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.
Keywords: Pleural mesothelioma (PM), cryoablation, pleurectomy and decortication, pain management, intercostal nerve
Highlight box.
Key findings
• In this real-world cohort of patients with pleural mesothelioma treated at a large integrated healthcare system, intercostal nerve cryoablation was associated with a trend toward reduced postoperative opioid use without compromising pain control compared with standard-of-care analgesia.
What is known and what is new?
• Intercostal nerve cryoablation has been proposed as an adjunct for thoracic pain control, however efficacy results have been mixed and its application in pleural mesothelioma surgery has not been studied.
• This study evaluates the role of intercostal nerve cryoablation in reducing inpatient opioid requirements among patients with pleural mesothelioma undergoing pleurectomy and decortication.
What is the implication and what should change now?
• Although not statistically significant, the absolute reduction of nearly 110 morphine milligram equivalents suggests a potentially meaningful clinical benefit of 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.
Introduction
Pleural mesothelioma (PM) is a rare and aggressive malignancy arising from the mesothelial cells lining the pleura, with a 5-year survival rate of approximately 10% (1-5). Clinical guidelines recommend a multimodal treatment strategy that includes surgery (6,7). Parenchymal-sparing pleurectomy and decortication is the currently preferred procedure, however it is highly morbid and associated with significant postoperative pain, which increases the risk for prolonged hospitalization, compromised respiratory effort, delayed ambulation, and other complications (8).
Opioid analgesics are a mainstay of postoperative pain management, but are associated with numerous adverse effects, such as oversedation, respiratory depression, gastrointestinal dysfunction, and opioid dependence (9,10). Increasingly, clinical practice guidelines for perioperative pain management after surgery emphasize opioid-sparing strategies to minimize the risk of adverse effects and opioid dependence (11-13). Recently, intercostal nerve cryoablation has been proposed as an adjunct for thoracic pain control. Intercostal nerve cryoablation involves applying a cryoprobe cooled to −40 to −70 ℃ to the intercostal nerves, inducing reversible destruction of the axon, known as Wallerian degeneration, which produces a temporary conduction block interrupting pain signal transmission (14,15). This therapeutic effect is immediate. Although numerous studies have demonstrated that incorporating intercostal nerve cryoablation during both minimally invasive thoracic procedures (e.g., pectus excavatum) and more invasive procedures (e.g., lung transplantation or thoracotomy) can reduce hospital length of stay (LOS), pain scores, and inpatient opioid consumption (16-22), other studies have failed to show a benefit (23,24).
Although cryoablation has been studied across a range of thoracic operations, its role in the surgical management of PM has not been established. However, given the substantial postoperative pain associated with cytoreductive surgery for PM and the limitations of current analgesic modalities, it is important to explore innovative approaches to enhance recovery and optimize pain control for these patients. Due to the mixed data on the benefit of cryoablation, we aimed to evaluate whether adjunctive intercostal nerve cryoablation during pleurectomy and decortication for PM would reduce opioid use. We hypothesized that cryoablation would decrease inpatient opioid requirements and improve other perioperative outcomes such as pain, epidural duration, hospital LOS, and 30-day complications, while maintaining a favorable safety profile. We present this article in accordance with the TREND reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1-0076/rc).
Methods
Study population
Following institutional review board approval from the Kaiser Permanente Northern California (KPNC) (#2200797), a multicenter, retrospective analysis was performed of consecutive adult patients with histologically confirmed PM who underwent pleurectomy and decortication at KPNC between January 2015 and December 2024. KPNC is a large integrated healthcare system with 21 medical centers, serving approximately 4.4 million patients or 33% of Northern California’s population (25). Surgical services for PM at KPNC were regionalized to four hospitals in 2014 (26). All participating institutions were also informed of and agreed to the study. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. Individual consent for this retrospective analysis was waived.
All pleurectomy and decortication operations were performed uniformly by one surgeon and consisted of open thoracotomy, extended radical parietal and visceral pleurectomy, complete lung decortication, pericardial resection as necessary with biologic mesh reconstruction, diaphragm resection as necessary with biologic mesh reconstruction, and complete mediastinal lymph node dissection (27).
Analgesic protocols
Patients who received intraoperative intercostal nerve cryoablation were compared to those who did not receive cryoablation. Intercostal nerve cryoablation was introduced to KPNC in 2024 and implemented for all pleurectomy and decortication surgeries that year, given evidence of its effectiveness in reducing postoperative pain following other thoracic operations (16,17,21). Patients who underwent surgery between 2015 and 2023 did not receive cryoablation. In patients who received cryoablation, the cryoSPHERE ablation probe (AtriCure Inc., Mason, OH, USA) was applied to the 4th–8th intercostal spaces under direct visualization and cooled to −60 ℃, where it was held at each intercostal space for 2 minutes, for a total additional procedure time of 10 minutes (Figure 1). Based on dermatomal maps of the thorax, this provides analgesic coverage from T4 to T8, spanning the entire thoracotomy incision, as well as two intercostal spaces above and below, respectively (28).
Figure 1.
Intraoperative images of intercostal nerve cryoablation during pleurectomy and decortication for pleural mesothelioma.
Postoperative multimodal analgesia was given to all patients (with or without cryoablation) per standard of care, which included a thoracic epidural (or paravertebral block when an epidural was contraindicated), scheduled acetaminophen, scheduled gabapentin, oxycodone as needed, and hydromorphone as needed for breakthrough pain. Of note, KPNC institutional anesthesia protocols encourage clinicians to keep thoracic epidurals in place as long as safely possible postoperatively to limit systemic opioids. Perioperative analgesic management remained consistent during the study period.
Outcomes
The primary outcome was the total median inpatient opioid requirement [morphine milligram equivalents (MME)], calculated from the total amount of medications with known morphine equivalencies (primarily oxycodone and less frequently hydromorphone, morphine, and fentanyl) administered from incision closure to hospital discharge. Secondary outcomes included the proportion of patients requiring no inpatient postoperative opioids, patient-reported neuropathic symptoms associated with cryoablation, subjective pain scores, epidural duration (in days), postoperative hospital LOS, and 30-day postoperative complications. Neuropathic symptoms included hypo- or hyperalgesia, allodynia, and numbness, assessed at 3- and 6-month post-procedure. Thirty-day postoperative complications included tracheostomy, reintubation, acute respiratory distress syndrome, bronchopleural fistula, pulmonary embolism, myocardial infarction, deep vein thrombosis, pneumonia, new onset atrial fibrillation, surgical wound infection, unexpected return to the operating room, or death.
Data collection
Using the KPNC cancer registry (meeting Surveillance, Epidemiology, and End Results standards) and HealthConnect®, Kaiser Permanente’s EPIC-based electronic health record, we extracted patient-level data on surgery date, age, sex, race, Neighborhood Deprivation Index, body mass index, Elixhauser Comorbidity Index, smoking history, asbestos exposure, histology, clinical stage, neuropathic symptoms (among the cryoablation patients), and postoperative complications. Pain scores were collected from a Numeric Pain Rating Scale (0 = no pain to 10 = unbearable pain) administered every 4 hours by our institution’s nursing staff and extracted from the electronic health record. Opioid utilization data were gathered from the medication administration record and were quantified as total standard MME (29).
Statistical analysis
We compared baseline characteristics and outcome variables between the two groups using the Wilcoxon rank-sum, Pearson’s Chi-squared, or Fisher’s exact tests. To assess the association between cryoablation and opioid use, we performed univariate and multivariable analyses adjusting for age, sex, race/ethnicity, Neighborhood Deprivation Index, and Elixhauser Comorbidity Index. All statistical significance was defined as P<0.05. Analyses were performed using R v4.3.1 (R Foundation for Statistical Computing, Vienna, Austria).
Results
Patient characteristics
A total of 64 patients with PM underwent pleurectomy and decortication during the study, of whom 22 (34%) had surgery in 2024 and received cryoablation and 42 (66%) had surgery between 2015 and 2023 and did not receive cryoablation (Table 1). Significantly more patients in the cryoablation cohort were White and had a documented history of asbestos exposure. There were no other significant differences in baseline characteristics, including age and sex, between the groups.
Table 1. Characteristics of study cohort by receipt of intercostal nerve cryoablation.
| Characteristics | Overall (N=64) | Cryoablation (N=22) | No cryoablation (N=42) | P value |
|---|---|---|---|---|
| Age at surgery, years | 0.28 | |||
| Mean (SD) | 71.7 (10.7) | 73.1 (11.9) | 70.9 (10.1) | |
| Median (IQR) | 73.0 (68.8–78.3) | 74.0 (70.3–80.5) | 73.0 (68.0–78.0) | |
| Sex, n (%) | 0.60 | |||
| Female | 15 (23.4) | 6 (27.3) | 9 (21.4) | |
| Male | 49 (76.6) | 16 (72.7) | 33 (78.6) | |
| Race/ethnicity, n (%) | 0.01 | |||
| African American | 5 (7.8) | 2 (9.1) | 3 (7.1) | |
| Asian/Pacific Islander | 5 (7.8) | 2 (9.1) | 3 (7.1) | |
| Hispanic | 11 (17.2) | 0 (0.0) | 11 (26.2) | |
| Other/unknown | 2 (3.1) | 2 (9.1) | 0 (0.0) | |
| White | 41 (64.1) | 16 (72.7) | 25 (59.5) | |
| Elixhauser Comorbidity Index | 0.77 | |||
| Mean (SD) | 4.9 (2.6) | 4.7 (2.0) | 5.0 (2.8) | |
| Median (IQR) | 5.0 (3.0, 6.0) | 4.5 (3.0, 6.0) | 5.0 (3.0, 6.8) | |
| Asbestos exposure, n (%) | 0.03 | |||
| Yes | 44 (68.8) | 19 (86.4) | 25 (59.5) | |
| No | 20 (31.2) | 3 (13.6) | 17 (40.5) | |
| Smoking status, n (%) | 0.13 | |||
| Never | 31 (48.4) | 14 (63.6) | 17 (40.5) | |
| Former | 28 (43.8) | 8 (36.4) | 20 (47.6) | |
| Current | 5 (7.8) | 0 (0.0) | 5 (11.9) | |
| Body mass index, n (%) | 0.77 | |||
| <25 kg/m2 | 25 (39.1) | 10 (45.5) | 15 (35.7) | |
| 25.0–29.9 kg/m2 | 29 (45.3) | 9 (40.9) | 20 (47.6) | |
| ≥30 kg/m2 | 10 (15.6) | 3 (13.6) | 7 (16.7) | |
| Insurance, n (%) | 0.11 | |||
| Commercial | 11 (17.2) | 4 (18.2) | 7 (16.7) | |
| Medicare/Medicaid | 44 (68.8) | 12 (54.5) | 32 (76.2) | |
| Non-Kaiser Permanente | 7 (10.9) | 5 (22.7) | 2 (4.8) | |
| Other | 2 (3.1) | 1 (4.5) | 1 (2.4) | |
| Neighborhood Deprivation Index Quartile, n (%) | 0.26 | |||
| 1 (least deprived) | 16 (25.0) | 8 (36.4) | 8 (19.0) | |
| 2 | 20 (31.3) | 6 (27.3) | 14 (33.3) | |
| 3 | 19 (29.7) | 7 (31.8) | 12 (28.6) | |
| 4 (most deprived) | 9 (14.1) | 1 (4.5) | 8 (19.0) | |
IQR, interquartile range; SD, standard deviation.
Outcomes
Median inpatient opioid use was 40% lower in the cryoablation group [145 MME, interquartile range (IQR), 22–464 MME] compared to the no cryoablation group (254 MME, IQR, 87–503 MME); however, this difference was not statistically significant (P=0.46) (Table 2). Notably, 23% of patients who received cryoablation required no inpatient postoperative opioids, compared to 12% in the no cryoablation group (P=0.29). There were no patient-reported neuropathic symptoms in the cryoablation group at either the 3- or 6-month postoperative time points. Median pain scores, epidural duration, hospital LOS, and 30-day postoperative complications (Table 3) were also similar between groups. Cryoablation was not associated with opioid usage on either univariate (P=0.73) or multivariable analysis (P=0.74) (Table 4).
Table 2. Clinical outcomes by receipt of intercostal nerve cryoablation.
| Outcomes | Overall (N=64) | Cryoablation (N=22) | No cryoablation (N=42) | P value |
|---|---|---|---|---|
| Inpatient opioid use, MME | 0.46 | |||
| Median (IQR) | 243 (44–490) | 145 (22–464) | 254 (87–503) | |
| Mean (SD) | 437 (597) | 400 (537) | 456 (632) | |
| No inpatient postoperative opioid use, n (%) | 10 (16) | 5 (23) | 5 (12) | 0.29 |
| Subjective pain score† | 0.25 | |||
| Median (IQR) | 2.0 (0.0–3.0) | 1.5 (0.0–3.0) | 2.5 (0.0–3.0) | |
| Mean (SD) | 2.0 (1.9) | 1.6 (1.7) | 2.3 (2.0) | |
| Epidural duration, days | 0.85 | |||
| Median (IQR) | 5.1 (4.0–6.7) | 5.7 (4.7–6.6) | 5.0 (4.0–6.6) | |
| Mean (SD) | 5.2 (1.7) | 5.2 (1.6) | 5.2 (1.8) | |
| Hospital LOS, days | 0.39 | |||
| Median (IQR) | 10.0 (8.0–14.0) | 10.0 (8.3–15.5) | 9.5 (8.0–14.0) | |
| Mean (SD) | 12.5 (8.8) | 14.0 (11.4) | 11.6 (7.1) | |
†, score of 0 = no pain, score of 10 = unbearable pain. IQR, interquartile range; LOS, length of stay; MME, morphine milligram equivalents; SD, standard deviation.
Table 3. Thirty-day postoperative complications by receipt of intercostal nerve cryoablation.
| Complication | Overall (N=64) | Cryoablation (N=22) | No cryoablation (N=42) | P value |
|---|---|---|---|---|
| Tracheostomy | 2 (3.1%) | 1 (4.5%) | 1 (2.4%) | >0.99 |
| Reintubation | 4 (6.3%) | 3 (13.6%) | 1 (2.4%) | 0.11 |
| Acute respiratory distress syndrome | 1 (1.6%) | 1 (4.5%) | 0 (0.0%) | 0.34 |
| Bronchopleural fistula | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | N/A |
| Pulmonary embolism | 3 (4.7%) | 2 (9.1%) | 1 (2.4%) | 0.27 |
| Myocardial infarction | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | N/A |
| Deep vein thrombosis | 7 (10.9%) | 4 (18.2%) | 3 (7.1%) | 0.22 |
| Pneumonia | 7 (10.9%) | 2 (9.1%) | 5 (11.9%) | >0.99 |
| Atrial fibrillation | 22 (34.4%) | 10 (45.5%) | 12 (28.6%) | 0.18 |
| Wound infection | 3 (4.7%) | 1 (4.5%) | 2 (4.8%) | >0.99 |
| Unexpected return to operating room | 5 (7.8%) | 2 (9.1%) | 3 (7.1%) | >0.99 |
| Died within 30 days | 4 (6.3%) | 2 (9.1%) | 2 (4.8%) | 0.60 |
N/A, not available.
Table 4. Multivariable regression analysis for morphine milligram equivalents.
| Variable | Mean difference (95% CI) | P value |
|---|---|---|
| Cryoablation exposure (yes vs. no) | −50 (−351, 250) | 0.74 |
| Age (per year) | −12 (−27, 2.5) | 0.10 |
| Biological sex | ||
| Female | Reference | |
| Male | −133 (−477, 211) | 0.44 |
| Race/ethnicity | ||
| Non-White | Reference | |
| White | 218 (−110, 545) | 0.19 |
| Neighborhood deprivation index | ||
| 1–2 (less deprived 50%) | Reference | |
| 3–4 (more deprived 50%) | −138 (−452, 175) | 0.38 |
| Elixhauser Comorbidity Index (per point) | 100 (40, 159) | 0.001 |
CI, confidence interval.
Discussion
In this multicenter cohort of 64 patients undergoing pleurectomy and decortication for PM, intercostal nerve cryoablation provided postoperative pain control that was comparable to standard of care, as reflected by the similar pain scores between the cryoablation and non-cryoablation groups. Median inpatient opioid use was lower among patients in the cryoablation group, although this difference was not statistically significant. Importantly, no patients who received cryoablation developed the historically associated neuropathic symptoms such as hypo- or hyperalgesia, allodynia, or prolonged numbness. Furthermore, cryoablation was also not associated with higher 30-day postoperative complication rates or extended LOS. Altogether, these findings support the favorable safety profile of intercostal nerve cryoablation and suggest that it may serve as a safe adjunct to multimodal postoperative analgesia, with the potential to reduce opioid use among patients undergoing pleurectomy and decortication without compromising pain control.
To our knowledge, this is the first real-world analysis to evaluate the use of intercostal nerve cryoablation in patients with PM undergoing pleurectomy and decortication. Although intercostal nerve cryoablation is most widely recognized for its role in pediatric thoracic surgery—particularly during minimally invasive repair of pectus excavatum—it has more recently been adopted in adult patients undergoing non-pectus repair thoracic and cardiac procedures (22). Kleiboeker et al. found that lung transplant recipients who received intercostal nerve cryoablation as part of an opioid-sparing protocol had a significant reduction in total inpatient opioid usage, epidural use, and opioids prescribed at discharge (18). Similarly, Isaza et al. reported that cryoablation achieved pain control comparable to thoracic epidural analgesia in a cohort of lung transplant patients (16). Beyond pectus excavatum repair and lung transplantation, cryoablation has been associated with reductions in opioid usage among patients undergoing surgical stabilization of rib fractures, open thoracic abdominal aneurysm repair, minimally invasive cardiac surgery, and full sternotomy for open-heart surgery (28,30,31).
Our findings align with other studies in thoracic surgery in which cryoablation has not consistently demonstrated statistically significant improvements in postoperative pain outcomes. In a cohort of patients undergoing thoracotomy for hiatal hernia repair, lung resection, and double lung transplant, Pourak et al. observed no significant differences in LOS or opioid-related outcomes, such as MME on the day prior to discharge and the proportion of patients discharged on opioids (23). Similarly, Weksler et al. found no significant reduction in postoperative MME or pain scores from cryoablation among patients who underwent minimally invasive thoracic surgery (mostly lung resection) (24). The nonsignificant statistical differences in opioid requirements reported in both their studies and ours may, in part, reflect limited statistical power to detect differences between treatment groups. In our study, in particular, this highlights a challenge of studying PM given its markedly low incidence (1 per 100,000 persons) (5). Although we captured 22 cryoablation cases for PM within a single year, representing a substantial volume given the rarity of this disease, future multi-institutional studies are needed to investigate this effect further among a collectively larger cohort.
Moreover, despite not being statistically significant, we believe that the absolute reduction of 109 MME (254 vs. 145 MME) is clinically meaningful. This is a reduction equivalent to approximately 15 tablets of 5 mg oxycodone or 14 tablets of 2 mg hydromorphone. To our knowledge, there are no published definitions establishing what constitutes a clinically significant difference in MME, nor are there studies reporting postoperative opioid consumption following pleurectomy and decortication, limiting our ability to perform a formal power analysis.
While studies of cryoablation during pectus repair have demonstrated significant reductions in hospital LOS, results in non-pectus thoracic and cardiac procedures have been more variable. This variation likely reflects a combination of factors, including potentially greater procedural complexity, invasiveness, and older, often higher-risk patient populations. At the same time, we suspect that our patients did not experience the neuropathic symptoms that have been reported after cryoablation in minimally invasive thoracic surgery or pectus repair, likely due to the extensive nature of an extended pleurectomy and decortication, which essentially destroys the local intercostal nerves. As Pourak et al. propose, cryoablation’s analgesic effectiveness likely exists along a spectrum, underscoring the need for further investigation to clarify the clinical and procedural factors that mediate its impact (23).
Limitations
This study has several limitations. First, its retrospective, observational design introduces inherent potential for confounding, and we could not fully account for factors such as preoperative opioid use, baseline chronic pain conditions, or year of surgery. More specifically, receipt of cryoablation was based on operative date, which raises the potential for period effects due to temporal changes in perioperative analgesia. However, there have been no large-scale shifts, such as implementation of standardized perioperative pain pathways [e.g., enhanced recovery after surgery (ERAS) pathways], for PM patients at our institution, suggesting that perioperative management remained consistent during the study period. Although all procedures were performed by a single surgeon experienced in PM surgery, which reduced variability in pleurectomy and decortication and cryoablation techniques, there was likely user-dependent variability in the other analgesic modalities. Specifically, thoracic epidural analgesia is highly operator-dependent, which can result in variable analgesic effects (32). Second, institutional anesthesia policies encourage prolonged thoracic epidural use, regardless of pain control adequacy. This practice may have limited our ability to detect differences in postoperative opioid usage and hospital LOS. These are two secondary outcomes that also represent meaningful factors to consider in a formal cost-effectiveness analysis of cryoablation use. Third, outpatient opioid use was not assessed. However, because cryoablation analgesia persists for several months, we would expect reduced outpatient opioid requirements, consistent with several studies reporting lower proportions of patients requiring opioids at or after discharge (18,33,34). This long-lasting analgesic effect may be particularly beneficial for PM patients who are encouraged to engage in postoperative rehabilitation. Finally, because all patients were treated within the KPNC system, the generalizability of these findings to other hospitals and practice settings may be limited.
Conclusions
In this real-world cohort of patients with PM undergoing pleurectomy and decortication, adjunctive intercostal nerve cryoablation provided adequate pain control and demonstrated a favorable safety profile, with a potential benefit of reduced postoperative opioid consumption. Although the differences in opioid use did not reach statistical significance, the notable reductions in opioid consumption with cryoablation suggest a promising trend that supports further investigation of cryoablation as a potential component of enhanced recovery protocols in this patient population. Future studies with larger sample sizes, standardized analgesic protocols, and prospective designs are warranted to better define the impact of cryoablation on analgesic efficacy and postoperative recovery following pleurectomy and decortication.
Supplementary
The article’s supplementary files as
Acknowledgments
None.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the institutional review board of Kaiser Permanente Northern California (IRB: 2200797). All participating institutions were also informed of and agreed to the study. Individual consent for this retrospective analysis was waived.
Footnotes
Reporting Checklist: The authors have completed the TREND reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1-0076/rc
Funding: This work was supported by the Kaiser Permanente Northern California Division of Research and AtriCure Investigator-Sponsored Research (to J.B.V.), the National Cancer Institute (T32 CA009672 to A.S.B.), and the Association for Academic Surgery/Association for Academic Surgery Foundation Clinical Outcomes and Health Services Research Award (to A.S.B.).
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1-0076/coif). J.B.V. serves as an unpaid editorial board member of Journal of Thoracic Disease from September 2024 to August 2026. The other authors have no conflicts of interest to declare.
Data Sharing Statement
Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1-0076/dss
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