Six Years of Quality Improvement in Pectus Excavatum Repair: Implementation of Intercostal Nerve Cryoablation and ERAS Protocols for Patients Undergoing Nuss Procedure

Infographic · Mar 2025 · 1 min read

In brief

Six-year quality improvement study demonstrates that intercostal nerve cryoablation reduced hospital stay by 62% and opioid use by 87% in Nuss procedure patients. Adding ERAS protocols further decreased discharge opioids by 83% and postoperative pain scores by 25%, showing synergistic benefits for pectus excavatum repair outcomes.

Intercostal nerve cryoablation reduced hospital stay by 62% and inpatient opioid use by 87% compared to epidural analgesia alone.
Adding ERAS protocol to cryoablation further decreased discharge opioids by 83% and postoperative day-one pain scores by 25%.
Cryoablation increased operative time by 25% but significantly improved recovery metrics without increasing complications.
Combined cryoablation and ERAS protocols offer synergistic benefits for pain control and faster discharge after Nuss procedure.
Quality improvement approach demonstrates feasibility of reducing opioid exposure in pediatric chest wall surgery.

Written by the GCMD Library team from the infographic.

A clinical comparison infographic displaying three surgical treatment options arranged horizontally. Each approach is illustrated with anatomical diagrams showing the esophagus and lower esophageal sphincter. Color-coded sections present success rates, complication profiles, and technical considerations for each procedure. Statistical data is presented in percentage format with visual indicators.

Jordan M. Rook, Lisa K. Lee, Justin P. Wagner, Veronica F. Sullins, Steven L. Lee, Shant Shekherdimian, Daniel A. DeUgarte, Christine E. Dichter, Howard C. Jen

Background: The Nuss procedure for pectus excavatum is associated with prolonged hospitalizations due to pain. We evaluated implementation of intercostal nerve cryoablation and enhanced recovery after surgery (ERAS) protocols on outcomes of Nuss procedures performed over six years at a single institution.

Methods: This retrospective cohort study included patients who underwent Nuss procedure from 10/2017 to 09/2023. Patients received epidurals prior to 06/2019, cryoablation from 06/2019 to 07/2021, and ERAS with cryoablation and intraoperative methadone administration after 07/2021. We used multivariable linear regression to evaluate length of stay (LOS), inpatient morphine milligram equivalents (MMEs), and discharge opioids. We assessed the balancing measures of operative time, postoperative pain scores, and complications.

Results: We identified 62 patients; 15 who received epidurals, 18 cryoablation, and 29 cryoablation with ERAS. Cryoablation was associated with a 62.3% (p < 0.001) decrease in length of stay, an 86.6% (p < 0.001) decrease in inpatient MMEs, and a 72.9% (p < 0.001) decrease in discharge opioids. Cryoablation was additionally associated with 24.5% (p = 0.02) longer operative times and 46.4% (p = 0.04) higher postoperative day one pain scores. Subsequent implementation of an ERAS protocol was associated with a further 82.8% (p = 0.04) decrease in discharge opioids and a 25.0% (p = 0.04) decrease in postoperative day one pain scores.

Conclusions: Over six years of quality improvement efforts, we found the implementation of cryoablation and ERAS protocols to be associated with a significant decrease in length of stay and opioid exposures. Protocolized pain management and cryoablation may work synergistically to improve outcomes without compromising patient experience.

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