The initial report by Lawson et al.  highlighted the positive impact that the Nuss correction of PE could have on the physical and physiological well-being of a pediatric population.
Roberts et al.  have also shown that this operation can also have an important impact on the patients’ perception of quality of life. The authors administered a questionnaire before surgery and 6 to 12 months after repair by the Nuss procedure, that it is to say in a short- and midterm. A multicenter study on a very large population (247 responders) found that surgical repair of PE can significantly improve the body image difficulties and limitation on physical activity experienced by patients . Krasopoulos et al. confirmed a similar impact on young male adults, always in the short term . Like in the abovementioned studies, questionnaires were administered only 1 year after surgical repair of PE, leaving the doubt on the long-term patient satisfaction and quality of life after MIRPE. We believe results can be skewed by the relatively short period of time passed between surgery and the survey, considering the interviewed/surveyed patients are still children. In fact, having passed such a short period of time and being the bar still positioned, the worse aspects of the surgical correction process (hospitalization, postoperative pain, immobilization, ICU, etc. could influence the patient’s opinion on the surgery. Other authors explored satisfaction and quality of life after PE repair in the long run but only on adult patients operated during adulthood. Sacco Casamassima et al. in 2006 and Hanna et al. in 2013 reported favorable long-term results achieved with the Nuss procedure in adults with a high rate of patient satisfaction, significant improvement in self-image, and excellent midterm cosmetic result. It is to remember that previous studies found an increased rate of early postoperative complications in adults compared with children and adolescents, the more frequent complications being pulmonary embolism (specific of the adult population), pleural effusion, and bar displacement. Furthermore, because of difference in costal cartilage flexibility, there is a biomechanical disadvantage in performing the Nuss procedure in adults . We then thought to interview patients operated during childhood but become adults, with a minimum of a 5-year follow-up. So, we administered the questionnaire introduced by Krasopoulos et al.  and modified by Sacco Casamassima et al. .
In our long-term assessment evaluation of patient satisfaction and quality-of-life improvement after surgery, respondents to the survey expressed high levels of satisfaction in terms of self-image and quality of life.
Moderate-severe prolonged chest pain was the main complaint in this study. Nevertheless, being most patients satisfied with the final cosmetic result, pain perception did not interfere with overall satisfaction and their willingness to undergo the operation again. Improvement in cosmetic appearance and health in general is translated in most patients in an improvement in social life.
Moreover, we found the high overall satisfaction after surgery was not correlated with the deformity severity and the presence of physical symptoms before correction. This could be an expression of deformity experienced transversely in the same way regardless of its severity. The discomfort is not only common to the whole population but such as to make everyone equally happy regardless of whether they were symptomatic or not. Perhaps preoperative psychological discomfort affects patients more than physical symptoms do.
Finally, there is a statically significant correlation between incidence of postoperative appearance on everyday life and postoperative satisfaction: the more this aspect affects their lives, the less the satisfaction is and vice versa.
Anecdotally, apart from the questionnaire and the shown results, we were enthused because of the tremendously positive comments received in the e-mails and phone calls to the patients. It was not rare to hear how much better the patients are feeling about themselves, how much better their exercise tolerance is, how much better they are behaving, and how much better they are doing in sports. However, a common complaint, apart from the pain, was the impossibility of practicing sports during the bar stay.
The degree of postoperative pain after MIRPE has been shown to be the overriding factor in the patient’s perception of the quality of the postoperative course. This result was found on an adult population as well by Casamassima et al. . Postoperative pain may require a more aggressive analgesic regimen. Currently, the two most common pain control strategies following the Nuss procedure are thoracic epidural infusion and intravenous patient-controlled analgesia (PCA). In addition, a variety of multimodal regimens utilizing chest wall indwelling catheter infusions and local or regional nerve blocks have recently been proposed to lessen pain and decrease perioperative opioid use. Great effort must be spent in order to improve pain management after surgery; with this goal, studies should be encouraged in order to compare different analgesic regimens. Perioperative pain management has always been a prerogative of anesthesiologists, but great interest has been evoked by the introduction of intraoperative intercostal nerve cryoablation, which temporarily ablates peripheral nerves, during the Nuss procedure [11,12,13]. Cryoanalgesia is a promising adjunct in the care of pediatric patients undergoing MIRPE and would make the surgeon part of the pain management equipe.