Download PDF
CC BY 4.0 · European J Pediatr Surg Rep. 2024; 12(01): e50-e53
DOI: 10.1055/a-2349-9668
Case Report

Bilateral Lung Injury with Delayed Pneumothorax following Preoperative Cryoanalgesia for Pectus Excavatum Repair in a 13-year-old Boy

Clara Massaguer 
1   Department of Pediatric Surgery, Hospital Sant Joan de Deu, Universitat de Barcelona, Barcelona, Catalunya, Spain
,
Laura Saura-García
1   Department of Pediatric Surgery, Hospital Sant Joan de Deu, Universitat de Barcelona, Barcelona, Catalunya, Spain
,
Pedro Palazón
1   Department of Pediatric Surgery, Hospital Sant Joan de Deu, Universitat de Barcelona, Barcelona, Catalunya, Spain
,
Gastón Echaniz
2   Department of Anesthesiology, Hospital Sant Joan de Déu Barcelona, Catalunya, Spain
,
Maria Carme Roqueta Alcaraz
2   Department of Anesthesiology, Hospital Sant Joan de Déu Barcelona, Catalunya, Spain
,
Xavier Tarrado
1   Department of Pediatric Surgery, Hospital Sant Joan de Deu, Universitat de Barcelona, Barcelona, Catalunya, Spain
› Author Affiliations
› Further Information
Also available at
   Permissions and Reprints

Abstract

A 13-year-old male patient with marfanoid features and pectus excavatum with Haller index 4 and correction index of 38% underwent the Nuss procedure with cryoanalgesia 9 days prior, which transpired uneventfully. Preoperative spirometry was normal, and echocardiogram showed light aortic valve dilation. A month later, during a routine outpatient checkup, he referred middle abdominal pain, denying respiratory symptoms nor thoracic pain. He presented bilateral apical and right basal hypophonesis. Chest X-ray revealed bilateral pneumothorax and right pleural effusion. Consequently, the patient was admitted to the emergency room, and a chest computed tomography was ordered, reporting right apical blebs. Bilateral thoracoscopy was performed, and apexes were checked for pulmonary blebs to rule out primary pneumothorax. In the right chest, a wedge resection of a distorted area on the apex and pleuroabrasion were done. Four air leaking eschars were found when performing lung expansion under water as leaking test, corresponding to cryoanalgesia intercostal eschars, and subsequently closed by primary suture. In the left chest, there were no blebs. However, another four pleural lesions with intact pleura in the left lower lobe were also found. Postoperative course was uneventful and chest drains were removed 48 hours after surgery. He remains asymptomatic 21 months after discharge.

Cryoanalgesia in pectus excavatum is spreading due to the improvement in postoperative pain control. However, some complications may occur.

Keywords

pneumothorax - cryoanalgesia - pectus excavatum - Nuss procedure - Minimally Invasive Pectus Excavatum Repair (MIRPE)

Supplementary Material



Publication History

Received: 08 May 2023

Accepted: 29 February 2024

Accepted Manuscript online:
21 June 2024

Article published online:
26 July 2024

© 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Nuss D, Obermeyer RJ, Kelly RE. Nuss bar procedure: past, present and future. Ann Cardiothorac Surg 2016; 5 (05) 422-433
    CrossrefPubMedGoogle Scholar
  • 2 Ma B, Sun Y, Hao C, Liu X, Shen S. Patient-controlled intravenous analgesia with or without ultrasound-guided bilateral intercostal nerve blocks in children undergoing the Nuss procedure: a randomized, double-blinded, controlled trial. Pain Res Manag 2022; 2022: 5776833
    PubMedGoogle Scholar
  • 3 Frawley G, Frawley J, Crameri J. A review of anesthetic techniques and outcomes following minimally invasive repair of pectus excavatum (Nuss procedure). Paediatr Anaesth 2016; 26 (11) 1082-1090
    CrossrefPubMedGoogle Scholar
  • 4 Kirupaharan S, Briatico D, Robinson T, Fitzgerald P, Walton JM. Postoperative management of pediatric patients undergoing minimally invasive repair of pectus excavatum: where are we now?. J Pediatr Surg 2022; 57 (05) 927-931
    CrossrefPubMedGoogle Scholar
  • 5 Lai K, Notrica DM, McMahon LE. et al. Cryoablation in 350 Nuss procedures: evolution of hospital length of stay and opioid use. J Pediatr Surg 2023; 58 (08) 1435-1439
    CrossrefPubMedGoogle Scholar
  • 6 Arshad SA, Ferguson DM, Garcia EI, Hebballi NB, Buchanan AC, Tsao K. Cryoanalgesia is associated with decreased postoperative opioid use in minimally invasive repair of pectus excavatum. J Surg Res 2022; 271: 1-6
    CrossrefPubMedGoogle Scholar
  • 7 Cockrell HC, Hrachovec J, Schnuck J, Nchinda N, Meehan J. Implementation of a cryoablation-based pain management protocol for pectus excavatum. J Pediatr Surg 2023; 58 (07) 1239-1245
    CrossrefPubMedGoogle Scholar
  • 8 Keller BA, Kabagambe SK, Becker JC. et al. Intercostal nerve cryoablation versus thoracic epidural catheters for postoperative analgesia following pectus excavatum repair: preliminary outcomes in twenty-six cryoablation patients. J Pediatr Surg 2016; 51 (12) 2033-2038
    CrossrefPubMedGoogle Scholar
  • 9 Rettig RL, Rudikoff AG, Lo HYA. et al. Cryoablation is associated with shorter length of stay and reduced opioid use in pectus excavatum repair. Pediatr Surg Int 2021; 37 (01) 67-75
    CrossrefPubMedGoogle Scholar
  • 10 Cadaval Gallardo C, Martínez J, Bellía-Munzon G. et al. Thoracoscopic cryoanalgesia: a new strategy for postoperative pain control in minimally invasive pectus excavatum repair. Crioanalgesia toracoscópica: nueva estrategia para el control del dolor postoperatorio en cirugía del pectus excavatum. Cir Pediáatr 2020; 33 (01) 11-15
    PubMedGoogle Scholar
  • 11 Morikawa N, Laferriere N, Koo S, Johnson S, Woo R, Puapong D. Cryoanalgesia in patients undergoing Nuss repair of pectus excavatum: technique modification and early results. J Laparoendosc Adv Surg Tech A 2018; 28 (09) 1148-1151
    CrossrefPubMedGoogle Scholar
  • 12 Whittaker DK. Degeneration and regeneration of nerves following cryosurgery. Br J Exp Pathol 1974; 55 (06) 595-600
    PubMedGoogle Scholar
  • 13 Evans PJ. Cryoanalgesia. The application of low temperatures to nerves to produce anaesthesia or analgesia. Anaesthesia 1981; 36 (11) 1003-1013
    CrossrefPubMedGoogle Scholar
  • 14 Djebbar S, Rossi IM, Adler RS. Ultrasound-guided cryoanalgesia of peripheral nerve lesions. Semin Musculoskelet Radiol 2016; 20 (05) 461-471
    Article in Thieme ConnectPubMedGoogle Scholar
  • 15 Byas-Smith MG, Gulati A. Ultrasound-guided intercostal nerve cryoablation. Anesth Analg 2006; 103 (04) 1033-1035
    CrossrefPubMedGoogle Scholar
  • 16 Nicolás M, Acosta CM, Martinez Ferro M. et al. Short communication: ultrasound-guided percutaneous cryoanalgesia of intercostal nerves for uniportal video-assisted thoracic surgery. Ultrasound J 2022; 14 (01) 33
    CrossrefPubMedGoogle Scholar
  • 17 Finneran Iv JJ, Gabriel RA, Swisher MW. et al. Ultrasound-guided percutaneous intercostal nerve cryoneurolysis for analgesia following traumatic rib fracture -a case series. Korean J Anesthesiol 2020; 73 (05) 455-459
    CrossrefPubMedGoogle Scholar
  • 18 Zobel MJ, Ewbank C, Mora R, Idowu O, Kim S, Padilla BE. The incidence of neuropathic pain after intercostal cryoablation during the Nuss procedure. Pediatr Surg Int 2020; 36 (03) 317-324
    CrossrefPubMedGoogle Scholar
  • 19 Parrado R, Lee J, McMahon LE. et al. The use of cryoanalgesia in minimally invasive repair of pectus excavatum: lessons learned. J Laparoendosc Adv Surg Tech A 2019; 29 (10) 1244-1251
    CrossrefPubMedGoogle Scholar