Intercostal nerve cryoablation versus thoracic epidural for postoperative analgesia following pectus excavatum repair: a systematic review and meta-analysis

OBJECTIVES: Minimally invasive pectus excavatum repair via the Nuss procedure is associated with significant postoperative pain that is considered as the dominant factor affecting the duration of hospitalization. Postoperative pain after the Nuss procedures is commonly controlled by thoracic epidural analgesia. Recently, intercostal nerve cryoablation has been proposed as an alternative method with longacting pain control and shortened hospitalization. The subsequent objective was to systematically review the outcomes of intercostal nerve cryoablation in comparison to thoracic epidural after the Nuss procedure.

METHODS: Six scientific databases were searched. Data concerning the length of hospital stay, operative time and postoperative opioid usage were extracted. If possible, data were submitted to meta-analysis using the mean of differences, random-effects model with inverse variance method and I2 test for heterogeneity.

RESULTS: Four observational and 1 randomized study were included, enrolling a total of 196 patients. Meta-analyses demonstrated a significantly shortened length of hospital stay [mean difference -2.91 days; 95% confidence interval (CI) -3.68 to -2.15; P <0.001] and increased operative time (mean difference 40.91 min; 95% CI 14.42-67.40; P <0.001) for cryoablation. Both analyses demonstrated significant heterogeneity (both I-2 = 91%; P <0.001). Qualitative analysis demonstrated the amount of postoperative opioid usage to be significantly lower for cryoablation in 3 out of 4 reporting studies.

CONCLUSIONS: Intercostal nerve cryoablation during the Nuss procedure may be an attractive alternative to thoracic epidural analgesia, resulting in shortened hospitalization. However, given the low quality and heterogeneity of studies, more randomized controlled trials are needed.