Abdominal Compartment Syndrome: A Rare Complication of Plication of the Diaphragm

Case report: repair of eventration of the diaphragm in an octogenarian

Eventration of the diaphragm is a cephalad displacement of the diaphragm because of congenital or acquired causes. The diaphragm maintains its anatomical continuity and normal attachments. It may be partial or complete and unilateral or bilateral. Most adult presentations are asymptomatic, but patients may present with respiratory, gastrointestinal, or cardiac symptoms. Surgical repair is indicated in the symptomatic patient with the most common being diaphragmatic plication. We present surgical repair of a symptomatic left diaphragmatic eventration in an octogenarian.

Paradoxical Motion on Sniff Test Predicts Greater Improvement Following Diaphragm Plication

BACKGROUND

Diaphragm plication (DP) improves pulmonary function and quality of life for those with diaphragm paralysis or dysfunction. It is unknown whether differing degrees of diaphragm dysfunction as measured by sniff testing affect results after plication.

METHODS

Patients who underwent minimally invasive DP from 2008 to 2019 were dichotomized based on sniff test results: paradoxical motion (PM) versus no paradoxical motion (NPM); the latter included normal, decreased, and no motion. Preoperative and postoperative pulmonary function testing (PFT) after DP was compared between groups. The impact of the diaphragm height index, a measure of diaphragm elevation, was also assessed.

RESULTS

A total of 26 patients underwent preoperative sniff testing, DP, and postoperative PFT. Including all patients, DP resulted in a 17.8% ± 5.5% improvement in forced expiratory volume in 1 second (P < .001), a 14.4% ± 5.3% improvement in forced vital capacity (P < .001), and a 4.7% ± 4.6% improvement in the diffusing capacity of carbon monoxide (P = .539). There were greater improvements in the PM group (n = 16) compared with the NPM group (n = 10) for forced expiratory volume in 1 second (27.2% ± 6.0% versus 3.9% ± 6.2%; P = .017) and forced vital capacity (28.1% ± 5.3% versus -0.5% ± 3.3%; P = .001). There was no difference in the change in the diffusing capacity of carbon monoxide between groups. There were no differences between patients with PM and NPM in the postoperative course or complications. No value for diaphragm height index predicted improvement in PFT after DP.

CONCLUSIONS

Patients with PM on sniff test have dramatically greater objective improvements in pulmonary function after plication compared with those without PM. Most patients without PM do not demonstrate improvement in standard PFT. Improvements in dyspnea require additional study.

Hepatic Compartment Syndrome After a Right-sided Diaphragm Plication

We present a case of acute hepatic failure due to hepatic vein outflow obstruction after a unilateral right diaphragm plication that required reoperation. This complication does not appear to have been reported previously. After reoperation and the removal of several plication sutures, hepatic vein outflow was restored, and hepatic function normalized soon thereafter.

Congenital unilateral diaphragmatic eventration in an adult: A rare case presentation

We present a rare case of 32year old female with congenital diaphragmatic eventeration female presenting in an adult. She had symptoms of intermittent dyspnea and occasional epigastric discomfort. Patient had no previous history of trauma. Physical examination showed bowel sound involving the left hemithorax. Imaging modalities confirmed the diagnosis of a congenital left diaphragmatic eventeration. Patient underwent plication of the diaphragm using the abdominal approach. Intra-operatively, the left diaphragm was attenuated. Plication was done with 1st layer of imbricating silk heavy sutures buttressed by a second layer of interrupted absorbable sutures. She post-operatively had atelectasis on the left lung. Incentive spirometry and deep breathing exercises were started with resolution of the atelectasis after 1 week post-operatively. Patient had an unremarkable post-operative stay with resolution of symptoms. There are reports that diaphragmatic eventration diagnosed even as late 70 years old, highlighting the dogma that this is an asymptomatic disorder does not need all the time surgical therapy. But we still recommend surgical therapy as soon as diagnosis is confirmed. In this patient, there was no recurrence of symptoms after a follow-up of 2 years. Whether surgery indeed improved lung functions in these vastly asymptomatic patients, these questions could be an active area of research in the long term outcomes of these patients.

Best Approach and Benefit of Plication for Paralyzed Diaphragm

Diaphragmatic eventration and diaphragmatic paralysis are 2 entities with different etiology and pathology, and are often clinically indistinguishable. When symptomatic, their treatment is the same, with the objective to reduce the dysfunctional cephalad excursion of the diaphragm during inspiration. This can be achieved with diaphragmatic plication through the thorax or the abdomen with either open or minimally invasive techniques. We prefer the laparoscopic approach, due to its easy access to the diaphragm and to avoid pain associated with intercostal incisions and instrument use. Short-term and long-term results are excellent with this technique.

Is video-assisted thoracoscopic diaphragmatic plication a widespread technique for diaphragmatic hernia in adults? Review of the literature and results of a national survey

Diaphragmatic plication is the most accepted treatment for symptomatic diaphragmatic hernia in adults. The fact that this pathology is infrequent and this procedure not been widespread means that this is an exceptional technique in our field. To estimate its use in the literature, we carried out a review in English and Spanish, to which we added our series. We found only six series that contribute 59 video-assisted mini-thoractomy for diaphragmatic plications in adults, and none in Spanish. Our series will be the second largest with 18 cases. Finally, we conducted a survey in all the Spanish Thoracic Surgery units in Spain: none reported more than 10 cases operated by thoracoscopy in the last 8 years (except our series) and most continue employing thoracotomy as the main approach. We believe that many patients with symptomatic diaphragmatic hernia could benefit from the use of such techniques.

Long-term results of diaphragmatic plication in adults with unilateral diaphragm paralysis

BACKGROUND

In this study we aimed to evaluate the long-term outcome of diaphragmatic plication for symptomatic unilateral diaphragm paralysis.

METHODS

Thirteen patients who underwent unilateral diaphragmatic plication (2 patients had right, 11 left plication) between January 2003 and December 2006 were evaluated. One patient died postoperatively due to sepsis. The remaining 12 patients [9 males, 3 females; mean age 60 (36-66) years] were reevaluated with chest radiography, flouroscopy or ultrasonography, pulmonary function tests, computed tomography (CT) or magnetic resonance imaging (MRI), and the MRC/ATS dyspnea score at an average of 5.4 (4-7) years after diaphragmatic plication.

RESULTS

The etiology of paralysis was trauma (9 patients), cardiac by pass surgery (3 patients), and idiopathic (1 patient). The principle symptom was progressive dyspnea with a mean duration of 32.9 (22-60) months before surgery. All patients had an elevated hemidiaphragm and paradoxical movement radiologically prior to surgery. There were partial atelectasis and reccurent infection of the lower lobe in the affected side on CT in 9 patients. Atelectasis was completely improved in 9 patients after plication. Preoperative spirometry showed a clear restrictive pattern. Mean preoperative FVC was 56.7 ± 11.6% and FEV1 65.3 ± 8.7%. FVC and FEV1 improved by 43.6 ± 30.6% (p < 0.001) and 27.3 ± 10.9% (p < 0.001) at late follow-up. MRC/ATS dyspnea scores improved 3 points in 11 patients and 1 point in 1 patient at long-term (p < 0.0001). Eight patients had returned to work at 3 months after surgery.

CONCLUSIONS

Diaphragmatic plication for unilateral diaphragm paralysis decreases lung compression, ensures remission of symptoms, and improves quality of life in long-term period.

Diaphragm plication for eventration or paralysis: a review of the literature

Although etiology and pathology of symptomatic diaphragm paralysis and eventration are distinct, their treatments are the same: to reduce dysfunctional caudal excursion of the diaphragm during inspiration by plication. Minimally invasive diaphragm plication techniques have emerged as equally effective and less morbid alternatives to open plication. This review focuses on the etiology, pathophysiology, diagnosis, and treatment of diaphragmatic eventration or paralysis in adults.

Diaphragmatic eventration

Symptomatic diaphragmatic eventration is an uncommon condition and is sometimes impossible to distinguish clinically from paralysis. Patients who are asymptomatic require no treatment; patients who are symptomatic benefit significantly from diaphragm plication. The choice of plication approach is dependent upon the expertise of the surgeon.

Abdominal compartment syndrome post-late Bochdalek hernia repair: A case report

The aim of this case report is to discuss the rare postoperative complication of abdominal compartment syndrome in a 19-year-old Caucasian Greek male that was electively operated on for a congenital diaphragmatic hernia. The hernia was completely asymptomatic and was found in chest radiography for employment reasons. Abdominal compartment syndrome is related in most reports with trauma and abdominal operations. Timely diagnosis is key to the prevention of further organ damage and multisystem organ dysfunction because the syndrome once instituted is highly fatal.

Abdominal compartment syndrome: a concise clinical review

OBJECTIVE

There has been an increased awareness of the presence and clinical importance of abdominal compartment syndrome. It is now appreciated that elevations of abdominal pressure occur in a wide variety of critically ill patients. Full-blown abdominal compartment syndrome is a clinical syndrome characterized by progressive intra-abdominal organ dysfunction resulting from elevated intra-abdominal pressure. This review provides a current, clinically focused approach to the diagnosis and management of abdominal compartment syndrome, with a particular emphasis on intensive care.

METHODS

Source data were obtained from a PubMed search of the medical literature, with an emphasis on the time period after 2000. PubMed "related articles" search strategies were likewise employed frequently. Additional information was derived from the Web site of the World Society of the Abdominal Compartment Syndrome (http://www.wsacs.org).

SUMMARY AND CONCLUSIONS

The detrimental impact of elevated intra-abdominal pressure, progressing to abdominal compartment syndrome, is recognized in both surgical and medical intensive care units. The recent international abdominal compartment syndrome consensus conference has helped to define, characterize, and raise awareness of abdominal compartment syndrome. Because of the frequency of this condition, routine measurement of intra-abdominal pressure should be performed in high-risk patients in the intensive care unit. Evidence-based interventions can be used to minimize the risk of developing elevated intra-abdominal pressure and to aggressively treat intra-abdominal hypertension when identified. Surgical decompression remains the gold standard for rapid, definitive treatment of fully developed abdominal compartment syndrome, but nonsurgical measures can often effectively affect lesser degrees of intra-abdominal hypertension and abdominal compartment syndrome.