thoracoscopy, sternal elevator, vacuum bell in the operating room, or subxiphoid incision. — Sean Saint Peter
9:31Passing the bar from left chest to right chest is preferred by some surgeons because right-to-left passage points the introducer directly at the ventricle. — Speaker 9
10:12Bar passage direction (left-to-right versus right-to-left) is surgeon preference and likely does not make significant difference as long as the substernal space is well dissected and visualization is clear. — Sean Saint Peter

Cases discussed

0:3616-year-old male with pectus excavatum presenting with shortness of breath on exertion

Points of disagreement

3:01Use of cryoanalgesia for pectus excavatum pain management
- Sean Saint Peter: Cryoanalgesia provides superior outcomes with 1-day length of stay and dramatically reduced opioid use; equipoise was lost after seeing results.
- Steven Rothenberg: Initially skeptical but became convinced after 4 cases; outcomes are unbelievable despite concerns about long-term data.
- Victor Garcia: Agrees cryoanalgesia works but concerned about absence of long-term studies and potential for chronic neuropathic pain; prefers erector spinal catheters as alternative with known safety profile.
8:08Frequency of sternal elevator use
- Steven Rothenberg: Uses sternal elevator in about 10% of cases; thoracoscopy provides adequate visualization in most younger patients.
- Victor Garcia: Uses sternal elevator in every case to eliminate guesswork and ensure consistent safe passage at the same interspace.

Open questions

What are the long-term outcomes and potential complications of cryoanalgesia, particularly regarding chronic neuropathic pain?
What is the optimal bar length for pectus excavatum repair to balance stability and outcomes?
Should sternal elevator be used routinely in all cases or selectively based on patient characteristics?
Does the direction of bar passage (left-to-right versus right-to-left) affect safety or outcomes?

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 for Pectus Repair: When One Postoperative Day Changes the Trial

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 Presentation

A 16-year-old male presented with exertional dyspnea and a pectus index of 5.5 1:57. He had no comorbidities. The plan was chest wall reconstruction, and the question was which perioperative pain strategy to use alongside multimodal analgesia.

The Decision Point

The team at Children's Mercy had been running a randomized trial comparing epidural to patient-controlled analgesia for postoperative pain control in pectus repair. Neither arm was performing well — length of stay remained stubbornly at four days 2:37. Thirty patients had been enrolled in each group when the investigators added a third arm: cryoanalgesia, a technique using cold temperatures to create a conduction block that interrupts pain impulses to the brain 1:57.

The first patient treated with cryoanalgesia went home on postoperative day one 2:37. At that point, as one of the discussants put it, equipoise was lost 2:37. The trial stopped. The question was whether to adopt the technique broadly, despite the absence of long-term safety data.

What They Did

The Children's Mercy team adopted cryoanalgesia as their standard approach. The technique is straightforward: under thoracoscopic visualization, a cryoprobe is applied to the underside of ribs 4 through 7 for two minutes per rib 2:25. Rib 8 and below are avoided due to risk of abdominal wall paralysis 2:29. The procedure added time to the operation, but the results were immediate and dramatic. Median length of stay dropped from four days to one 2:37, and median morphine equivalents fell sharply 2:46.

Not every center followed the same path. Cincinnati Children's adopted erector spinal catheters instead — ultrasound-guided catheters placed by the pain service, juxtaposed to but not within the vertebral space 4:09. Patients go home on postoperative day two with the catheters still in place; families remove them at home on day three, for a total catheter duration of five days 4:19. This approach also reduced opioid requirements both in-hospital and after discharge 4:33, though it did not match the single-day discharge achieved with cryoanalgesia.

A third center reported success with an aggressive multimodal regimen alone — preoperative counseling, gabapentin before and after surgery, methadone, clonidine, bowel regimen medications, and antiemetics 6:02 — achieving a length of stay under two days and opioid cessation by one week postoperatively 6:19.

The Unresolved Question

One discussant, initially skeptical of cryoanalgesia due to concerns about operative time and reports of neuralgia, adopted the technique after four cases and described the change as "unbelievable," adding, "I feel bad that I waited so long" [q7]. His observation was specific: "It's not just when they go home, it's how they feel when they go home" 5:08.

But another discussant remained cautious. Cryoanalgesia works, he acknowledged, but there are no long-term studies 3:04. Unlike drugs, medical devices and implants are not required to undergo clinical trials before market introduction 3:24. The concern is not whether the technique controls acute pain — that question has been answered — but whether it produces delayed complications that have not yet been captured in the literature. The outcome of this specific case was not discussed.

What the Case Changes

The judgment here is not about whether cryoanalgesia works for acute pain — the evidence for that is clear and consistent across centers. The judgment is about how much long-term safety data you require before adopting a technique that changes patient experience this profoundly. One discussant framed it as a need for a registry. The alternative approaches — erector spinal catheters and intensive multimodal regimens — offer intermediate results with more established safety profiles. The choice depends on how you weight immediate benefit against unknown long-term risk, and whether you believe a technique this effective can wait for data that may take years to accumulate.

Takeaways from this story

Cryoanalgesia reduced pectus repair length of stay from 4 days to 1 day and dramatically cut opioid use compared to epidural or PCA
Cryoprobe technique: 2 minutes per rib on ribs 4-7; avoid rib 8 or below due to abdominal wall paralysis risk
Erector spinal catheters offer an alternative: 2-day hospital stay, catheters removed at home on day 3, reduced opioid needs
No long-term cryoanalgesia studies exist; medical devices don't require clinical trials before market introduction unlike drugs

Pain Control Evolution and Technical Refinements in Pectus Excavatum Repair

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

When Traditional Analgesia Fails

Epidural and PCA both plateau at four-day stays. A randomized trial of 110 patients comparing epidural to patient-controlled analgesia showed neither approach meaningfully reduced length of stay — both groups remained hospitalized around four days 2:37. The limitation was not technique failure but an analgesic ceiling: conventional regional and systemic opioid strategies could not suppress the intercostal nerve pain enough to permit earlier discharge. This plateau forced a search for alternatives that could interrupt pain transmission more completely.

Cryoanalgesia Mechanics and Boundaries

Freeze ribs 4 through 7 for two minutes each; never go lower. The technique is straightforward: count down to the fourth rib and apply the cryoprobe to the undersurface for two minutes per rib, treating ribs 4 through 7 2:25. The critical boundary is rib 8 — cryoablation at or below this level risks abdominal wall paralysis from inadvertent injury to lower intercostal nerves that supply the rectus abdominis 2:29. The cold causes a conduction block that interrupts pain impulses to the brain 1:57, and the clinical effect is immediate: length of stay dropped from four days to one day, with median morphine equivalents reduced so dramatically that the comparison to epidural shows values that are not even on the same planet [c4, c5].

The regulatory gap matters clinically. Medical devices and techniques do not require the clinical trials mandated for pharmaceuticals before market introduction 3:24. This means cryoanalgesia entered practice without long-term outcome data 3:04. For a procedure that ablates nerves in adolescents who will live another seventy years, the absence of ten- or twenty-year follow-up is not a theoretical concern — it is a knowledge gap that should temper enthusiasm. One discussant who adopted cryoanalgesia after initial skepticism acknowledged the transformation: "it's not just when they go home, it's how they feel when they go home" 5:08. But feeling better at discharge is not the same as confirmed safety at maturity.

Erector Spinae Catheters as the Conservative Alternative

Ultrasound-guided catheters stay five days, with families removing them at home on day three. Placed by the pain team under ultrasound guidance, erector spinae catheters sit juxtaposed to but not within the vertebral space 4:09. Patients stay two days in hospital, then go home with the catheter on a pump; families remove it on postoperative day three 4:19. This approach reduced opioid requirements both in-hospital and after discharge 4:33, achieving a two-day length of stay without nerve ablation. It is slower than cryoanalgesia but avoids the unknown long-term risk.

Multimodal Foundations That Apply Regardless of Regional Technique

Gabapentin, methadone, clonidine, bowel regimen, and antiemetics form the scaffold. Preoperative counseling sets expectations; gabapentin pre- and postoperatively addresses neuropathic pain; methadone provides long-acting opioid coverage; clonidine reduces sympathetic hyperactivity; bowel regimen prevents opioid-induced constipation; antiemetics address nausea 6:02. With this regimen alone — no cryoanalgesia, no erector spinae catheter — one center achieved length of stay under two days with patients off opioids by one week 6:19. The lesson is that regional techniques amplify but do not replace a disciplined multimodal base.

Bar Stability Is Surgical, Not Analgesic

Early flippage means the bar was sitting wrong before you secured it. Bars that flip do so early, and the cause is positioning: the bar sat in an awkward intercostal space, was not wrapped tightly, or was not secured well 6:39. One discussant stated flatly, "bar flippage is completely a surgical issue" 6:59. Computational modeling shows shorter flat bars exert more pressure on the sternum than traditional U-shaped bars, increasing stability 7:40. The implication: if you are seeing flips, examine your bar selection and positioning technique before attributing the problem to pain control choices that permit early mobilization.

Sternal Elevation and Introducer Direction

Use the elevator in deep stiff chests; pass the bar left-to-right to point the introducer away from the ventricle. Sternal elevator use allows less tissue damage and better repair in patients with rigid, deeply depressed sternums 8:27. For bar passage direction, left-to-right means the introducer tip points away from the right ventricle during substernal transit, whereas right-to-left aims the tip directly at the ventricle 9:31. The discussants agreed this is surgeon preference as long as the substernal space is well dissected 10:12, but the anatomic logic favors left-to-right in cases where visualization is suboptimal.

The discussants emphasized that cryoanalgesia's dramatic reduction in opioid use and length of stay has transformed discharge readiness, but the absence of long-term safety data remains the unresolved concern that should guide informed consent and institutional adoption decisions.

Takeaways from this story

Cryoanalgesia treats ribs 4-7 only; rib 8 or below risks abdominal wall paralysis from lower intercostal nerve injury
Medical devices enter practice without the long-term trials required for drugs, leaving cryoanalgesia's durability unknown
Erector spinae catheters stay 5 days with home removal on day 3, achieving 2-day stays without nerve ablation
Bar flippage is a surgical positioning problem, not a pain control issue; bars flip when sitting in wrong intercostal space
Pass the bar left-to-right so the introducer tip points away from the ventricle during substernal passage

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 variations. The discussion centers on cryoanalgesia as a pain management option that dramatically reduced length of stay to one day and opioid use, though long-term safety data remain absent. Alternative approaches include erector spinal catheters (2-day length of stay) and multimodal regimens achieving under 2-day stays. Technical considerations include bar length selection (shorter bars may be more stable), use of sternal elevators for safety, and surgeon preference regarding left-to-right versus right-to-left bar passage.

Key takeaways

Cryoanalgesia reduced pectus excavatum LOS from 4 to 1 day and dramatically cut opioid use, but long-term safety data are absent. (2:37)
Erector spinal catheters offer 2-day LOS with reduced opioid needs vs 4-5 days with epidurals; families remove catheters at home on day 3. (4:19)
Multimodal pain regimens (gabapentin, methadone, clonidine, NSAIDs) achieve <2-day LOS with patients off opioids by 1 week post-op. (6:02)
Bar flippage stems from incorrect interspace placement or poor positioning before securing, not pain management choice—technique is key. (6:39)
Sternal elevator use (10% of cases or routinely) plus thoracoscopy/vacuum bell minimizes cardiac injury risk during substernal dissection. (8:19)

Keywords

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

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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