S. Y. Chen1, S. J. Mack1, 2, L. I. Kelley-Quon1, 3, 4, E. S. Kim1, 4 4Keck School of Medicine, University of Southern California, Department Of Surgery, Los Angeles, CA, USA 1Children’s Hospital Los Angeles, Division Of Pediatric Surgery, Los Angeles, CA, USA 2Thomas Jefferson University, Sidney Kimmel Medical College, Philadelphia, PA, USA 3Keck School of Medicine, University of Southern California, Department Of Population And Public Health Sciences, Los Angeles, CA, USA
Introduction: Intraoperative intercostal nerve cryoablation has been shown to reduce post-operative pain in adults undergoing thoracotomy and children undergoing pectus excavatum repair. Cryoablation in pediatric cancer patients has not been well described. We hypothesize that cryoablation reduces opioid use in pediatric oncology patients undergoing thoracotomy.
Methods: An IRB-approved, retrospective chart review was performed for all oncology patients who underwent thoracotomy at a tertiary, freestanding children’s hospital from 1/1/2017-5/31/2021. Measured outcomes included cumulative post-operative opioid use measured in morphine milligram equivalents per kilogram (MME/kg), pain scores scaled 0-10, and receipt of an opioid prescription at discharge. Univariate analysis compared patients who received cryoablation to patients who did not receive cryoablation. Controlling for age and prior thoracotomy, multivariable regression analyses were performed to evaluate associations between cryoablation and post-operative opioid use and receipt of an opioid prescription at discharge.
Results: Overall, 32 patients (19M:13F)(median age 15 years) underwent thoracotomy. The most common diagnoses were metastatic osteosarcoma (n=18, 56.3%), metastatic Ewing’s sarcoma (n=4, 12.5%), pleuropulmonary blastoma (n=2, 6.3%), and metastatic Wilms tumor (n=2, 6.3%). Overall, 16/32 (50.0%) patients underwent >1 thoracotomy; 53 thoracotomies were performed overall and included in our analysis. Cryoablation was used in 14/53 (26.4%) thoracotomies. Throughout the entire post-operative hospitalization, children receiving cryoablation had lower median opioid use compared to children who did not receive cryoablation (0.37 MME/kg, IQ range 0.20-1.0 MME/kg vs. 1.2 MME/kg, IQ range 0.57-2.6 MME/kg, p=0.01)(Figure). Median maximum daily pain scores were lower in cryoablation patients (median max=6; IQ range 5-8) than non-cryoablation patients (median max=8; IQ range 6-10), with significant difference first noted on postoperative day 4 (p=0.01). Children receiving cryoablation were less frequently prescribed opioids at discharge (21.4% vs. 61.5%, p=0.01). On multivariable regression analysis, cryoablation was associated with 1.83 MME/kg less postoperative opioid use (95% CI: -3.25, -0.14) and a decreased likelihood of receiving an opioid prescription at discharge (OR 0.14; 95% CI: 0.03, 0.64) compared to children who did not receive cryoablation.
Conclusion: Cryoablation significantly decreases post-thoracotomy pain and opioid use in pediatric oncology patients and should be considered as part of a multi-modal approach to post-operative pain management.
