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Jeb pectus excavatum sunken chest cryoanalgesia John Densmore, MD, pediatric surgeon, Children's Wisconsin

Jeb’s new chest: How innovative approaches are making chest wall surgery less painful

“Oh, my gosh! Why does your chest look like that?” the other kids asked, after 14-year-old Jeb Koops peeled off his shirt at a pool party. The comments didn’t seem to faze Jeb, who calmly explained the medical condition he was born with. But it sent a pang through his mother. 

Jeb was still a toddler when his parents learned that the dip in his chest — like a scoop in the center of his breastbone — was pectus excavatum, also known as sunken chest or funnel chest. About one in 400 babies are born with the chest wall condition, which can compress the heart and lungs as the breastbone grows inward. Because Jeb also has cystic fibrosis (CF), another condition that affects the lungs, doctors suggested that Jeb might eventually want corrective surgery to expand his lung space.

As Jeb grew, the indentation in his chest deepened. Jeb, a naturally positive, resilient kid, insisted that he didn’t care what his chest looked like. But by 15, he started to worry about the long-term impact on his health. 

“What if this is going to get in my way?” he asked his parents. “What if I have heart issues later or, if because I have CF, I can’t breathe?”

The family talked it over with Jeb’s doctors and learned more about what chest wall surgery would entail. After months of thinking it over, Jeb decided to do it. At Children’s Wisconsin, he met John Densmore, MD, a pediatric surgeon who leads the congenital chest wall program. Dr. Densmore understood Jeb’s situation more than most — he was born with pectus excavatum himself and underwent a major, open-chest surgery when he was just 9. 

“It certainly informs the way that I think about and care for kids and families who are struggling with this,” said Dr. Densmore, who has led the multidisciplinary efforts of Children’s Wisconsin to reduce kids’ pain, length of stay and narcotic use after chest wall surgery. “And so I have this view that I need to bring the best evidence to bear on recovery for these kids.”

Surgery has come a long way since Dr. Densmore was a boy. When he first joined the Children’s Wisconsin staff as a surgical resident, he learned the Nuss procedure, a minimally invasive surgery that implants a curved metal bar to lift the sternum and reshape the chest. The bar is removed a few years later, and patients are left with very small scars on the sides of their chest instead of a large chest incision like he has. Children’s Wisconsin was one of the first pediatric centers to adopt the Nuss procedure and has a long history of successful outcomes.

But for Jeb and other patients, newer advancements have made the chest wall surgery experience even better.

A multidisciplinary approach to pain management

Jeb pectus excavatum sunken chest cryoanalgesia John Densmore, MD, pediatric surgeon, Children's WisconsinWhile doctors have known for years how to fix a caved-in chest, they hadn’t yet figured out how to improve what could be an excruciating recovery. “It’s the equivalent of torture-level pain. There’s no escape from it. It’s really persistent, it’s constant and it’s a huge challenge,” said Dr. Densmore. “And yet kids still saw the benefit with the correction of their chest walls.”

Other medical centers nationwide tried various approaches to reduce patients’ pain. Around 2017-2018, Children’s Wisconsin formed a multidisciplinary focus group that included Dr. Densmore and Michelle L. Czarnecki, APNP, a pain management nurse practitioner and researcher with the Jane B. Pettit Pain and Headache Center, as well as other colleagues who work with patients in the chest wall program.

They decided to try a multimodal pain strategy. They began giving patients an early oral regimen of different types of pain medications and then made adjustments as they watched how kids responded.

The results were swift and impressive: patients’ hospital stays fell from a week post-surgery to just two days.

Soon after, Dr. Densmore turned to pain psychologist Chasity Brimeyer, PhD, for help with pre-operative evaluations.

“I really needed another set of eyes and her expertise,” said Dr. Densmore. “It’s a special group of kids. They’re coming to terms with their bodies at a time when there’s a huge change happening over the front of their chest that is a unique problem. And not every kid needs surgery, but I need help figuring out which kids would benefit and also recognizing which kids would be at risk to develop a pain syndrome or a dependence on narcotics as part of their recovery.”

In addition to assessing patients’ mental and behavior health, Dr. Brimeyer teaches patients and their families coping strategies to help manage the stress and pain associated with surgery. When needed, she offers patients additional counseling.

“Research tells us that fearing pain and feeling ill-equipped to manage pain after surgery can make recovery longer and more uncomfortable,” said Dr. Brimeyer. “Patients and families feel empowered by learning psychological tools for managing pain.”

Children’s Wisconsin was one of the first hospitals to offer a biopsychosocial approach — which encompasses everything from physical tools to psychological strategies to social supports — to help kids manage surgical pain, said Dr. Brimeyer.

Dr. Desnmore and Dr. Brimeyer are both on the faculty of the Medical College of Wisconsin, the academic partner of Children’s Wisconsin. This commitment to education, research and innovation allows Children’s Wisconsin doctors to constantly be pushing the boundaries of what is possible. And it’s all done in the name of improving patient care.

“It’s just another layer of getting our patients prepared,” said Dr. Densmore.

Freezing pain at the source

When Jeb showed up in the Children’s Wisconsin operating room for the Nuss procedure in December 2023, the team had another tool to reduce his post-surgical pain: cryoanalgesia. Also known as cryoablation, the technique uses extreme cold to freeze nerves. With a small, camera-guided probe that reaches -60 degrees Celsius, Dr. Densmore destroyed nerve fibers in the affected region of Jeb’s chest, disrupting pain signals to Jeb’s brain until the nerves would regrow several weeks later.

After the surgery, Jeb told his parents: “I feel like I just did 80 pushups.” But other than some muscle soreness, he felt remarkably well.

When Dr. Densmore first started studying the research on cryoanalgesia, he was intrigued but cautious. Children’s Wisconsin was already seeing great gains with its multimodal pain approach, and he wanted to make sure that a new technique would add value and not complications. “We moved there in a very conscientious way rather than rushing to be the first ones on the block,” he said. “We were more interested in doing it well for our kids.”

Dr. Densmore first began using cryoanalgesia in late 2019 with older, adult-sized patients, for whom chest wall surgery can be even more painful. “We tried it on some of our most predictably challenging patients, knowing that those might be the places where we saw the greatest dividend,” said Dr. Densmore. “I pretty readily recognized how powerful the tool was.”

So powerful, in fact, that the Children’s Wisconsin team significantly scaled back the other pain relievers patients received because they were no longer necessary. “Many of our kids have gone through their recoveries without any narcotics at all except for ones given in the operating room,” said Dr. Densmore.

More than 40 patients at Children’s Wisconsin have had the Nuss procedure with cryoanalgesia. The technique doubles a patient’s time in the operating room — the surgery now takes four hours — but drastically reduces their recovery time. Before cryoanalgesia, kids often endured post-operative pain for a month or more. Now kids might have aches as their nerves start to regrow three to four weeks later, but it’s manageable with over-the-counter pain relievers.

In fact, Jeb’s mom picked up his prescription for opioid pain relievers, but he didn’t even need them. “It’s amazing,” she said. “I feel so fortunate that he was able to receive cryoanalgesia because it’s made recovery so much easier.”

Life post-surgery

Jeb pectus excavatum sunken chest cryoanalgesia John Densmore, MD, pediatric surgeon, Children's WisconsinWith the pain significantly reduced, families can now focus on the benefits of the procedure. Many patients, including Jeb, report that breathing feels easier after their chest wall is raised. It also lifts their confidence.

“If a kid wants to see a change in their chest, there’s often an underlying vulnerability that they feel that has to do with their sense of their own health, their sense of resignation that this thing is going deeper and deeper with time, and they don’t know when it’s going to stop or how deep it’s going to be at the end,” said Dr. Densmore. “We’re actually impacting kids’ confidence in their own health.”

Jeb’s family noticed an immediate change. “He seems to stand taller because you kind of hunch over when you have pectus,” said his mom. “His older brothers were home from college, and they were like, ‘Whoa, you look buff now.’ And he told us, ‘You can’t see my hole through my shirt anymore’ because his shirts used to indent in a bit.”

After the surgery, 16-year-old Jeb quickly resumed life as a high school sophomore: hanging out with friends, playing video games and attending school basketball games and other events. Next year, he plans to return to the football field, where he plays wide receiver.

“Jeb’s case is remarkable on multiple levels,” said Dr. Denmore. “Meeting him was a joyful moment in my clinic because I saw a young man who’s out there playing football, who’s defiant that he has CF, what was once a crippling pulmonary condition. He’s just out there living his life. And so I thought, ‘This is amazing.’ I’ve never had a kid with CF and pectus, and look at how far we’ve come.”

While outcomes for teens like Jeb have come a long way, Dr. Densmore hasn’t given up on making them even better. Eventually, he hopes to make it a same-day surgery. “There’s always more work to be done.”