Impact of intercostal nerve cryoablation on opioid use in pleural mesothelioma surgery: results from a high-volume integrated regional center.

BACKGROUND

Pleural mesothelioma is a rare and aggressive malignancy treated with a multimodal approach that includes surgery. Unfortunately, pleurectomy and decortication surgery is highly morbid and is associated with significant postoperative pain. To reduce harmful side effects associated with opioid use, intercostal nerve cryoablation has emerged as a potential adjunct for thoracic pain control. However, its role among patients with pleural mesothelioma has not been established. We aimed to evaluate whether intercostal nerve cryoablation reduces inpatient opioid use among patients undergoing pleurectomy and decortication for pleural mesothelioma.

METHODS

In 2024, our regionalized surgical practice began using cryoablation as an adjunct to standard-of-care analgesia following pleurectomy and decortication. The cryoSPHERE ablation probe (AtriCure) was uniformly applied to the 4th-8th intercostal spaces under direct visualization and was cooled to -60 ℃, and was held at each intercostal space for 2 minutes. We retrospectively compared patients with pleural mesothelioma who underwent pleurectomy and decortication and received cryoablation (surgery in 2024) to those who did not receive cryoablation (surgery between 2015 and 2023). The primary outcome was inpatient opioid consumption [morphine milligram equivalents (MME)]. We also evaluated the proportion of patients requiring no inpatient opioids, neuropathic symptoms, pain scores, epidural duration, hospital length of stay (LOS), and 30-day postoperative complications.

RESULTS

Among 64 patients, 22 (34%) received cryoablation and 42 (66%) did not. Those with cryoablation had lower median opioid use [145 MME; interquartile range (IQR), 22-464 MME] than those who did not (254 MME; IQR, 87-503 MME), although this difference was not statistically significant (P=0.46). Five (23%) patients with cryoablation required no inpatient opioids compared to 5 (12%) patients without cryoablation (P=0.29). There were no neuropathic symptoms observed with cryoablation. Additionally, there were no differences in pain scores, epidural duration, LOS, and 30-day complications between cohorts.

CONCLUSIONS

In this real-world cohort of patients with pleural mesothelioma treated at a large integrated healthcare system, cryoablation was associated with a trend toward reduced postoperative opioid use without compromising pain control compared to standard-of-care analgesia. Cryoablation was not associated with neuropathic symptoms or increased 30-day postoperative complications. Although not statistically significant, the absolute reduction of 109 MME suggests a potential clinical benefit from adjunctive cryoablation during pleurectomy and decortication, especially given its favorable safety profile. Further studies are warranted to clarify cryoablation's role and identify the patients most likely to benefit.