# Update Course Rewind: Pectus Excavatum 2021 — GCMD Library Did you miss our 9th Annual Update Course last year? Don't worry, we are summarizing our favorite sessions from years past. In this episode, Drs. Steven Lee, Shawn St. Peter, Victor García, Steven Rothenberg, Whit Holcomb, & Justin Wagner will talk you through some updates in pain control management and tricks for the Nuss procedure. Hosts: Dr Todd Ponsky, Dr Ellen Encisco & Dr Cecilia Gigena Also, Mark your calendars for our next 10 Annual Update course 2022 in August 30! Join us: https://globalcastmd.wufoo.com/forms/zjvig871ne79wa/ Type: podcast · 11 min · posted 2026-07-29 Canonical: https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670 ## Chapters - [0:00](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=0) Introduction and Cryoanalgesia for Pain Control - [3:50](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=230) Alternative Pain Management Approaches - [7:00](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=420) Surgical Technique Updates - [10:25](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=625) Summary and Closing ## Statements - "A randomized trial of 110 patients comparing epidural and PCA for pectus excavatum pain control showed that epidurals did not provide superior pain relief" — Cecilia Gigena (clinical) [1:02](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=62) - "After implementing cryoanalgesia, a patient went home on post-operative day one, which was a dramatic improvement over previous pain control methods" (clinical) [1:21](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=81) - "Cryoanalgesia uses cold temperatures to cause a conduction block that interrupts pain impulses to the brain" — Cecilia Gigena (clinical) [1:56](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=116) - "The cryoanalgesia technique involves freezing underneath ribs four through seven for two minutes per rib" — Cecilia Gigena (clinical) [2:09](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=129) - "Cryoanalgesia should not be performed on rib eight or below because it can cause abdominal wall paralysis" — Cecilia Gigena (clinical) [2:09](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=129) - "With cryoanalgesia, hospital length of stay decreased from four days to one day" (clinical) [2:33](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=153) - "Cryoanalgesia dramatically reduced median morphine equivalents compared to previous pain control methods" — Cecilia Gigena (clinical) [2:43](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=163) - "There are no long-term studies on cryoanalgesia outcomes" (clinical) [2:52](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=172) - "Medical devices and techniques are not required to undergo clinical trials before introduction to market, unlike medications" — Cecilia Gigena (guideline) [3:14](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=194) - "Erector spinae catheters are placed by the pain team with ultrasound guidance and are juxtaposed to but not in the vertebral space" (clinical) [4:08](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=248) - "Erector spinae catheters stay in for five days, with hospital stay of two days, and catheters are pulled out by the family on the third day while at home" (clinical) [4:08](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=248) - "Erector spinae catheters reduced opioid requirements both in the hospital and outside of the hospital" — Cecilia Gigena (clinical) [4:30](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=270) - "With erector spinae catheters, hospital stay is two days, which is much less than the four or five days seen with epidurals" — Cecilia Gigena (clinical) [4:30](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=270) - "Cryoanalgesia changed not just when patients go home but how they feel when they go home" (opinion) [4:50](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=290) - "For multimodal pain therapy, the best treatments are preoperative counseling, gabapentin both pre and postoperatively, methadone, clonidine, bowel regimen medications and antiemetics" — Cecilia Gigena (clinical) [5:40](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=340) - "With multimodal pain control at one institution, length of stay is under two days and patients are off opioids by one week" — Cecilia Gigena (clinical) [6:20](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=380) - "If bars are going to flip, they flip early because they were sitting in a bad spot, the bar was not wrapped tight enough, or it was not secured well" (clinical) [6:40](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=400) - "Bar flippage is completely a surgical issue related to bar positioning and securing technique" (opinion) [6:40](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=400) - "Computational modeling showed that shorter flat bars have more pressure on the sternum compared to traditionally U-shaped bars, making them more stable" — Cecilia Gigena (clinical) [7:00](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=420) - "Sternal elevator is used in about 10% of cases at one institution" — Cecilia Gigena (clinical) [7:40](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=460) - "In younger patients with average anatomy, thoracoscopy provides adequate visualization without needing a sternal elevator" — Cecilia Gigena (clinical) [8:00](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=480) - "In really deep stiff pectus cases, sternal elevation allows less tissue damage and a better repair" — Cecilia Gigena (clinical) [8:20](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=500) - "One surgeon uses the sternal elevator in every case to eliminate guesswork and enable passage in and out at the same intercostal space" — Cecilia Gigena (clinical) [8:40](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=520) - "Thoracoscopy, sternal elevator, vacuum bell in the operating room, or subxiphoid incision all serve the purpose of avoiding cardiac injury" — Cecilia Gigena (clinical) [9:00](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=540) - "Passing the bar from left chest to right chest is preferred by some surgeons because going right to left means the introducer points directly at the ventricle" (opinion) [9:30](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=570) - "Bar passage direction probably does not make a significant difference as long as the substernal space is well dissected and everything is clear" (opinion) [10:00](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=600) ## Transcript 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. --- Not medical advice · citation policy: https://library.globalcastmd.com/ai