Surgical treatment of diaphragmatic eventration using video-assisted thoracic surgery: a prospective study

BACKGROUND

This study seeks to evaluate results regarding the repair of diaphragmatic eventration using video-assisted thoracic surgery (VATS).

METHODS

We performed a prospective observational study including patients referred to us for surgical treatment of diaphragmatic eventration during a 12-year period. Clinical, radiologic, and functional data were prospectively recorded. VATS was performed with two thoracoports and a 4-cm mini-thoracotomy. Diaphragmatic plication was performed using two nonresorbable running sutures from periphery to the cardio-phrenic angle. Follow-up data (clinical examination, chest roentgenogram, lung function tests at 3, 6, 12 months, and annually thereafter) were also prospectively recorded.

RESULTS

Twelve patients (4 male adults, mean age 57.7 +/- 14.8 years) were operated on between 1992 and 2003. The left side was involved in 8 patients and the mean height of diaphragm elevation was 7.5 +/- 1.8 cm. All patients experienced symptoms related to the disease; in 2 patients the operation was carried out to achieve weaning from mechanical ventilation. The etiologic mechanism could be identified in 11 out of 12 patients (trauma, n = 9; Charcot-Marie disease, n = 1; calcified para-aortic nodes, n = 1). Mean operative time, drainage output, and hospital stay were 77 +/- 15 minutes, 0.8 +/- 04 L, and 3.4 +/- 0.7 days, respectively. No mortality was observed; 1 patient experienced postoperative pneumonia, which was treated using antibiotics. All patients experienced amelioration of symptoms and long-term lung function tests revealed a marked improvement of both the forced volume capacity and the forced expiratory volume at 1 second. No relapses were observed at follow-up chest roentgenogram.

CONCLUSIONS

Treatment using VATS is a safe and effective alternative to conventional surgery. Functional improvement persists at long-term follow-up.

Paralysis of the phrenic nerve as a risk factor for suboptimal Fontan hemodynamics

OBJECTIVE

The introduction of the Fontan operation for single ventricle physiology was based on the dual principle of the pulmonary blood flow. It is postulated that normal breathing movements are necessary for passive blood flow into the lungs. We compared patients with and without palsy of the phrenic nerve regarding the sufficiency of Fontan hemodynamics.

METHODS

We analyzed 85 consecutive patients, who were available for follow-up after completion of their total cavopulmonary connection (TCPC) between February 1992 and February 2003. The median age at TCPC completion was 4.3 (range 1.3-37) years. Sixty were operated on with an extracardiac conduit and 25 with a lateral tunnel. Fifty patients underwent postoperative heart catheterization with contrast angiography. The diagnosis of diaphragm paralysis was made using echocardiography, fluoroscopy and X-ray examination. Surgical diaphragm plication was performed in 13 patients (Four before and nine after Fontan operation) at a median of 2.2 years after the diagnosis.

RESULTS

Twenty-one patients developed fixed palsy of the phrenic nerve during a total of 225 operations before and including completion of TCPC. There were no differences in the incidence of phrenic nerve paralysis between small children (aged <3 years) and older patients or between patients with the extracardiac and intracardiac Fontan procedures. There were no differences in the duration of mechanical ventilation. However, prolonged pleural effusions and a hospital stay of longer than 2 weeks were noted more frequently in patients with palsy (P<0.05). During the median follow-up of 4.6 (range: 0.7-11.4) years significantly more patients with phrenic nerve palsy developed chronic ascites compared to those without palsy (8 of 20 vs. 2 of 65; P<0.001).

CONCLUSIONS

Phrenic nerve palsy was recognized as a risk factor for suboptimal Fontan hemodynamics due to the hindrance of passive venous blood flow. Patients with phrenic nerve palsy have a longer hospital stay and a higher incidence of prolonged pleural effusions and of chronic ascites, than those without. Early diaphragm plication may be favorable to optimize the Fontan circuit in these patients. Completion of the TCPC in patients with diaphragm paralysis should be viewed critically.

Phrenic nerve injury after blunt trauma

Phrenic nerve injury resulting from blunt trauma is unusual and may closely mimic diaphragmatic rupture. Diagnosis remains difficult and is often delayed. A prompt diagnosis requires a high index of suspicion. We describe one patient with phrenic nerve injury in whom the diagnosis was made late at the time of injury. Radiograph, ultrasonography, and computed tomography were helpful in the diagnosis. Video-assisted thoracic surgery was performed on our patient for diagnostic purposes. Left phrenic nerve injury and pericardial injury were found. Diaphragmatic plication was performed through a miniature left posterolateral thoracotomy. This case was presented to show the unusual nature of phrenic nerve injury.

[Diaphragmatic paralysis after cardiac surgery in children: value of plication]

Phrenic nerve injury is a recognized and severe complication after cardiac surgery. Diaphragmatic paralysis leads to difficulty of weaning the child from the ventilator surgical plication is an easy and safe procedure that result in early clinical and physiological improvements.

Augmented breath phase volume and timing relationships in the anesthetized rat

Augmented breaths (ABs), or sighs, are airway protective reflexes and part of the normal repertoire of respiratory behaviors. ABs consist of two phases, where phase I volume and timing resembles preceding eupnic breaths, and phase II is an augmenting motor pattern and occurs at the end of phase I. Recent evidence suggest multiple respiratory motor patterns can occur following dynamic functional reconfiguration of one respiratory neural network. It follows that the response of the respiratory network to modulatory inputs also may undergo dynamic reconfiguration. We hypothesized that lung-volume related feedback during ABs would alter AB timing differentially during phase I and II. We measured phase I and II volumes and durations in urethane anesthetized rats with decreased lung volume secondary to three models of varying phrenic motor impairment (spinal injury alone, unilateral phrenicotomy, and combined injuries). AB phase I and II inspired volume were decreased after phrenic motor impairment (p<0.05). In contrast, only phase I duration following injury was altered compared to controls. Phase II duration remaining unchanged despite the greatest effect of injury on volume occurring during phase II. Thus, sigh volume-timing relationships differ between phases of an augmented breath suggesting that the response of the respiratory network to modulatory inputs has changed. These data support the hypothesis that multiple respiratory behaviors occur following dynamic reconfiguration of the respiratory neural network.

Combination of diaphragmatic plication with major abdominal surgery in patients with phrenic nerve palsy

The role of simultaneous prophylactic diaphragmatic plication during major abdominal operations is evaluated. In five patients with a history of phrenic nerve injury, postoperative ventilation requirements and hospital stay were significantly reduced when synchronous diaphragmatic plication was performed, compared with corresponding values obtained during previous abdominal operation without diaphragmatic plication. In addition, diaphragmatic plication was associated with postoperative improvement of respiratory mechanics and blood gas exchange.

Incidence and treatment of diaphragmatic paralysis after cardiac surgery in children

OBJECTIVE

Diaphragmatic paralysis (DP) caused by phrenic nerve injury is potentially life-threatening in infants. Phrenic nerve injury due to thoracic surgery is the most common cause of DP in children. We retrospectively analyzed incidence, surgical details, management and follow-up of our patients with DP after cardiac surgery to develop an algorithm for the management and follow-up.

METHODS

Retrospective analysis of 43 patients with DP after cardiac surgery performed between 1996 and 2000.

RESULTS

Median age at cardiac surgery was 1 month (range 3 days to 9 years). Incidence of DP was 5.4%. A trend towards higher incidences of DP were observed after arterial switch operation (10.8%, P=0.18), Fontan procedure (17.6%, P=0.056) and Blalock-Taussig Shunt (12.8%, P=0.10). Median time from cardiac surgery to surgical plication was 21 days (range 7-210 days). Transthoracic diaphragmatic plication was performed in 29/43 patients, no plication was done in 14/43 patients. Patients in whom diaphragmatic plication was required were younger (median age 2 months, range 21 days to 53 months versus 17.5 months, range 4 days to 110 months; P<0.001). Indications for plication were failure to wean from ventilator (n=22), respiratory distress (n=4), cavopulmonary anastomosis (n=2), and failure to thrive (n=1). All these symptoms resolved after diaphragmatic plication, however, 8/29 patients with plication and 2/14 without plication died. Cause of death was not related to diaphragmatic plication in any patient. Position of plicated diaphragm was normal in 18/21 surviving patients 1 month after plication. In 2/12 surviving patients without plication hemidiaphragm showed a normal position 1 year after surgery. The rate of pulmonary infections was not significantly different during 12-60 months follow-up.

CONCLUSIONS

DP is an occasional complication of cardiac surgery. High incidences of DP were seen after arterial switch operation, Fontan procedure and Blalock-Taussig shunt (BT). Respiratory insufficiency requires diaphragmatic plication in most infants with DP whereas older children may tolerate DP. Transthoracic diaphragmatic plication is an effective treatment of DP and achieves relief of respiratory insufficiency in most patients. Spontaneous recovery from postsurgical DP is rare.

The prevention of nerve injury in aortic arch aneurysmal surgery

In a case of aortic arch aneurysm associated with adhesion to the surrounding structures, we devised an operative technique to avoid nerve injury during the surgical procedure. By preserving the adventitial layer of the aortic arch aneurysm to which the phrenic and recurrent nerves were attached, injury to the nerves was avoided, and the aneurysmectomy was completed with the distal anastomosis being performed intraluminally.

Prolonged hemidiaphragmatic paralysis following interscalene brachial plexus block

We present a case of persistent phrenic nerve paralysis after a successful interscalene brachial plexus block. In addition, there was no observed diaphragmatic stimulation, and the patient underwent an uneventful early postoperative period. Warning signs of a complication were either missed or absent until several days after discharge from the ambulatory surgical unit.

Right Phrenic Nerve Injury Following Electrical Disconnection of the Right Superior Pulmonary Vein

This report describes a case of transient paresis of the right diaphragm following the transcatheter radiofrequency ablation for the electrical disconnection of pulmonary veins, which recovered completely during the observational period in a 61-year-old woman with paroxysmal atrial fibrillation. For electrical disconnection of pulmonary veins, careful preventive measures for phrenic nerve damage are required.

Unilateral diaphragmatic paralysis following thoracic outlet surgery: a case report

In this report, a young female, who initially presented with left upper extremity pain, eventually underwent surgery for presumed thoracic outlet syndrome. Following surgery, she developed shortness of breath. Diagnostic studies revealed an elevated left hemidiaphragm secondary to injury to the phrenic nerve.

An overlooked association of brachial plexus palsy: diaphragmatic paralysis

Diaphragmatic paralysis in newborns is related to brachial plexus palsy. It can be overlooked if thorough examination isn't done. We present a two-weeks-old baby with a birth weight of 3800 grams who had a left-sided brachial plexus palsy and torticollis with an undiagnosed left diaphragmatic paralysis even though he was examined by different physicians several times. The role of physical examination, the chest x-rays of patients with brachial paralysis and the treatment modalities of diaphragmatic paralysis due to obstetrical factors are discussed.

Transient phrenic nerve palsy after cardiac operation in infants

OBJECTIVE

The aims of this study were to prove the presence of transient phrenic nerve palsy in children after cardiac surgery by successive recordings of diaphragmatic action potentials (DAPs), and to decide the indication of diaphragmatic plication in infants with postoperative phrenic nerve palsy.

METHODS

The DAPs were recorded from 11 infants (age 0-54 months) under artificial ventilation after cardiac surgery. The successive DAP recordings were performed within 3-4 days (0W), 1 week (1W) and 2 weeks (2W) after operation to make a final decision for diaphragmatic plication to wean artificial ventilation.

RESULTS

The patients were divided into 3 groups according to the DAP changes in successive recordings, namely, patients with normal DAPs at 0W, patients with transient depression of DAPs at 0W followed by recovery to normal DAPs by 1W and/or 2W, and patients with persistent depression of DAPs of the affected side necessitating plication of hemidiaphragm.

CONCLUSIONS

In infants with phrenic nerve palsy after cardiothoracic surgery, persistently abnormal DAPs in repeated electrophysiologic examinations for at least 2 weeks after surgery are a useful guidance to support clinical and radiological evidence for an indication of diaphragmatic plication.

Thoracoscopic plication of the diaphragm for postoperative phrenic paralysis: a report of two cases

Unilateral phrenic nerve paralysis after cardiothoracic surgery is not uncommon. When symptomatic, it can require surgical treatment. Plication of the diaphragm through a thoracotomy is known to provide excellent long-term results. Plication is now being performed via video-assisted thoracoscopic surgery (VATS). We report the cases of two patients with postoperative left phrenic nerve paralysis who underwent plication of the diaphragm using VATS and achieved total relief of all symptoms.

Complications of surgery for thoracic outlet syndrome

Having read through the previous litany of potential disasters and complications, one could ask the obvious question, "Why would anyone want to do this kind of surgery?" The answer is that most people elect not to! Nevertheless, for those who decide to venture into this field, there is the tremendous reward of being able to help patients who would otherwise continue to live with extremely disabling and disheartening symptoms. A sound knowledge of the regional anatomy and tutelage by those knowledgeable in particular areas of surgery that may not have been a part of the individual surgeon's prior training is essential. The author was fortunate to have the help of a very accomplished and generous vascular surgeon, Dr. William Abbott of the Massachusetts General Hospital for many months when I began on what I have considered a fascinating and intellectually rewarding odyssey.

Laparoscopic diaphragmatic plication: long-term results of a novel surgical technique for postoperative phrenic nerve palsy

BACKGROUND

Paralysis of the diaphragm is a severe complication of cardiothoracic surgery carrying significant morbidity and mortality. This study demonstrates a novel minimally invasive technique for treatment of phrenic nerve injuries presenting with symptomatic eventration of the diaphragm. It also presents long-term results of three patients treated with this operation.

METHODS

Chest x-ray proved eventration of the left diaphragm in all patients. Two patients required treatment due to prolonged respirator therapy/assisted ventilation for 4 weeks after cardiac surgery. One patient suffered from progressive dyspnea caused by increasing left-sided diaphragmatic elevation and underwent surgery 2 years after cardiac surgery. In all cases, a minimally invasive abdominal approach was chosen. During surgery the dome of the diaphragm was pulled down via three percutaneously inserted retention stitches. This resulted in two or three folds of the diaphragm located within the abdomen. These diaphragmatic folds were subsequently tightened using 12 to 15 unresorbable sutures with extracorporally prepared knots. Surgical as well as long-term follow-up results are presented of all patients and a review of the current literature is provided.

RESULTS

Mean operating time was 203 min; mean intraoperative blood loss was 130 ml. No major complications occurred during surgery or the postoperative period. At a median follow-up of 72 months no recurrence was observed.

CONCLUSIONS

Laparoscopic diaphragmatic plication provides excellent relief of symptoms caused by diaphragmatic paralysis. There is no perioperative morbidity, and hospital stay is short. The laparoscopic approach, therefore, is an attractive surgical alternative for the treatment of phrenic nerve palsy and should be considered in all suitable patients.

Electrophysiological evaluation of phrenic nerve injury during cardiac surgery--a prospective, controlled, clinical study

Background

According to some reports, left hemidiaphragmatic paralysis due to phrenic nerve injury may occur following cardiac surgery. The purpose of this study was to document the effects on phrenic nerve injury of whole body hypothermia, use of ice-slush around the heart and mammary artery harvesting.

Methods

Electrophysiology of phrenic nerves was studied bilaterally in 78 subjects before and three weeks after cardiac or peripheral vascular surgery. In 49 patients, coronary artery bypass grafting (CABG) and heart valve replacement with moderate hypothermic (mean 28°C) cardiopulmonary bypass (CPB) were performed. In the other 29, CABG with beating heart was performed, or, in several cases, peripheral vascular surgery with normothermia.

Results

In all patients, measurements of bilateral phrenic nerve function were within normal limits before surgery. Three weeks after surgery, left phrenic nerve function was absent in five patients in the CPB and hypothermia group (3 in CABG and 2 in valve replacement). No phrenic nerve dysfunction was observed after surgery in the CABG with beating heart (no CPB) or the peripheral vascular groups. Except in the five patients with left phrenic nerve paralysis, mean phrenic nerve conduction latency time (ms) and amplitude (mV) did not differ statistically before and after surgery in either group (p > 0.05).

Conclusions

Our results indicate that CPB with hypothermia and local ice-slush application around the heart play a role in phrenic nerve injury following cardiac surgery. Furthermore, phrenic nerve injury during cardiac surgery occurred in 10.2 % of our patients (CABG with CPB plus valve surgery).

Phrenic nerve injury associated with high free right internal mammary artery harvesting

BACKGROUND

The right phrenic nerve is at risk of injury during high mobilization of the right internal mammary artery (RIMA). The incidence and implications of this injury have not been previously defined.

METHODS

Prospectively collected data on all patients who underwent RIMA harvesting between January 1995 and February 2002 were analyzed. Thirty-one patients with right phrenic nerve injury were identified and the medical charts reviewed. Phrenic nerve injury was diagnosed when a postoperative chest roentgenogram showed the right hemidiaphragm to be two or more intercostal spaces higher than the left, or transection of the nerve was seen intraoperatively. Investigations included fluoroscopy and spirometry in upright and supine positions. Diaphragm plication was offered for symptom control. Subsequent follow-up was undertaken to determine the incidence of spontaneous recovery of diaphragm function and the benefits of diaphragm plication.

RESULTS

Seven hundred and eighty-three patients underwent high mobilization of the RIMA with proximal detachment for use as a free graft. Thirty-one patients with right hemidiaphragm dysfunction were identified in the postoperative period providing an injury incidence of 4% (confidence interval, 2.6% to 5.3%). Of these, 12 patients underwent diaphragm plication (4 early and 8 late), 14 patients achieved spontaneous recovery, and 5 patients were lost to follow-up. The supine to upright forced vital capacity ratios at the time of phrenic nerve dysfunction, after diaphragm plication, and after spontaneous recovery were 0.79, 0.90, and 0.96 respectively.

CONCLUSIONS

The incidence of phrenic nerve injury associated with high RIMA harvesting was 4% but spontaneous recovery may be anticipated in two thirds (14 of 22) of patients in whom the injury is identified postoperatively. High RIMA harvesting should be used with caution in patients with preoperative pulmonary dysfunction in whom phrenic nerve injury would be poorly tolerated.

The pulmonary physician in critical care * illustrative case 4: neuromusculoskeletal disorders

The case history is presented of a patient admitted to the ICU with ventilatory insufficiency following thoracotomy for thymic resection. The role of non-invasive ventilation for weaning in patients following phrenic nerve injury is discussed.