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APSA - Is same day discharge possible following the Nuss repair for pectus excavatum - R. Luke Rettig

Video Published 2022-05-24 Updated 2026-06-02

Timestops (20)

We just have one more presentation to go in ABSA

We just have one more presentation to go in ABSA, from ABSA, and for this whole event, so here's, we have Doctor Luke Re…

And thank you for the opportunity for me to present our rese…

And thank you for the opportunity for me to present our research on pectus excavatum and same-day discharge at APSA 2021…

Historically, the NEST procedure has been associated with a significant amount of pain, and this pain leads to increased…

Our study looked at the NUS procedure with intercostal nerve…

Our study looked at the NUS procedure with intercostal nerve cryoablation and an enhanced recovery after surgery protoco…

And historically

And historically, as we know from some of our previous papers, patients have been in pain for about 24 hours after this …

So what we did with the intercostal nerve block was we used …

So what we did with the intercostal nerve block was we used buppivacaine proximal to the site of intercostal nerve cryoa…

We had 15 patients in both groups.

We had 15 patients in both groups. All patients were male, and the patient characteristics were similar in both groups w…

None of the patients in the INC group were discharged prior …

None of the patients in the INC group were discharged prior to postoperative day 2. The length of stay was decreased in …

We found that 10 patients in the IMD group never even used o…

We found that 10 patients in the IMD group never even used opioids after discharge, whereas 5, the remaining 5, use them…

And none of those were a difference between the group

And none of those were a difference between the group, groups. In the INB group, though, um, 0 returned to the EED, wher…

The same day discharge is possible in Ped Ecoban and patient…

The same day discharge is possible in Ped Ecoban and patients. If you would like a copy of the ERATS protocol, please em…

I wanna begin with the question

I wanna begin with the question, uh, just because it can be done, uh, should it be done? And I personally don't feel tha…

Um, and from the standpoint of, is this approved for by the FDA, uh, is, is a question of whether it should be used. Uh,…

And the drug industry

And the drug industry, and the medical device industry rather, has been, I think, fairly conspicuous by the fact that ma…

So, I'm gonna be cautious about this, uh, Luke, because we really are concerned about chronic neuropathic pain. And I'm …

Uh, so I say cryoablation is not ready for prime time, uh, and just because you can't do it doesn't really justify us. I…

Thank you for your comment, Doctor Garcia.

Thank you for your comment, Doctor Garcia. I, I understand where you're coming. From there have been some papers and we …

Um, so this has been going on for a few years and we've shown that it's been actually been safe and all the, a lot of th…

And then I saw the introduction of intracostal nerve cryoabl…

And then I saw the introduction of intracostal nerve cryoablation, and then these patients were staying in the hospital …

So I think the benefits 100% outweigh whatever potential lon…

So I think the benefits 100% outweigh whatever potential long-term effects that we actually haven't seen. Thank you, Doc…

Topic Overview

A surgical resident presents outcomes of same-day discharge after Nuss procedure for pectus excavatum using intercostal nerve cryoablation combined with an enhanced recovery protocol and intercostal nerve block. The study found 10 of 15 patients discharged on postoperative day zero with reduced opioid use and lower costs compared to cryoablation alone. A discussant raises concerns about the long-term safety of cryoablation in children, noting the lack of rigorous FDA trials for medical devices and potential for chronic neuropathic pain, advocating for randomized controlled trials and registry tracking before widespread adoption.

Key Takeaways

Same-day discharge achieved in 67% of Nuss patients using cryoablation plus nerve block vs 0% with cryoablation alone. (2:42)
Adding intercostal nerve block to cryoablation cut hospital stay from 58 to 12 hours and reduced opioid use significantly. (2:59)
67% of nerve block patients never used opioids post-discharge; zero ED returns vs 27% in cryoablation-only group. (3:19)
Long-term safety of cryoablation in children remains unknown; chronic neuropathic pain risk warrants RCTs and registry tracking. (5:41)
Medical devices lack rigorous FDA trials compared to drugs; adverse events may be underreported per Kaiser Health News. (4:53)

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

Speaker 1 — host
Luke Reddick — guest
Victor Garcia — guest
Speaker 4 — host

Chapters

0:00Introduction — Host introduces the final APSA presentation on same-day discharge after pectus repair and the discussant from Cincinnati Children's Hospital.
0:19Study Presentation: Same-Day Discharge Protocol — Dr. Reddick presents research comparing Nuss procedure with cryoablation plus enhanced recovery protocol and nerve block versus cryoablation alone, demonstrating feasibility of same-day discharge with reduced opioid use and costs.
4:32Discussant Commentary: Safety Concerns — Dr. Garcia questions whether same-day discharge should be pursued, expressing concerns about long-term consequences of cryoablation, lack of rigorous FDA trials for medical devices, and potential for chronic neuropathic pain.
6:33Response and Closing — Dr. Reddick responds that long-term neuropathy rates have been very low in their experience, patients are satisfied, and benefits outweigh potential risks. Host closes the session.

Key claims

0:36Pectus excavatum affects 1 in about 400 patients — Luke Reddick
0:39Pectus excavatum has a male predominance at about a 4:1 ratio — Luke Reddick
0:39The Nuss procedure is the gold standard for pectus excavatum fixation — Luke Reddick
0:46The Nuss procedure has been historically associated with a significant amount of pain leading to increased hospital lengths of stay and costs — Luke Reddick
0:57Intercostal nerve cryoablation has helped patients with pain and decreased length of stay — Luke Reddick
1:23Intercostal nerve cryoablation was performed at sites T3 through T7 on both sides of the chest — Luke Reddick
1:31Patients have been in pain for about 24 hours after intercostal nerve cryoablation because it sometimes takes that long for the full effects to kick in — Luke Reddick
1:55Bupivacaine was used proximal to the site of intercostal nerve cryoablation for the intercostal nerve block — Luke Reddick
2:23There were 15 patients in both study groups, all male — Luke Reddick
2:26Patient characteristics were similar in both groups with regards to Haller index, pectus correction index, age, and ethnicity — Luke Reddick
2:36Follow-up in the INB group was 7.5 months, whereas follow-up in the INC group was 29 months — Luke Reddick
2:4210 out of 15 patients in the INB group were discharged on postoperative day zero, with the remaining 5 discharged on postoperative day one — Luke Reddick
2:53None of the patients in the INC group were discharged prior to postoperative day 2 — Luke Reddick
2:59Length of stay was decreased in the INB group at 12 hours compared to 58 hours in the INC group — Luke Reddick
3:04OR time was the same in both groups — Luke Reddick
3:07Cost was statistically significantly less in the INB group compared to the INC group — Luke Reddick
3:07Amount of opioids used were statistically significantly less in the INB group than the INC group — Luke Reddick
3:1910 patients in the INB group never used opioids after discharge, whereas the remaining 5 used them sparingly — Luke Reddick
3:49Zero patients in the INB group returned to the emergency department, whereas 4 in the INC group returned to the emergency department — Luke Reddick
4:53Medical devices typically are not subjected to the same rigorous, robust trials that drugs are — Victor Garcia
5:24Many adverse consequences for medical devices are either underreported or not reported, as suggested by Kaiser Health News — Victor Garcia
5:41Long-term consequences of cryoablation are unknown, particularly for children — Victor Garcia
5:52There is concern about chronic neuropathic pain as a consequence of cryoablation — Victor Garcia
7:08Patients previously stayed 7, 8, or 9 days in the hospital with thoracic epidurals for Nuss procedure — Luke Reddick
7:16With introduction of intercostal nerve cryoablation, patients stayed in the hospital for 3 days — Luke Reddick
6:39Long-term neuropathy rate with cryoablation is very low in their patient population — Luke Reddick
7:29High rates of neuropathy have not been observed in their patients with cryoablation — Luke Reddick

Points of disagreement

4:37Appropriateness of cryoablation for same-day discharge in pediatric pectus patients
- Victor Garcia: Cryoablation is not ready for prime time due to unknown long-term consequences, lack of rigorous FDA trials, and concerns about chronic neuropathic pain. Advocates for randomized controlled trials and registry tracking.
- Luke Reddick: Cryoablation has been safe in their experience with very low long-term neuropathy rates, high patient satisfaction, and benefits that outweigh potential risks. Protocol enables same-day discharge with reduced pain and opioid use.

Open questions

What are the long-term consequences of intercostal nerve cryoablation in pediatric patients?
Should cryoablation undergo randomized controlled trials before widespread adoption?
What is the optimal follow-up duration to assess for chronic neuropathic complications?

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:

Same-Day Discharge After Nuss Procedure: Combining Cryoablation With Nerve Block

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

For the care team · Explainer · AI-written, human-reviewed

Why This Exists

Pectus excavatum — the funnel chest deformity affecting roughly 1 in 400 patients, predominantly male at a 4:1 ratio — is corrected surgically with the Nuss procedure, which has been the gold standard for decades 0:36 0:39 0:39. The operation involves placing a curved metal bar beneath the sternum to reshape the chest wall. The problem has never been whether the repair works; the problem has been the pain. Historically, postoperative pain from the Nuss procedure kept patients hospitalized for a week or more with thoracic epidurals, driving up costs and opioid exposure 0:46 7:08. Intercostal nerve cryoablation — freezing the nerves that transmit chest wall pain — reduced hospital stays to around three days 0:57 7:16. The question now is whether same-day discharge is feasible, and if so, whether it should be pursued.

The Core Clinical Problem

Cryoablation works, but not immediately. The full analgesic effect takes roughly 24 hours to develop, leaving a perioperative pain gap during which patients still require significant analgesia 1:31. This delay has historically necessitated at least an overnight stay. If that gap could be bridged with a complementary intervention, same-day discharge might become realistic — but only if pain control, safety, and long-term outcomes remain acceptable.

How the Approach Works

The protocol under study combines three elements: the standard Nuss repair with intercostal nerve cryoablation at T3 through T7 bilaterally, an enhanced recovery after surgery (ERAS) pathway, and an intercostal nerve block using bupivacaine placed proximal to the cryoablation sites 1:23 1:55. The nerve block provides immediate local anesthesia while the cryoablation effect develops over the first postoperative day. The ERAS protocol structures the perioperative care to minimize opioid use and accelerate functional recovery.

In a 15-patient cohort treated with this combined approach, 10 patients were discharged on postoperative day zero and the remaining 5 on postoperative day one, yielding a median length of stay of 12 hours 2:42 2:59. This compared to a historical control group of 15 patients who received cryoablation alone, none of whom were discharged before postoperative day two, with a median stay of 58 hours 2:53 2:59. Operating room time was identical between groups 3:04. Inpatient opioid consumption was significantly lower in the nerve-block group, and 10 of the 15 patients in that cohort never used opioids after discharge; the remaining 5 used them sparingly 3:07 3:19. Hospital costs were significantly reduced 3:07. No patients in the nerve-block group returned to the emergency department, compared to 4 returns in the cryoablation-alone group 3:49. Complication rates — Foley reinsertion, pneumothorax requiring chest tube, surgical site infection, urinary tract infection, and urgent care visits — did not differ between groups.

Where Practice Is Contested

The discussant raised a fundamental objection: just because same-day discharge can be achieved does not mean it should be [q1]. The concern centers on cryoablation itself, not the discharge protocol. Medical devices are not subjected to the same rigorous clinical trials as pharmaceuticals, and adverse events may be underreported 4:53 5:24. The long-term consequences of cryoablation — particularly in children — remain unknown 5:41. Chronic neuropathic pain is a specific worry 5:52. The discussant argued that cryoablation is "not ready for prime time" and called for a randomized controlled trial and a registry to track long-term outcomes [q2][q4].

The presenting surgeon countered that their institution has followed cryoablation patients for several years and observed very low rates of long-term neuropathy 6:39 7:29. Patients return satisfied, and the benefits — dramatic reductions in hospital stay, opioid use, and cost — outweigh the theoretical long-term risks that have not materialized in their cohort [q6]. The historical trajectory supports this: thoracic epidurals kept patients hospitalized for 7 to 9 days; cryoablation alone reduced that to 3 days; adding the nerve block and ERAS pathway has now enabled same-day discharge in two-thirds of patients 7:08 7:16.

This is not a disagreement about data. Both parties accept the short-term outcomes. The disagreement is about the adequacy of the evidence base for a technique that alters nerve function in adolescents who will live with the consequences for decades. The presenting team argues that years of clinical experience without observed harm constitute sufficient evidence. The discussant argues that absence of observed harm in a single-center cohort is not the same as proof of safety, and that the standard for introducing a new intervention in children should be higher.

When to Involve This Team

Referral for pectus excavatum repair is typically driven by a combination of physiologic impairment (exercise intolerance, dyspnea, chest pain) and psychosocial impact. The Haller index — the ratio of chest width to the distance between sternum and spine — is commonly used to quantify severity, though it is not the sole determinant of surgical candidacy. If you are managing an adolescent with symptomatic pectus excavatum, referral to a pediatric surgeon with experience in the Nuss procedure is appropriate. The discussion presented here did not address specific referral criteria or timing, but the evolution of pain management protocols means that the conversation with families about what to expect postoperatively has changed substantially. Same-day discharge is now a realistic goal at centers using this combined approach, though the long-term safety of cryoablation remains an area of active debate.

Takeaways from this story

Intercostal nerve block with bupivacaine bridges the 24-hour delay in cryoablation onset, enabling same-day discharge in two-thirds of patients.
Combined cryoablation and nerve block reduced median hospital stay from 58 hours to 12 hours without increasing complications or ED returns.
Long-term neuropathy rates after cryoablation remain contested: one center reports very low rates, but rigorous long-term trials are lacking.
Medical devices like cryoablation probes are not subject to the same FDA trial requirements as pharmaceuticals, raising regulatory concerns.

Same-Day Discharge After Nuss Repair: Bridging the Cryoablation Gap

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

Iterative refinement in pain management changes what is possible

The history of Nuss procedure recovery illustrates how incremental improvements in pain control fundamentally alter surgical care models 7:08 7:16 2:42. The progression from thoracic epidurals with prolonged hospital stays 7:08, to intercostal nerve cryoablation alone with shorter stays 7:16, to enhanced recovery protocols with nerve blocks enabling same-day discharge 2:42 demonstrates that each advance in analgesia unlocks the next level of optimization. The lesson is not that cryoablation is sufficient — it is that identifying the remaining pain gap (the delay before cryoablation takes full effect 1:31) and addressing it with adjunctive nerve blocks creates the conditions for outpatient surgery 1:55 2:42. When you see a procedure with a predictable recovery timeline, ask what is keeping patients in the hospital at each interval, then target that specific barrier.

The cryoablation lag is the problem to solve

Intercostal nerve cryoablation at T3-T7 bilaterally 1:23 provides excellent analgesia once established, but the full effect takes time to manifest 1:31. This delay creates a perioperative pain window that historically required inpatient management 2:53. The innovation here is recognizing that this is a bridging problem, not a failure of cryoablation itself 1:31 1:55. Administering bupivacaine proximal to the cryoablation sites 1:55 provides immediate local anesthetic effect while the cryoablation takes hold. The result: most patients discharged on postoperative day zero, with the remainder discharged on day one 2:42, compared to none before day two in the cryoablation-alone group 2:53. When a technique works well but has a known temporal limitation, the solution is often not abandoning the technique but adding a time-limited adjunct 1:55.

Opioid reduction is the downstream marker of adequate pain control

The opioid consumption data tells you whether your pain strategy actually works in the real world 3:07 3:19. In the nerve block group, most patients never used opioids after discharge, and the remainder used them sparingly 3:19. Inpatient opioid use was statistically significantly lower than in the cryoablation-alone group 3:07. These are not marginal differences — they represent a qualitative shift in the pain experience 3:07 3:19. When evaluating a new perioperative protocol, do not rely solely on length of stay or patient satisfaction scores. Opioid consumption is an objective, hard-to-game metric that reflects whether patients are comfortable enough to function without narcotics 3:07 3:19. If your innovation does not move that number, it is not solving the pain problem.

Medical device adoption outpaces evidence generation

Cryoablation for intercostal nerves in pediatric patients highlights a broader tension in surgical innovation: medical devices are not subjected to the same rigorous trials as pharmaceuticals 4:53, and adverse events are often underreported 5:24. The long-term consequences of cryoablation in children remain unknown 5:41, and chronic neuropathic pain is a legitimate concern 5:52. The counterargument — that observed long-term neuropathy rates are very low 6:39 7:29 — is based on institutional experience rather than registry data or randomized trials 6:39 7:29. This is the reality of surgical practice: you often adopt techniques based on case series and expert opinion, not Level I evidence 4:53. The judgment call is whether the immediate, measurable benefits (reduced length of stay 2:59, lower costs 3:07, fewer ED returns 3:49) justify proceeding in the absence of long-term safety data 5:41. Reasonable surgeons disagree on this threshold. What is not reasonable is pretending the uncertainty does not exist or dismissing calls for registries and trials as obstructionist 4:53 5:24 5:41. If you are going to use a device in children without long-term data, you have an obligation to contribute to that data generation 5:41.

Takeaways from this story

Cryoablation's onset delay can be bridged with local anesthetic nerve blocks, enabling same-day discharge in most patients.
Opioid consumption — not just length of stay — is the objective metric for evaluating perioperative pain protocols.
Medical devices lack the rigorous trial requirements of drugs; long-term cryoablation safety in children remains unknown.
Enhanced recovery protocols reduced hospital stay and eliminated ED returns in the nerve block cohort.

Same-Day Discharge After Nuss Repair: Innovation or Premature Adoption?

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

Intercostal nerve cryoablation combined with enhanced recovery protocols now enables same-day discharge after Nuss repair for pectus excavatum. The technique has reduced hospital stays from 7-9 days with thoracic epidurals to 3 days with cryoablation alone, and now to 12 hours with the addition of intercostal nerve blocks 7:08 7:16 2:59. But should this approach be widely adopted before long-term safety data exist?

The Case for Caution

Victor Garcia argues that cryoablation "is not ready for prime time" [q2]. His concern rests on three foundations. First, medical devices are not subjected to the same rigorous trials that drugs undergo 4:53. The FDA approval pathway for devices lacks the clinical trial infrastructure that would reveal long-term complications. Second, adverse consequences for medical devices are often underreported or not reported, as suggested by Kaiser Health News 5:24. The surveillance system may not capture what happens years after the procedure. Third, and most critically, "we really don't know what the long-term consequences of this" are, particularly regarding chronic neuropathic pain in children [q3] 5:41 5:52.

Garcia calls for a randomized controlled trial and a registry to track outcomes systematically before the technique becomes standard [q4]. The historical parallel he invokes — well-intended surgical innovations that later proved harmful — frames this as a question of appropriate evidence thresholds rather than resistance to progress.

The Case from Experience

Luke Reddick's position emerges from direct clinical observation across three eras of pain management for this operation. His group's data show that 10 of 15 patients in the intercostal nerve block cohort were discharged on postoperative day zero, with the remaining 5 discharged on day one 2:42. None in the cryoablation-only group went home before day two 2:53. Length of stay dropped from 58 hours to 12 hours 2:59. Opioid requirements fell significantly, with 10 patients never using opioids after discharge and 5 using them sparingly 3:07 3:19. No patients in the enhanced protocol group returned to the emergency department, compared to 4 in the cryoablation-only group 3:49. Costs decreased significantly 3:07.

On the neuropathy concern, Reddick states that "our long term neuropathy rate is essentially very low, if not anything" [q5] 6:39. His group has followed these patients for years without observing the high rates of neuropathic complications Garcia fears 7:29. From this experience base, he concludes that "the benefits 100% outweigh whatever potential long-term effects that we actually haven't seen" [q6].

Where They Agree

Both recognize that cryoablation represents a major advance over thoracic epidurals. Neither disputes that the technique reduces acute postoperative pain, shortens hospital stays, and decreases opioid consumption. Garcia does not argue for returning to week-long admissions — his concern is about the adequacy of evidence for the current iteration, not the direction of progress. Both would support better tracking of outcomes. The disagreement is not whether cryoablation works in the short term, but whether short-term efficacy justifies widespread adoption before long-term safety is established.

What Would Resolve It

Garcia explicitly calls for a randomized controlled trial comparing cryoablation protocols to standard approaches, with long-term follow-up, and a registry to track all patients undergoing the procedure [q4]. This would generate the device-level evidence he argues is currently missing. Reddick's position would be strengthened by publishing the multi-year follow-up data he references, particularly the denominator — how many patients have been followed for how long, and what systematic assessment tools were used to detect neuropathy.

The follow-up duration in the presented study is asymmetric: 7.5 months in the enhanced protocol group versus 29 months in the cryoablation-only group 2:36. Neither timeframe captures the "long-term" outcomes Garcia seeks. The disagreement may ultimately rest on different thresholds for evidence sufficiency when the alternative is prolonged hospitalization, high opioid exposure, and the complications that accompany both. Whether that trade-off justifies proceeding without the trial Garcia requests remains unresolved.

Takeaways from this story

Enhanced protocol with nerve blocks reduced length of stay from 58 to 12 hours, with 10/15 patients discharged same-day.
Medical devices lack the rigorous trial requirements of pharmaceuticals, raising concerns about unreported long-term complications.
Chronic neuropathic pain risk from cryoablation in children remains unknown despite short-term institutional experience showing low rates.
Follow-up duration was 7.5 months in the enhanced protocol group versus 29 months in cryoablation-only group.

Keywords

pectus excavatum chronic neuropathic pain Nuss procedure intercostal nerve cryoablation intercostal nerve block thoracic epidural lobotomy bupivacaine opioids Kaiser Permanente Los Angeles Medical Center Cincinnati Children's Hospital APSA

Hashtags

#pectusexcavatum #nuss procedure #samesdaydischarge #cryoablation #APSA #pediatric surgery #chestwall #minimallyinvasivesurgery #PediatricSurgery #ERAS #SameDayDischarge

Transcript

We just have one more presentation to go in ABSA, from ABSA, and for this whole event, so here's, we have Doctor Luke Reddick. Um, he, we're gonna see his presentation on whether pectus patients can be discharged the same day from the hospital after their repair. Then we'll hear from Doctor Victor Garcia from Cincinnati Children's Hospital and get his thoughts on the matter. Hello, everyone. My name is Luke Reddick, and I'm a surgical resident at Kaiser Permanente Los Angeles Medical Center. And thank you for the opportunity for me to present our research on pectus excavatum and same-day discharge at APSA 2021. Pectus excavatum affects 1 in about 400 patients. It has a male predominance at about a 4:1 ratio, and the Nest procedure is the gold standard for fixation. Historically, the NEST procedure has been associated with a significant amount of pain, and this pain leads to increased hospital lengths of stay, which increase hospital costs. Now, with the introduction of intercostal nerve cryoablation, this has helped patients with their pain and also has helped to decrease the length of stay. Our study looked at the NUS procedure with intercostal nerve cryoablation and an enhanced recovery after surgery protocol in addition to intercostal nerve block, and this was compared to the NUS procedure with intercostal nerve cryoablation alone. The intercostal nerve cryoablation was performed at sites T3 through T7 on both sides of the chest. And historically, as we know from some of our previous papers, patients have been in pain for about 24 hours after this intercostal nerve cryoablation, uh, because it sometimes takes that long for the full effects to kick in. We hypothesized that using an enhanced recovery after surgery protocol, in addition to intercostal nerve block, that this would help them with their pain. So what we did with the intercostal nerve block was we used buppivacaine proximal to the site of intercostal nerve cryoablation, and we thought that this would help with perioperative pain. A primary outcome was same-day discharge, and secondary outcomes included returns to the emergency department, returns to urgent care, returns to the operating room, a cost analysis, and an analysis of inpatient and outpatient opioid use. We had 15 patients in both groups. All patients were male, and the patient characteristics were similar in both groups with regards to Haller index, pectus correction index, age, and ethnicity. The follow-up in the IMD group was 7.5 months, whereas the follow-up in the INC group was 29 months. We found that 10 out of 15 patients were able to be discharged on postoperative day zero, with the remaining 5 in the INB group being able to be discharged on postoperative day one. None of the patients in the INC group were discharged prior to postoperative day 2. The length of stay was decreased in the I&D group at 12 hours compared to 58 hours. The OR time was the same in both groups. The cost was statistically significantly less in the IND group compared to the INC group, and the amount of opioids that were used were statistically significantly less in the IMB group than the INC group. We found that 10 patients in the IMD group never even used opioids after discharge, whereas 5, the remaining 5, use them sparingly. All patients had resolution of syndrome. Now, the complications, we looked at Foley catheter removal and replacement. We looked at pneumothorax requiring chest tube placement. We looked at infections, surgical site, and also UTIs, and we looked at returns to urgent care. And none of those were a difference between the group, groups. In the INB group, though, um, 0 returned to the EED, whereas in the INC group, 4 returned to the emergency department. We concluded that the NUS procedure and intercostal nerve cryoablation with enhanced recovery after surgery protocol and intercostal nerve block was better than just the NUS procedure and intercostal nerve cryoablation. The same day discharge is possible in Ped Ecoban and patients. If you would like a copy of the ERATS protocol, please email me below at robert@el. Reddick@kP.org, and thank you so much for listening. Bye. Well, Doctor Riddick, uh, I wanna thank you for that presentation and I wanna thank the organizers for this opportunity. I wanna begin with the question, uh, just because it can be done, uh, should it be done? And I personally don't feel that cryoablation is ready for prime time. Uh, and the reason is, is that we really don't know what the long-term consequences of this. You know, when we look at medical devices, uh, the track record is not a very positive one from the standpoint that, uh, these devices typically are not, uh, subjected to the same rigorous, robust trials that, so, let's say drugs are. Um, and from the standpoint of, is this approved for by the FDA, uh, is, is a question of whether it should be used. Uh, frankly, because it has not been subjected to the clinical trials that drugs, uh, have, have been and should be used. And the drug industry, and the medical device industry rather, has been, I think, fairly conspicuous by the fact that many of the adverse consequences for medical devices are either underreported or not reported, as suggested by the Kaiser Health News. Uh, so we don't know what the long-term, uh, consequences of this device, uh, are, of this procedure, nor do we know what the long-term consequences are, uh, particularly for children. So, I'm gonna be cautious about this, uh, Luke, because we really are concerned about chronic neuropathic pain. And I'm reminded about the consequences of uh lecotomy, uh, that were really introduced by a well-intended surgeon who thought that he could address, uh, consequences as far as health, um, and mental illness. Uh, so I say cryoablation is not ready for prime time, uh, and just because you can't do it doesn't really justify us. I'm arguing for a trial, randomized controlled trial, as well as a registry so that we can track right Doctor Red results. Sorry, sorry. Thank you, Doctor Garcia. Doctor Reddick, any response? Thank you for your comment, Doctor Garcia. I, I understand where you're coming. From there have been some papers and we have followed these patients for a few years now, and our long term neuropathy rate is essentially very low, if not anything. Um, so this has been going on for a few years and we've shown that it's been actually been safe and all the, a lot of these patients, you know, come back to our clinic, they're super happy and They really went through that original surgery and their pain was incredibly controlled. So I've seen before how we would do it, you know, with thoracic epidurals, and these patients would stay 7 days, 89 days in the hospital. And then I saw the introduction of intracostal nerve cryoablation, and then these patients were staying in the hospital for 3 days, which is incredible. And then we did this. protocol, and now these patients are able to go home the same day of discharge. So I understand your concern with the long term, you know, effects of intercostalal cryoablation, but I've also seen, haven't seen really high rates of neuropathy. And in our patients specifically, that's really not an issue. So I think the benefits 100% outweigh whatever potential long-term effects that we actually haven't seen. Thank you, Doctor Reddick. A little bit of blows after the bell, but I think the judges were looking the other way, so they didn't notice. Uh, all right. Uh, phenomenal papers.

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