Freezing Out Pain: Innovations for Pectus Excavatum Recovery
John DiFiore, MD returns to Butts & Guts to discuss cryoablation, a new, innovative technique that has improved patient recovery times and pain control after pectus excavatum surgery.
Freezing Out Pain: Innovations for Pectus Excavatum Recovery
Scott Steele: Butts & Guts, a Cleveland Clinic Podcast, exploring your digestive and surgical health from end to end.
Hi everybody and welcome to another episode of Butts & Guts. I'm your host, Scott Steele, the Chair of Colorectal Surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio. I'm very pleased to have, for appearance number two on Butts & Guts, Dr. John DiFiore who's the director of Cleveland Clinic’s Center of Excellence for Pectus Excavatum. John, welcome back to Butts & Guts.
John DiFiore: Thank you, Scott. Great to be here.
Scott Steele: For all of our listeners that did not have the opportunity to hear one of your previous podcasts, and I encourage everybody to go back and listen to a little bit of an overview on the Nuss procedure and pectus excavatum from a previous episode on Butts & Guts.
Can you tell our audience a little bit about your background, where you're from, where did you train, and how'd you come to the point that you're here at the Cleveland Clinic?
John DiFiore: Thank you, Scott. I'm actually a native New Yorker, grew up right outside New York City and was pretty much in New England until I moved to Cleveland to be with Cleveland Clinic. I went to Dartmouth College. I went back to New York to Columbia University for medical school, and then did all my training in surgery in the Harvard system in Boston. I was there for 10 years for general surgery and did my pediatric surgical training at Boston Children's Hospital. My first staff position 22 years ago was here at Cleveland Clinic and I've been here ever since.
Scott Steele: Well, we're very glad that you made that move here to the Midwest.
John DiFiore: It's been terrific.
Scott Steele: Yeah. Awesome. Can you give us a little bit, I know you covered this in your last podcast, but set the stage for us. Give us a little bit of an overview of this Nuss procedure and specifically a little bit more about the pectus excavatum.
John DiFiore: Sure. Pectus excavatum is a fairly common condition that probably a lot of our listeners have at least seen and maybe not know what it was. It refers to what's commonly known as a sunken chest or an indentation of the sternum or the breastbone.
For many years, it was treated with a fairly invasive surgery called the Ravitch procedure, which was a four to five hour operation involving a long hospital stay and removal of the cartilage parts of the ribs. It was a very effective operation, but really quite invasive.
About 25 years ago, Dr. Nuss introduced a technique involving placement of a metal bar behind the sternum that pushes it out into the normal position. The best analogy that I think works well is that it works essentially like braces on your teeth. While the bar is in place, which is typically a period of three years, the ribs, cartilage, and sternum, all reshape and remodel while they're in the normal position. So that when the bar comes out, the sternum remains in a normal position.
The primary indications for surgery are shortness of breath and exercise intolerance, which are probably the two common symptoms. Those are related to limitations on the expansion of the lungs and the chest because the chest is sunken in and the volume is reduced. There is also very typically some compression of the right ventricle and the right atrium that impairs cardiac filling and cardiac performance, which also plays a role.
Secondarily, although usually a primary concern for patients is the appearance of the chest, but the physiologic benefits are clear and the appearance of the chest is dramatically improved as well.
Scott Steele: John, let's take a step up. Something that I actually really don't know or don't remember, is this a genetic defect? Are people prone to this? Are the risk factors for pectus excavatum or is this just something just like, you're born with a different shaped head, or you got bigger feet, or anything, how does this all kind of come together?
John DiFiore: Yeah. Great question. Yeah, essentially it's an isolated variation that certain patients are predisposed to. We don't have any data or information really on a genetic link. There does not seem to be a genetic relationship to it. Although we see it in families occasionally because of the large volume of patients we see at our center here, there's not a strong association or risk between siblings or between family members.
Scott Steele: Is there anything that you can do if you're a parent out there and you notice your kid might have this, or is this just something, let them grow, see how it does, they may grow out of it and you go from there?
John DiFiore: Good question. There isn't really anything you can do to alter the course of the shape of the chest wall. Just about all patients will observe a significant change, a significant deepening of their indentation during their rapid growth spurt in the early teen years. We think that's related to the cartilage and it's part of the ribs basically growing too fast.
When that section of the rib becomes too long, too quickly, it pushes the sternum backward. A lot of patients aren't really aware of it until 12, 13, or 14 when they start growing rapidly. Then they notice this indentation, but there really isn't much you can do about it. There is not a non-operative treatment for this in terms of physical therapy or exercises and there's nothing really you can do to prevent it.
Scott Steele: Oh, that's fantastic information. Well, let's jump ahead. I'm a parent out there, my child is experiencing either issues associated with some of the physiology that you were talking about, or even the appearance of that, and get on the internet and they talk about this Nuss procedure. Talking about a bar and three years or whatever the issue is. That's pretty scary.
Can you talk a little bit about cryoablation? What does this mean and how does it work and how does it fit into this entire concept of the Nuss procedure in a pectus?
John DiFiore: The Nuss procedure, it's a major operation in terms of putting a brace or a piece of hardware internally in the chest, but it has a very attractive safety record. The complication rate is less than 1%. Our numbers here are extremely high in terms of the number of cases we do and our complication rate is 1% or less. It's an extremely safe operation and that's the first thing that I would mention certainly to two families relative to how much this is going to be bothering their teenagers and how important it is to get it repaired.
When we first started doing the surgery 20 years ago, and really up until I would say 2016, one of the main issues was pain control after the operation. When you put this brace behind the sternum and push everything out, it's almost like going to the orthodontist and having him completely correct your teeth all in one setting.
You can imagine there's a lot of stress on the muscles, and the ribs, and the sternum, which caused a lot of pain. Now, we initially dealt with that with epidural catheters. Typically, that was a week in the hospital and two weeks or more of opioid medication in the recovery after going home.
In 2016, about four years ago, I started a new protocol using intravenous PCA, or patient controlled analgesia, where the patient presses a button to deliver intravenous medication. That improved actually the pain control and dropped our length of stay to about five days. One of the problems with that, however, was that it relied on the patient to push the button. If they fell asleep during the night, often their pain would escalate to eight or nine and trying to recover from that became fairly difficult.
Two years later in 2018, I added a significant change to the pain protocol, which was preoperatively. Before patients came in the hospital, we had them start taking pain medication, which included Gabapentin, also known as Neurontin, which a lot of patients are actually familiar with. Celebrex, which is a nonsteroidal antiinflammatory, and Tylenol, those three.
Intraoperatively we began to place what are called intercostal nerve blocks. Each rib has an intercostal nerve that runs along the bottom of the rib and that's what provides sensation to the chest. During the surgery on both the left and right sides for essentially all of the ribs of the chest, I perform an injection with a long acting novocane essentially it's called Bupivacaine or Marcaine. That really dramatically improved our pain control for those first 10 or 12 hours when patients were typically having trouble.
Using the intercostal nerve blocks, plus the preoperative pain protocol, which we continued after discharge, patients were going home in about three days. Most of them were getting off of their opioid pain medication in about a week. Now this was 2018 when really the opioid crisis became much more of a focus appropriately so. I think that really pushed our team to look for ways to not just get patients home sooner, but to get them using less in the way of opioid medication.
About seven months ago, at the end of 2019, I added to that protocol something called cryoablation. Cryoablation involves using a special probe essentially to freeze the nerves. Again, those intercostal nerves that run under the rib and we do it from the third to the eighth rib on both sides. Essentially that interrupts all of the sensation to the chest.
That's combined with the injection nerve blocks that I just mentioned, we do both. So the first 10, 12 hours, the nerve blocks with the Bupivacaine are really in effect and then the cryoablation effect takes over. We have really noticed a dramatic improvement in a number of parameters.
In our first group of patients, actually for patients that were under 19 years of age, which is the vast majority. All of our patients went home the next day. 60% of the patients took no oxycodone at all and were just on non-opioid medication. What's even more impressive is that the average pain score in the hospital that night and the next day was two out of 10. Not only are patients going home the next day, but their pain control has been dramatically improved.
The third factor, which was one of the things that really drove this was the opioid issue. Of all our patients, we only gave them a two day prescription for oxycodone and although I don't know exactly how many tablets they all took, but nobody called in for a refill. When I see them back in the office, most of them say, "Well, I took one or two of those pain pills you prescribed, but that was it."
We've had dramatic reduction in length of stay, dramatic improvement in pain scores, and dramatic reduction in the amount of opioid medication that patients use after surgery. It's been a game changer.
Scott Steele: Oh, that's fantastic. Let's go on now to segment that I like to call Truth or Myth and tell us kind of what's behind the scenes in terms of this. First of all, truth or myth, if somebody has a Nuss bar they cannot perform any physical activity?
John DiFiore: That is definitely a myth. Now, the first three months that the bar is in place, there are significant activity restrictions because we want the bar to become stable in position so it doesn't shift or move around, but after three months, patients can do 95% of their activities.
They can get back to sports, they can get back to exercise, they can drive their car actually just a couple of weeks after surgery. There are a handful of activities that we wait until six months after surgery. Primarily contact sports like football, and soccer, and some of the rotational sports. I call the upper body rotational sports like golf, and tennis, and swinging a baseball bat. After six months, there are absolutely no restrictions.
I have patients playing every sport you can imagine football, soccer, hockey, baseball, golf, skiing, pole vaulting, wrestlers, you name it, they can do it. After three months, you can do just about anything. After six months, you can do anything that you want literally.
Scott Steele: Truth or myth. Once the bar is removed, the recurrence rate is high?
John DiFiore: That is a myth. Again, a good question. The recurrence rate in our series is one to 2%. By recurrence rate, that means that sometimes the sternum will drop back maybe a centimeter or less. In fact, we over-correct to kind of account for that, but we have never had a patient we've had to re-operate on for a substantial recurrence.
Now, if you look at the original literature, the recurrence rate was listed at about five to 6%, but with improvement in techniques and leaving the bar in for three years instead of two years, which was the original recommendation, the recurrence rate is around 1%.
Scott Steele: Truth or myth. Whereas the cryoablation allows you to go home earlier from surgery, it leaves longterm problems associated with sensation?
John DiFiore: Good question. That is a myth. It is true that when patients go home after cryoablation, most of them will feel that a good portion of their chest is numb and that's expected because we've essentially numbed the nerves that bring sensation to the chest.
In three to six months after surgery, the small area of the nerve that is frozen is able to regenerate and reconnect so that the sensation returns. In a small subset of patients, about 10%, it will take up to nine to 12 months for their sensation to return, but it returns in almost all patients.
Scott Steele: I know you talked about this very briefly, but can you tell a little bit more about really the importance behind this idea of decreasing opiod use especially in teenagers and how the Cleveland Clinic has made this a top priority?
John DiFiore: Well, I think institutionally, as you know being a clinician yourself, we've basically been approached with a mandate to find better ways to take care of patients pain that do not use significant amounts of opioids.
I think institutionally, we have been able to do that both by just finding other medications to give orally, but as it is the case with pectus, finding new ways to treat pain that don't involve medication. In this case, it's addressing the actual nerves that transmit the pain and we're able to block those with the cryoablation.
Scott Steele: Fantastic. What's on the horizon as far as additional research or treatment regarding either cryoablation, or Nuss procedure, or pectus in general?
John DiFiore: Right now, the cryoablation is our main focus in terms of expanding that option to all of our patients and all of our patients this summer will be receiving cryoablation. It is a patient choice of course. I discuss that with patients thoroughly beforehand.
What we are going to be looking at is to expand on our understanding of cryoablation, particularly as it relates to the parameters we discussed. How good is the pain control? How does it affect their use of opioid medication? Do we see any problems or issues with the cryoablation? So far we have not, but we want to follow that out more longterm.
Scott Steele: Final, take home message for our listeners?
John DiFiore: For patients that have pectus excavatum, it's something that you should not feel you need to live with if it's bothering you from any standpoint. Either that you're having trouble breathing, you're having exercise limitation, or if you are not satisfied with the appearance of your chest, which for developing teenagers is much more and much different than strictly a cosmetic decision.
We have a superb operation that is extremely safe with outstanding results with a short time in the hospital, and with much less impact on activities after going home than it used to be.
The other thing Scott that the cryo has really allowed us to do is to offer the surgery more throughout the year. We have many more options in terms of timing. It used to be we'd have to do virtually all of these surgeries during the summer months when patients were out of school because of the length of time required for their hospital stay and their recovery.
Now, we can do the surgery on a vacation, a spring break, or a winter break, and patients can really get back to school within a couple of weeks after the surgery. That's expanded the availability to a large number of patients.
Scott Steele: Yeah, I think that's a great point and as you know during this time of kind of the pandemic, just to reiterate the safety of being able to come to the Cleveland Clinic for an appointment or virtually being able to walk through all this. We encourage everybody to revisit some of the recent episodes that talk about how we're keeping patients safe and caregivers safe during this coronavirus pandemic.
John as you know, I like to end up with all my guest quick hitters. You've had some in the past, but let's explore you a little bit more if you will.
John DiFiore: Sure, sure.
Scott Steele: First of all, do you play music in the operating room and if so, what kind?
John DiFiore: I do. I play music in the operating room all the time. I'm a big Pandora favorite. I started off with an Eagle's radio selection and added some of my favorite artists who are artists like Billy Joel, Elton John, John Mayer, Bruce Hornsby. I'm a piano player so I like a lot of the piano base pop music. I would say those are my favorites. In fact, if I don't have music playing in the background, it's actually distracting.
Scott Steele: Number two, peanut butter, crunchy or smooth?
John DiFiore: Smooth absolutely.
Scott Steele: Number three, you're in the aisle to get candy for a movie what do you go to?
John DiFiore: That is such an easy question. That's peanut M&M's all day with a large popcorn and a diet Coke.
Scott Steele: Fantastic. And we do have a lot of kind of trainees that listen here – what’s your advice to a trainee that's considering a life as a pediatric surgeon?
John DiFiore: That's a great question. I would say, get as much exposure to it as you can during your residency. If you have extra time, certainly speak to, for the Cleveland Clinic residents, speak to us in the department. For residents at other institutions, go to a staff pediatric surgeon, introduce yourself, and get to know them, get to know their lifestyle, what they do, and how they do it. Then when you look to spend your time off for research or other activities during your residency, pick a pediatric surgery program that has a lot of depth in terms of research and case volume, and you'll get a great experience.
Well, that's great stuff. For more information on pectus excavatum and to download a free treatment guide, please visit clevelandclinic.org/pectus. That's clevelandclinic.org/pectus. P-E-C-T-U-S.
For additional information or to speak with a specialist at the Cleveland Clinic Children's Hospital, please call 216.442.4378. That's 216.442.4378. In times like these it's important to keep up with your medical care and rest assured that the Cleveland Clinic is here and we're taking all the necessary precautions to sterilize our facilities, protect our patients, and keep you safe. John, thanks for joining us on Butts & Guts.
John DiFiore: Thank you, Scott. Appreciate it.
Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts & Guts.