2024 Update Course - New Uses for Cryoanalgesia - Timothy Lautz, John DiFiore, & Thomas Inge

Um, all right, we're gonna move right on to cryoablation. Uh, we have, uh, a diverse crew here from different hospitals. So we got John DeFore from the Cleveland Clinic. Tim's up here again for like the, you're the expert in every topic. You are the absolute general surgeon, man. It's like, uh, and Tom Ee, uh, both of these guys are from Larry Children. So, um, take it away. All right, great. Uh, next slide. Actually, um, This slide coincides with actually a green, a blue, and a black. So we'll see if we can get through it. This is, we have 2 10 minute presentations here, so we'll see how we can do, um. I'm trying to find out from the international audience how many people are using cryo, uh, because that's not clear, uh, it's becoming pretty quickly the standard of care in the states and and in other places, but I'm curious to see just what our audiences that might affect, uh, where we go with the talk too depending on if people are new to it or not using it yet so. OK, so 30% have never used it and some on select cases have never used it but wanna start, so that's quite a bit, so about 50% have never used it. OK, that, that's very helpful. Let's have the next slide. I'm gonna basically go quickly through uh our technique at the clinic. We use a double lumen tube in all patients. Our, our freeze point is in the posterior axillary line about 4 centimeters from the vertebral column. With the original cryoprobe, we're gonna talk about some newer options. It's a 2-minute freeze cycle. We go from T3 to T8, although most of the literature is just to T7. Uh, after cryo, we do intercostal nerve blocks with subpleural injections. That's kind of the blue portion of the talk. If you can go to the next slide and start the video, this is on the, uh, left side of the chest. And, uh, one important landmark up top you can see the subclavian artery going over the top of the first rib that's how you, that's your landmark to count. So that's first we are doing cryoablation on the 3rd rib, um, again, uh, just where that muscle, uh, starts to starts to begin is a good landmark and, uh, 2 minute free cycle and then you just work your way down from the 3rd to the 7th rib. Uh, next slide. Uh, you can play this video. There's no, if you play, there we go. So, after we do that, I also do a subpleural injection with uh 0.25% marcaine with epinephrine. Uh, this works immediately as opposed to the 8 to 10 hour delay with the cryo nerve block. This is very simple to do. It takes about 15 seconds per uh per intraspace. That's a 25 gauge needle. It's actually a urological needle and if anybody's interested, I can, I can show you exactly, uh, the, the number to do that. But you can see the exposure that we get from the double lumin endotracheal tube, which is quite, uh, exceptional. Next slide, John, you like that better than percutaneous, uh, needle? Yeah, absolutely. I, I just. I, I think it, it, it's very quick to do and it's very easy to do and it, and you know that you're getting it right, right on the nerve. Um, so if you have never used cryo, and that's about 50% of our audience, what is the main reason? Cost, uh, takes too long, concern for chronic nerve pain, or some other reasons? A lot of others, which is probably equipment availability, I would imagine. OK. All right, OK, very good. So I was a, that's a good answer. I was expecting that, uh, a lot of people hesitate just because of the time involved. So I'm gonna talk just very briefly about that for people who are already using cryo. There is a new, uh, probe that's available that cuts down the time significantly. Uh, doing T3 to T8 bilaterally, it saves almost 30 minutes. So the tip now gets down to temperature about 20 seconds faster. The freeze cycle is 90 seconds instead of 2 minutes. It's 15 seconds less to thaw back to the temperature. There's also improvement on the shaft insulation so it can actually touch the lung because it only gets to room temperature. That's particularly important for people who are not using a double lumen tube where they're crossing the mediastinum and maybe have the lung as more of an issue. Uh, the shaft is also stiffer, so it's actually a lot easier to place. Uh, next slide. So, uh, on top is the old probe, uh, and the bottom is the new probe, um, they look different and there's different insulation on the shaft and the temperatures are different as you can see, um, so that is available, uh, why don't we skip this because we're only talking with the and. Uh, let's keep moving. Let's go through that and skip that. Um, I just wanna highlight, uh, one paper, um, I'm sorry, go back to that 11 paper by, uh, Seth Goldstein's group in Chicago where they did do a 1 minute free cycle instead of a 2 minute free cycle, and they had, uh, nerve blocks that were just as effective, a little bit of a limited study because they didn't actually measure pain scores, uh, or compare it directly to 2 minutes, but, uh, that is something you've seen it with my own eyes, OK, yeah, and, uh, and I think Tim's gonna talk about that, but, um. With the new probe it's only a 92nd freeze and there's actually another new probe that is 10 millimeters in size that is a 62nd freeze that gets down quicker with a larger ice ball that's coming out uh on October 1st, um, so. The options, uh, aren't, you're gonna not really gonna have to compromise your time in terms of the amount of freezing that you do. Uh, next slide. So this is a bit of a uh um a source of debate is, is whether or not to use a double lumen tube or not. Um, I use it in all cases. Uh, you saw the exposure of the intercostal nerves is really exceptional and it ensures that you're applying it posterior enough so, uh, so you, uh, you get the lateral cutaneous branch and I'm gonna show you a diagram. What I've noticed, and I've gotten multiple calls from other surgeons, go back one, please, multiple calls from other surgeons that say, well, you know, um, sometimes my blocks don't work, and invariably, it's been a surgeon using a single lumen tube. And, uh, doing the block too far anteriorly because they can't get posterior to that anterior axillary line. So next slide. We're really trying to make sure that we, uh, we cover that lateral cutaneous branch. Uh, next slide, uh, Doctor Kim from UCSF did the beautiful cadaver study showing that actually 18% of the nerve of the lateral cutaneous branch are posterior to the mid-axillary line. So if you don't get posterior enough, that's when you get blocks that are ineffective. So. I think uh that a double lumen tube greatly facilitates that um, a lot of groups have success with a single lumen tube doing the media style dissection going across from the right side to the left side. uh, next slide, I'm, I'm interested to see, um, who uses a double lumen tube and who uses a single lumen tube. Hey, hey, John, quick, quick question. So I haven't done one of these in 4 or 5 years, but I used to do a lot, and I never did the subpleural injection, and, and our, our results were quite good. I mean, it, we didn't, it didn't seem like we have to wait 8 or 10 hours for it to work. So was I just lucky or no, I, I think, I think you can, um. You can certainly do it without that. There's a few advantages that I have in an upcoming slide, but our anesthesiologists use zero opioid in, in the OR. Basically, they run, uh, anesthetic gas and propofol, and that's it. And there, there's a lot of strong anesthesia literature showing that the less opioid you use in the operating room, the less you use post-op. So, our study, um. Uh, has a very short length of stay, 1.1 days, and some of the least opioids avail uh, in terms of post-op use. Um, what's the result there? So 50 and 50%. OK. Uh, next slide. I have 2 minutes, so I'm actually gonna, let's, let's, I want to jump. Um, to keep going. Again I want to get to the black topic. OK. The, the black diamond. So Doctor Kim, again, this cadaver, what he also showed in the study was that there is a large collateral branch of the intercostal nerve that runs along the top of the nerve, separate from the main intercostal branch on the bottom of the nerve. So what he did in, uh, in a small series of patients was cryolate the main intercostal nerve on the bottom and also the top of the nerve below it. Next slide. And this is what that looks like. I've started doing this. I've done this in about 20 patients now, and you can play that video. In Doctor Kim's study, he had patients going home in 1 day instead of 2, but this is the standard location for freezing the nerve. And if you just go to the top of the rib below it. Now, there's not enough room to put them immediately, uh, under each other until you get further down in the chest. And I'm gonna show you as you move down toward T7 and T8, the interspace will widen enough so on the next freeze cycle you're going to see that you can do it immediately um below, uh, the, the standard freeze. So, um, anecdotally I've done this in about 20 patients. I would say the average pain scores, the peak pain scores have dropped from about 5 to about 3. Uh, it hasn't affected our length of stay because 98% of our patients go home the next day anyway. In Doctor Kim's study, his length of stay went from 2 days to 1 day, and, but what impressed me was that he had 9 out of his 22 patients reported pain scores of 0, which I thought was impressive, which is why I'm trying that. Again, this is, um, this is not a sanctioned, uh, use of that. Todd told me to make sure I say that it's kind of a new thing, but it's very easy to do. Of course, now the probe takes half the amount of time and now I'm doing double the number of blocks. So it. It kinda, uh, kinda washed out the time effect there, but, um, actually, you can stop there. I think, uh, I think that's all the time we have. Any questions before we go on to the next section? Awesome thanks. And now we're gonna kinda pivot into non-pus uses of cryo and so uh we can move on and so, uh, we're gonna talk about some of the basics which, um, we've already covered a little bit, some of the benefits in thoracotomy, which is what I as a surgical oncologist use this most commonly as, and then talk about some novel uses, especially if you start to use percutaneous applications of cryo. So we can go on. So just as a reminder, um, you know, some of the basics, um. You know, is that you do wanna stay far enough posterior, but you also wanna stay off of the sympathetic chains so you can, you know, certainly during thoracotomies you can visualize this very clearly, so I try to get about 3 to 4 centimeters away from that. And remember what's going on here is you're getting axonal degeneration by the freeze, but at the same time the epineurium is staying intact and that's what allows for the regeneration that occurs, um. You know, I, I don't think we need to talk about the pectus, you know, uh, category because that's really the paradigm and we've already covered that, but really as we go on to the next slide, um. Uh, we can talk about, I think we skipped a slide, but, um, when we're doing a thoracotomy, um, what are people doing for their postoperative pain control after a, not a neonatal thoracotomy, but, you know, a metastectomy for osteosarcomas or something like that. We can go to the poll now. Um, so what are people doing for that? A lot of epidurals, some paravertebrals, some IV pain meds, not a lot of cryo. I'm hoping I can, well, making a comeback, um, I'm hoping I can convince you, um, that cryo is a really good tool here, right? Epidurals are wonderful, but it is an invasive procedure that, um, you know, at least at our institution takes a little bit of time and you may or may not be leaving it fully, um, and it really only gets them through those first couple of days, whereas, as we know from Pus, the cryo is, um, getting you all through the recovery period. So, um, there have now been 3, pretty good publications about using this for, um, metastectomy, um, thoracotomies. When we're doing it just right through the, you know, we're doing a muscle sparing thoracotomy, um, and then just doing an open direct application of the cryoprobe. We have been doing 60 seconds for all of our cryo, both pectus and non-pectus. We've done like 300 attracure cases. All at 60 seconds and really seeing great results so you can really cut down the time. We're going 1 to 2 levels above, um, and below the thoracotomy. You do have to be a little bit careful about getting too low, which shouldn't, you know, you're not usually doing a low thoracotomy, but once you get to T10 or lower, you can start to get some pseudo hernias on the abdominal wall just from, um, affecting the, the motor branches there. Like I said, 60 seconds is sufficient. We also do temporary intercostal nerve blocks to help for those 1st 8 hours before it kind of sets in. We're using the standard probe, um, down to about age 3, and we've done kids down to about 18 months. There's a cardiac probe that they use for some of their ablations that you can use as like a smaller probe, um, if you're, um, doing smaller kids, but in smaller kids you do have to be really careful. We like to get a retractor in and hold the skin away because there's not a lot of chest wall musculature and you could get some skin freeze. uh, so Tim, that, that with the new probe. You, that problem is totally eliminated because the shaft insulation only gets to room temperature. So you can touch the lung, you, you can touch the skin. The only thing that gets cold is the, is the probe. So you should check it out. Um, you know, the benefits that we see is there's no epidural, there's no Foley, they're getting up and moving right away. The pulmonary toilet has been great. Um, we did a comparison in our group and we saw a 2 to 3 fold reduction in narcotic use during the hospitalization, basically sending these kids home without, uh, narcotic prescriptions, and for me. The best benefit is no waiting for my regional team, um, so as we, you know, this was our data and so, you know, we compared, um, what their results were, um, both compared to all of the routine group which was some just IV pain med only but also compared to those that had regional block and so you know in in this study we had. 23 thoracotomies who had cryo and you know even if you look at, you know, the um oral morphine equivalents during the state compared to those who had regionals it was way dramatically lower so 137 versus 533 so we're using a lot less opioid, um, and so we really this is routine for us now other than our neonatal thoracotomies, um, we've really gone to using this all the time. Now we're gonna talk a little bit about. Besides just the standard cryoprobe, once you start, you know, you know, again going back to the OR IR collaboration, once you start using the tools that the IR folks have available, which includes some of these percutaneous needle options, what else you can do? Yeah, absolutely gonna, um, I'm gonna pivot here to some, uh, stuff that's right up, uh, John's wheelhouse here, uh, in IR. Next slide. Um, So Next slide. Yeah, so, uh, we've also seen some real benefits of cryo, uh, treatment, cryoablation, uh, for rib fractures, but also, um, uh, slipping rib syndrome and other, uh, endochondromas, as you see here. Um, slipping rib rib syndrome. Anybody raise your hands, uh, that have, have seen this before, taking care of these patients, few in the audience, yeah, most actually. So, um, this is a condition, uh, with cartilaginous, uh, uh, union at the end of our ribs for our floating ribs in particular, but also, of course, we've got, uh, false ribs. That are higher up that we uh that we see sometimes a um a uh laxity in some of these, uh, uh, costochondral junctions and we can see the, uh, impingement on these, uh, intercostal nerves either the, the ones that are the largest, which are the inferior or even superior as these, uh, as the ribs, uh, do, uh, slip. And float, um, and, um, and actually encroach upon these nerves. So there's conservative management, and we've all seen patients that, you know, come to us with their pi already out, maybe even their gallbladder out, um, and nobody has arrived at the right diagnosis. A lot of colonoscopies and CTs and ultrasounds, um, but slipping rib syndrome can be, uh, the, uh, the cause of chronic abdominal wall pain. And, um, and they can end up in your, in your, in your clinic, uh, for what next? So, uh, always, uh, assess for it and, um, and when we, uh, find these, uh, these, uh, patients, uh, typically they are, uh, teenage girls, uh, more so than, than boys. When we find them, uh, what we find is that, uh, they'll often have. This somatic tenderness of the abdominal wall, uh, but they really won't have a visceral type tenderness. So in other words, you can get them to do a crunch or flex their abdominal walls muscles, and then you palpate and you can get actually more tenderness when they're, uh, when they're, when they're crunching than when they're relaxing. So that's a tip-off. Uh, back one slide, sorry, slides are getting, uh, getting ahead of me. Um, and so what, what we actually do with these patients with the slipping rib syndrome in particular, is, uh, that we will, uh, make the diagnosis. Again, often we'll have some incisional scars and, uh, in a normal Api on pathology, um, but, uh, but then refer them to chronic pain. And so chronic pain can do an evaluation, also elicit, uh, the same kinds of physical exam findings directing them. Uh, to a, a, a slipping rib and do an intercostal block, um, usually a steroid as well as, uh, a long acting. Uh, local, and you can actually determine whether this is the, the cause or not because it's a pretty diagnostic, uh, test. Um, once that's done it might last for a while, it could last for weeks, it could last for months, it may only last for days. Um, it depends. These patients are, uh, somewhat heterogeneous, but if there's an. Actual response, uh, the next step that would be reasonable is, uh, sometimes to, to go ahead and refer to surgery or to, to take them on as a surgical patient. Sometimes patients want to know is there an in between? And that's where, uh, more commonly these days, especially now that there are these needle, probes for the cryo, our IR folks are actually doing an ablation. Um, they may do an ablation actually at a, uh, you know, one at the, at just the right level or they more commonly are doing multiple levels, um, and, um, and then what we've, uh, we've had a number of these patients, this is actually an intraoperative photo, um, X-ray rather of them, uh, doing, uh, their needle probe placements and, um, and freeze thaw cycles, uh, so next slide. Um, so, uh, this is actually a paper from, uh, some of our friends in, uh, in Phoenix. I don't know if there's anybody from Phoenix here today, but maybe in the, uh, maybe in the audience. Um, and what they found is that when they're doing surgery, uh, actually for slipping rib syndrome, they will also use cryoablation intraoperatively. So kind of a marriage of the surgery to remove the rib tips, um, uh, or to stabilize a slipping, uh, cartilaginous, um, costal margin. Um, and, uh, and then also use, uh, use cryo for the, for the ablation at the same time to find you shorter length of stay, lesser narcotic use. So. 2 minutes coming up on this. Um, so, uh, we can also, and I think you may have been the trauma surgeon on call for this patient, right? I think I picked him up, uh, afterwards, but, um, but basically, if you have someone come in with a, just a terribly, uh, uh, flail chest or fractures, um, that gets stuck on a ventilator, uh, actually you can do a world of good. Um, with this technique as well by, uh, anesthetizing just those ribs that are intercostal spaces that is that are, um, the problem, get patients off the ventilator, pulmonary toilet, you, you anything else to add? No, and I would just reminder there's multiple ways to apply this, um, tool, right? So we're used to doing it with the standard probe from the intrathoracic approach, you know, one of our partners. Partners did one of these slipping rib cases yesterday. He did a plating and then you can do this external application of the cryo right there in the OR or you can refer to the um IR colleagues who are using the same needles for cryoabla liver lesions and lung nodules and other things like that. It's just a different application of the tools that they have in their armamentarium and so you can get one question or one more. Moving on. So what else can people, you know, we're doing these open-ended questions. What other tools, what other uses of cryo are people doing? Maybe we'll skip the poll, but then talk about actually it's not a poll. This is just a panel question. So, oh great, OK, yeah. Any other uses, uh, we that's out there. Hold on, hold on, right? And, uh, badpect carrying out them. I think, you know, psychosocially a fairly put together kid and family, um. I'm, I talked to John about this the other day, potentially just moving forward with cryo alone, not wanting to commit to a full ravage or anything like that. But my question is, particularly, uh, you may have experiences with the pulmonary metastatectomy, can you go back and do cryo again and again, because I would want to do that for the ravage eventually, but be very nervous that that would create some sort of neuroma or something bad. No, we've done this for, I've done this with at least 2 patients with osteochondromas that were fairly symptomatic and Um, uh, you know, we did it first, and then when we went and did the river section for osteochondroma, we re-cryo and they did just fine with it. Yeah, and I'll be able to tell you a little bit more about that too because the same patient, one of these patients that our, our folks did is coming up for me to, to take care of this week actually. Um, uh, and the question was, should they do another cryo because she got 8 months out of the original cryo and in fact they asked the question of, well, can you just do an ablation, a complete ablation with phenol and or alcohol, and that didn't seem like a really good approach, but I'm gonna use cryo when I actually operate as well, so we'll be able to see. Yeah, in terms of novel uses, I actually have a patient tomorrow, uh. What you'll find is when you start to use cryo more and more you get patients like this one, a 16 year old teenager with just this very unusual left sided chest pain came from an outside institution that huge workup they can't find anything and honestly I'm not sure what it is. There's no chest wall anomaly, but we're gonna do. Uh, we're gonna do, uh, just transcutaneous intercostal nerve blocks as a diagnostic tool. And if that works we'll probably go to cryoablation now. I was, I was going to do it transthoracically, but I was, I might talk to you, Tom, about having them do it percutaneously, um, because it, it's one of these techniques that, that you, you start to find more applications for it the more you use it, and there's a lot of it, there's a lot of very strong literature in the adult trauma literature about using it for rib fractures and if. And if you ask the cryo reps, that's where, that's where the vast majority of their calls are from, that they'll go into the OR for rib fractures with cryo and plating and things, and there's a lot of data on, on your cardiac pulmonary recovery to use it too. I mean, it, it works for sternotomy pain too. We don't think about it as much, but it, it works great for that too. This is awesome. I mean, it's a great tool that we can start planning tons of that. Thanks guys. This is great. Thank you very much. All right.