Intercostal nerve cryoablation versus thoracic epidural analgesia for minimal invasive repair of pectus excavatum: a randomized clinical trial (ICE-trial).

Summary

In this randomized clinical trial of adolescents and young adults undergoing the Nuss procedure, intercostal nerve cryoablation reduced median hospital stay from 4 to 1 day compared with thoracic epidural analgesia (P<.001). It also reduced opioid consumption by 83% during hospitalization and 97% after discharge, but persistent chest-wall hypoesthesia occurred in 56% at six months.

Key Findings

• Median hospital stay was 1 day with intercostal nerve cryoablation versus 4 days with thoracic epidural analgesia (P<.001).
• Opioid consumption was reduced by 83% during hospitalization and 97% after discharge with cryoablation.
• Persistent chest-wall hypoesthesia at six months occurred in 56% of patients after cryoablation.

Clinical Implications

Intercostal nerve cryoablation may be considered as an alternative to thoracic epidural analgesia for selected patients undergoing minimally invasive pectus excavatum repair, particularly when rapid mobilization, reduced opioid exposure, and shorter hospitalization are priorities. Informed consent should explicitly address the possibility of prolonged chest-wall numbness.

Limitations

• The study was single-center, unblinded, and included only 48 patients in the intention-to-treat analysis.
• Persistent hypoesthesia was common, and the long-term functional and quality-of-life consequences were not fully established.
• The findings may not generalize to older patients, open procedures, or institutions with different perioperative protocols.

Future Directions

Larger multicenter trials should compare cryoablation with contemporary multimodal analgesia, evaluate sensory recovery beyond six months, measure patient-reported quality of life and functional outcomes, and identify patients most likely to benefit without clinically important numbness.