Intercostal Cryoanalgesia in Pediatric Nuss Repair for Pectus Excavatum: A Three-Case Series From Ecuador

Pectus excavatum is the most common congenital anterior chest wall deformity, and although the Nuss procedure is the standard of care, postoperative pain remains a clinical challenge. Here, we report a three-case series from Quito, Ecuador, evaluating ultrasound-guided intercostal cryoanalgesia integrated with pediatric Nuss repair. Three adolescent males (14-15 years) with moderate-to-severe deformity (mean Haller index: 3.51) underwent two-bar Nuss repair with lateral stabilizers. Bilateral intercostal cryoanalgesia (T3-T8; two minutes per nerve; CO₂ cryoprobe) was performed at three timings: intraoperative (day zero), immediate preoperative (-24 hours), and delayed preoperative (-90 days). A standardized multimodal protocol included bilateral pectoralis nerve II blocks, a type of ultrasound-guided regional anesthetic technique used to manage chest wall pain, plus a dexmedetomidine infusion and scheduled non-opioid analgesics; tramadol was reserved for rescue via the intravenous route. There were no intraoperative complications or intensive care admissions. Pain decreased rapidly, as measured by the Visual Analog Scale, with day one scores of 2-3 and day three scores of 1-2; opioid rescue was minimal (0-1 dose within 24-48 hours), and the length of stay was short (3-4 days). No neurologic deficits or wound complications were observed. These observations support the feasibility and safety of intercostal cryoanalgesia in a middle-income setting and suggest that immediate preoperative application (-24 hours) may provide earlier analgesic onset than intraoperative timing, warranting larger comparative evaluations.