title: Impact of concomitant thoracic interventions on feasibility of Nuss procedure.
abstract: BACKGROUND
  This study aimed to analyze the feasibility of subsequent minimally invasive pectus repair, particularly modified Nuss procedure, combined with simultaneous thoracic procedures for different underlying intrathoracic diseases and conditions.
  
  
  METHODS
  A total of 110 patients, who underwent minimally invasive pectus repair in Nuss technique over a 5-year period, were retrospectively analyzed concerning complications, cosmetic results, and satisfaction. Six patients (5%) underwent the Nuss procedure with concomitant thoracic interventions. Patients with prior cardiac surgery or planned redo pectus repair were not examined and were excluded. The mean age of 6 patients (3 male and 3 female) was 11 years (range, 5.5-17.2). Two patients with former left-sided transabdominal diaphragmatic hernia repair and 1 with former lobectomy of the left lower lobe underwent thoracoscopic adhesiolysis. Two underwent thoracotomy: one for closure of a recurrent left-sided diaphragmatic hernia with fundoplication owing to a large hiatal hernia, another for lobectomy of the right middle lobe owing to recurrent infections and bronchodysplasia. One patient presented with anterior mediastinal mass, which was suspected to be benign, and underwent thoracoscopic complete resection. All patients underwent a 1-stage procedure with subsequent simultaneous Nuss procedure.
  
  
  RESULTS
  Simultaneous Nuss procedure was feasible without intraoperative complications in all patients (100%). Thoracoscopic adhesiolysis did not affect the feasibility of the Nuss procedure in 3 patients with former diaphragmatic hernia repair, particularly former lobectomy in one. Thoracotomy with middle-lobe lobectomy, as well as repair of recurrent diaphragmatic hernia and fundoplication in 2, did not affect modified Nuss technique and dispensed thoracoscopic guidance. Histopathologic analysis in one patient with a removed anterior mediastinal mass revealed Hodgkin lymphoma (stage IA), and the patient received multiagent chemotherapy. The postoperative course was uneventful in 5 of 6 patients. One patient required intermittent drainage of pleural effusion after simultaneous lobectomy. At follow-up (6 months-5 years), 6 patients had excellent cosmetic results and good quality of life confirmed by a questionnaire. There was no evidence of recurrent malignancy in one patient after 6 months.
  
  
  CONCLUSIONS
  Thoracic surgery and subsequent Nuss procedure can be performed simultaneously. Underlying conditions, such as prior repair of congenital diaphragmatic hernia or diaphragmatic eventration, as well as former lobectomy, had no impact on feasibility. Open thoracotomy can be combined with Nuss procedure dispensing thoracoscopy.
authors.affiliation: Department of Pediatric Surgery, Hannover Medical School, 30625 Hannover, Germany. mmetzelder@yahoo.com
authors.forename: Martin L
authors.initials: ML
authors.lastname: Metzelder
authors.forename: Benno M
authors.initials: BM
authors.lastname: Ure
authors.forename: Johannes
authors.initials: J
authors.lastname: Leonhardt
authors.forename: Lorenz
authors.initials: L
authors.lastname: Grigull
authors.forename: Karim
authors.initials: K
authors.lastname: Khelif
authors.forename: Claus
authors.initials: C
authors.lastname: Petersen
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D003131:Combined Modality Therapy; D005240:Feasibility Studies; D005260:Female; D005500:Follow-Up Studies; D005660:Funnel Chest / Q000175:diagnosis / Q000601:surgery*; D006548:Hernia, Diaphragmatic / Q000601:surgery*; D006551:Hernia, Hiatal / Q000151:congenital / Q000601:surgery*; D065630:Hernias, Diaphragmatic, Congenital; D006801:Humans; D008297:Male; D019060:Minimally Invasive Surgical Procedures / Q000379:methods; D011013:Pneumonectomy / Q000379:methods; D012189:Retrospective Studies; D018570:Risk Assessment; D019616:Thoracic Surgical Procedures / Q000295:instrumentation / Q000379:methods; D013906:Thoracoscopy / Q000379:methods*; D016896:Treatment Outcome