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

Our plain-English summary of Impact of intercostal nerve cryoablation on opioid use in pleural mesothelioma surgery: results from a high-volume integrated regional center, by A.S. Baskin, S. Elmankabadi, V. Zhang, et al (Journal of Thoracic Disease, 2026).

The study

• Authors: A.S. Baskin, S. Elmankabadi, V. Zhang, P. Mishra, K.C. Banks, J. Wei, J.B. Velotta
• Journal: Journal of Thoracic Disease
• Published: 2026;18(4):309
• Read it: PubMed · Publisher · Free full text

Abstract

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.

© AME Publishing Company.

In plain English

This retrospective study at Kaiser Permanente Northern California hospitals examined whether freezing the nerves between the ribs (intercostal nerve cryoablation) during pleurectomy and decortication for pleural mesothelioma reduced in-hospital opioid use. The authors compared 22 patients operated on in 2024 with cryoablation and 42 operated on in 2015 to 2023 without it. One surgeon performed all operations. All patients received standard pain treatment, including a thoracic epidural or, when an epidural was contraindicated, a paravertebral block. Median in-hospital opioid use was 145 morphine milligram equivalents with cryoablation and 254 without. This difference was not statistically significant (P=0.46). Five of 22 cryoablation patients (23%) and 5 of 42 others (12%) needed no opioids in hospital (P=0.29). No cryoablation patient reported nerve symptoms at 3 or 6 months. Pain scores, epidural duration, hospital stay and 30-day complications were similar between the groups. The authors concluded that cryoablation was associated with a trend toward less opioid use without compromising pain control, and called for further studies. They noted that the retrospective design could leave confounding and that opioid use after discharge was not assessed.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Multicenter retrospective comparison of patients who did and did not receive intercostal nerve cryoablation, divided by year of surgery
• Who was studied: 64 adults with histologically confirmed pleural mesothelioma who underwent pleurectomy and decortication at Kaiser Permanente Northern California, January 2015 to December 2024. 22 (34%) had surgery in 2024 with cryoablation and 42 (66%) had surgery in 2015 to 2023 without it. A documented history of asbestos exposure was more common in the cryoablation group: 19 of 22 (86.4%) versus 25 of 42 (59.5%), P=0.03.
• Exposure: The exposure studied was intraoperative intercostal nerve cryoablation, not asbestos. A cryoSPHERE probe (AtriCure) was applied to the 4th to 8th intercostal spaces, cooled to minus 60 degrees Celsius, and held for 2 minutes at each space. This was added to standard multimodal analgesia: a thoracic epidural (or a paravertebral block when an epidural was contraindicated), acetaminophen, gabapentin, and oxycodone or hydromorphone as needed.
• Main results:
  • Median inpatient opioid use was 145 MME (IQR 22 to 464) in the cryoablation group and 254 MME (IQR 87 to 503) in the no-cryoablation group. The difference was not statistically significant (P=0.46).
  • 5 of 22 cryoablation patients (23%) required no inpatient postoperative opioids, compared with 5 of 42 (12%) without cryoablation (P=0.29).
  • No patient-reported neuropathic symptoms occurred in the cryoablation group at 3 or 6 months after surgery.
  • Pain scores, epidural duration, hospital length of stay and 30-day complications were similar between the groups.
  • Cryoablation was not associated with opioid use in univariate (P=0.73) or multivariable analysis (P=0.74). In the multivariable analysis the mean difference was minus 50 MME (95% CI minus 351 to 250).
• The authors' conclusion: The authors concluded that adjunctive cryoablation provided adequate pain control with a favorable safety profile and a potential reduction in opioid use that was not statistically significant. They said this trend supports further investigation in larger, prospective studies.
• Limitations the authors state:
  • The retrospective, observational design allows confounding. Preoperative opioid use, baseline chronic pain and year of surgery could not be fully accounted for.
  • Because cryoablation was assigned by operative date, period effects from changes in pain care over time are possible.
  • Institutional policy encouraging prolonged thoracic epidural use may have limited the ability to detect differences in opioid use and length of stay.
  • Opioid use after discharge was not assessed.
  • All patients were treated within one health system, which may limit generalizability to other settings.
  • The small sample may have limited statistical power, and no formal power analysis could be performed.

Topics

Medical terms in this study, explained in our Lexicon: Pleural Mesothelioma.

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