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El-Magd ESA, Elgeidie A, Abbas A, Elmahdy Y, LotfyAbulazm I, Hamed H. Laparoscopic approach in the management of diaphragmatic eventration in adults: gastrointestinal surgical perspective. Updates Surg 2024; 76:555-563. [PMID: 37847484 PMCID: PMC10995002 DOI: 10.1007/s13304-023-01665-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 09/29/2023] [Indexed: 10/18/2023]
Abstract
The current literature is poor with studies handling the role of laparoscopy in managing diaphragmatic eventration (DE). Herein, we describe our experience regarding the role of laparoscopy in managing DE patients presenting mainly with gastrointestinal symptoms. We retrospectively reviewed the data of 20 patients who underwent laparoscopic diaphragmatic plication between January 2010 and December 2018. Postoperative outcomes and quality of life were assessed. Most DEs were left sided (95%). Laparoscopic diaphragmatic plication was possible in all patients, along with correcting all associated gastrointestinal and diaphragmatic problems. The former included gastric volvulus (60%), reflux esophagitis (25%), cholelithiasis (5%), and pyloric obstruction (5%), while the latter included diaphragmatic and hiatus hernia (10% and 15%, respectively).The average operative time was 142 min. All patients had a regular (reviewer #1) postoperative course except for one who developed hydro-pneumothorax. At a median follow-up of 48 months, midterm outcomes were satisfactory, with an improvement (reviewer #1) in gastrointestinal symptoms. Three patients (reviewer #1) developed radiological recurrence without significant clinical symptoms. Patient's quality of life, including all parameters, significantly improved after the laparoscopic procedure compared to the preoperative values. Laparoscopic approach is safe and effective for managing adult diaphragmatic eventration (reviewer #1).
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Affiliation(s)
- El-Sayed Abou El-Magd
- Department of General Surgery, Faculty of Medicine, Gastrointestinal Surgical Center GISC, Mansoura University, Gehan Street, Mansoura, 35511, Al Dakahlia, Egypt.
| | - Ahmed Elgeidie
- Department of General Surgery, Faculty of Medicine, Gastrointestinal Surgical Center GISC, Mansoura University, Gehan Street, Mansoura, 35511, Al Dakahlia, Egypt
| | - Amr Abbas
- Department of General Surgery, Faculty of Medicine, Gastrointestinal Surgical Center GISC, Mansoura University, Gehan Street, Mansoura, 35511, Al Dakahlia, Egypt
| | - Youssif Elmahdy
- Department of General Surgery, Faculty of Medicine, Gastrointestinal Surgical Center GISC, Mansoura University, Gehan Street, Mansoura, 35511, Al Dakahlia, Egypt
| | - Ibrahem LotfyAbulazm
- Department of General Surgery, Faculty of Medicine, Gastrointestinal Surgical Center GISC, Mansoura University, Gehan Street, Mansoura, 35511, Al Dakahlia, Egypt
| | - Hosam Hamed
- Department of General Surgery, Faculty of Medicine, Gastrointestinal Surgical Center GISC, Mansoura University, Gehan Street, Mansoura, 35511, Al Dakahlia, Egypt
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Bhende VV, Sharma TS, Krishnakumar M, Kumar A, Panesar G, Soni KA, Dhami KB, Patel MR, Sharma AS, Pathan SR, Majmudar HP. Hemi-Diaphragm Plication and/or Tracheostomy Are Valuable Adjunctive Procedures After Repair of Congenital Heart Defects in Children: A Systematic Review. Cureus 2023; 15:e48648. [PMID: 37954631 PMCID: PMC10638678 DOI: 10.7759/cureus.48648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2023] [Indexed: 11/14/2023] Open
Abstract
Diaphragmatic paralysis (DP), whether unilateral or bilateral, often leads to extended recovery and more severe complications, particularly in neonates and infants undergoing congenital heart surgery. This condition's impact is most pronounced after single-ventricle palliative procedures. Tracheostomy prevalence is rising in pediatric patients with congenital heart disease (CHD) despite its association with high resource utilization and in-hospital mortality. This study examines the reported incidence of diaphragmatic paralysis and timing of tracheostomy in pediatric patients undergoing surgery for congenital heart disease in the literature and a retrospective analysis of cases in our institution between 2018 and 2023, offering insights for prospective management. An electronic search of PubMed databases retrieved 10 studies on pediatric tracheostomy and 11 studies on DP. Our retrospective analysis included 15 patients, of whom 10 underwent tracheostomy, four underwent diaphragmatic plication, and one underwent both. Postoperative tracheostomy had an 11.8% mortality rate in our systematic review, rising to 40% in our observational study. Diaphragm repair and early diagnosis can reduce morbidity, prevent complications, and improve patients' quality of life.
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Affiliation(s)
- Vishal V Bhende
- Pediatric Cardiac Surgery, Bhanubhai and Madhuben Patel Cardiac Centre, Shree Krishna Hospital, Bhaikaka University, Karamsad, IND
| | - Tanishq S Sharma
- Pediatric Cardiac Surgery, Bhanubhai and Madhuben Patel Cardiac Centre, Shree Krishna Hospital, Bhaikaka University, Karamsad, IND
- Community Medicine, SAL Institute of Medical Sciences, Ahmedabad, IND
| | | | - Amit Kumar
- Pediatric Cardiac Intensive Care, Bhanubhai and Madhuben Patel Cardiac Centre, Shree Krishna Hospital, Bhaikaka University, Karamsad, IND
| | - Gurpreet Panesar
- Cardiac Anaesthesiology, Bhanubhai and Madhuben Patel Cardiac Centre, Shree Krishna Hospital, Bhaikaka University, Karamsad, IND
| | - Kunal A Soni
- Cardiac Anaesthesiology, Bhanubhai and Madhuben Patel Cardiac Centre, Shree Krishna Hospital, Bhaikaka University, Karamsad, IND
| | - Kartik B Dhami
- Cardiac Anaesthesiology, Bhanubhai and Madhuben Patel Cardiac Centre, Shree Krishna Hospital, Bhaikaka University, Karamsad, IND
| | - Mamta R Patel
- Central Research Services, Bhaikaka University, Karamsad, IND
| | - Ashwin S Sharma
- Internal Medicine, Gujarat Cancer Society Medical College, Hospital and Research Centre, Ahmedabad, IND
| | - Sohilkhan R Pathan
- Clinical Research Services, Bhanubhai and Madhuben Patel Cardiac Centre, Shree Krishna Hospital, Bhaikaka University, Karamsad, IND
| | - Hardil P Majmudar
- Pediatric Cardiac Surgery, Bhanubhai and Madhuben Patel Cardiac Centre, Shree Krishna Hospital, Bhaikaka University, Karamsad, IND
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Management of phrenic nerve injury post-cardiac surgery in the paediatric patient. Cardiol Young 2021; 31:1386-1392. [PMID: 34304750 DOI: 10.1017/s1047951121002882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Phrenic nerve injury is a common complication of cardiac and thoracic surgical procedures, with potentially severe effects on the health of a child. This review aims to summarise the available literature on the diagnosis and management of PNI post-cardiac surgery in paediatric patients with CHD. MAIN BODY The presence of injury post-surgery can be difficult to detect and may present with non-specific symptoms, emphasising the importance of an effective diagnostic strategy. Chest X-ray is usually the first investigation for a suspected diagnosis of PNI, which is usually confirmed using fluoroscopy, ultrasound scan, or phrenic nerve stimulation (gold standard). Management options include supportive ventilation and/or invasive diaphragmatic plication surgery. While the optimal timing of plication surgery remains controversial, it is now the most widely accepted treatment for PNI in children post-CHD surgery, especially for very young patients who cannot be weaned off supportive ventilation. Further research is needed to determine the optimal timing of surgical intervention for positive outcomes and to explore the benefits of using minimally invasive surgical techniques in children. CONCLUSION PNI is a common and serious complication of CHD surgery, therefore, its diagnosis and management in the paediatric population are of major importance. Further research is needed to determine the optimal timing of surgical intervention for positive outcomes and to explore the benefits of using minimally invasive surgical techniques in children.
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Hosokawa T, Shibuki S, Tanami Y, Sato Y, Ko Y, Nomura K, Oguma E. Fluorographic findings of diaphragmatic paralysis with spontaneous recovery. Pediatr Int 2021; 63:895-902. [PMID: 33205590 DOI: 10.1111/ped.14548] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 10/31/2020] [Accepted: 11/10/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Postoperative diaphragmatic paralysis is an unavoidable complication of cardiovascular surgery. Although diaphragmatic plication, as a surgical treatment, can be performed, spontaneous recovery is possible. We aimed to identify differences in fluorographic findings of diaphragmatic paralysis between pediatric patients with and without spontaneous recovery within 1 year of intrathoracic surgery. METHODS Ten children, who had been followed-up for at least 1 year post-surgery and who had not received diaphragmatic plication were included and classified into those with or without spontaneous recovery. The presence or absence of the paradoxical movement of the diaphragm and mediastinum was evaluated based on fluorographic findings. Fisher's exact test was used to compare the presence or absence of paradoxical movement between the groups. RESULTS Eight patients experienced spontaneous recovery. The mean ± standard deviation time to spontaneous recovery was 150 ± 114 days (range, 18-338 days). In the spontaneous recovery group, no patient had paradoxical movement of the mediastinum, and a significant between-group difference was observed in the presence of the paradoxical movement of the mediastinum (present/absent in patients with vs. without spontaneous recovery: 0/8 vs. 2/0, P = 0.02). There was no significant between-group difference in paradoxical movement of the diaphragm (present/absent in patients with vs. without spontaneous recovery: 1/7 vs. 2/0, P = 0.07). Pediatric patients without paradoxical movement of the mediastinum spontaneously recovered within 1 year of intrathoracic surgery. CONCLUSIONS Pediatric patients without paradoxical movement of the mediastinum, based on fluorography findings, spontaneously recovered within 1 year of surgery. The timing of spontaneous recovery varied between cases.
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Affiliation(s)
- Takahiro Hosokawa
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| | - Saki Shibuki
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| | - Yutaka Tanami
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| | - Yumiko Sato
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| | - Yoshihiro Ko
- Department of Cardiovascular Surgery, Saitama Children's Medical Center, Saitama, Japan
| | - Koji Nomura
- Department of Cardiovascular Surgery, Saitama Children's Medical Center, Saitama, Japan
| | - Eiji Oguma
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
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Hosokawa T, Tanami Y, Sato Y, Nomura K, Oguma E. A novel sonographic sign of paradoxical movement of diaphragmatic paralysis in pediatric patients after cardiovascular surgery. Radiol Case Rep 2021; 16:777-784. [PMID: 33537108 PMCID: PMC7841228 DOI: 10.1016/j.radcr.2021.01.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 01/14/2021] [Accepted: 01/15/2021] [Indexed: 11/04/2022] Open
Abstract
We demonstrate a quick sliding of the descending aorta toward the unaffected side of the diaphragm as a new sonographic finding during breathing in pediatric patients with diaphragmatic paralysis. We present three pediatric patients with diaphragmatic paralysis after cardiovascular surgery with this new sonographic finding. This finding consisted of paradoxical movement of the diaphragm as shown by fluorography. This sonographic sign was only obtained by a B-mode scan in the subxiphoid plane, was easily demonstrated at the patient's bedside, and may be useful for diagnosing severe diaphragmatic paralysis.
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Affiliation(s)
- Takahiro Hosokawa
- Department of Radiology, Saitama Children's Medical Center, 1-2 Shintoshin Chuo-ku Saitama, Saitama, 330-8777 Japan
| | - Yutaka Tanami
- Department of Radiology, Saitama Children's Medical Center, 1-2 Shintoshin Chuo-ku Saitama, Saitama, 330-8777 Japan
| | - Yumiko Sato
- Department of Radiology, Saitama Children's Medical Center, 1-2 Shintoshin Chuo-ku Saitama, Saitama, 330-8777 Japan
| | - Koji Nomura
- Department of Cardiovascular Surgery, Saitama Children's Medical Center, Saitama, Japan
| | - Eiji Oguma
- Department of Radiology, Saitama Children's Medical Center, 1-2 Shintoshin Chuo-ku Saitama, Saitama, 330-8777 Japan
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Parmar D, Panchal J, Parmar N, Garg P, Mishra A, Surti J, Patel K. Early diagnosis of diaphragm palsy after pediatric cardiac surgery and outcome after diaphragm plication - A single-center experience. Ann Pediatr Cardiol 2021; 14:178-186. [PMID: 34103857 PMCID: PMC8174623 DOI: 10.4103/apc.apc_171_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 04/17/2020] [Accepted: 11/27/2020] [Indexed: 11/24/2022] Open
Abstract
Objective : The aims of our prospective observational study were to evaluate the (1) reliability of clinical signs in the early detection of diaphragm palsy (DP); (2) reliability of ultrasonography using echo machine as a bedside tool for the diagnosis of DP; and (3) does early diaphragm plication result in the improved outcome? We also sought to determine the incidence and predominant risk factors for DP and diaphragm plication at our center. Materials and Methods : This prospective observational study included patients with suspected DP from January 2015 to December 2018. Patients with suspected DP were initially evaluated by bedside ultrasonography using echo machine and confirmed by fluoroscopy. Diaphragm plication was considered for patients having respiratory distress, difficult weaning, or failed extubation attempt without any obvious cardiac or pulmonary etiology. Patients were followed for 3 months after discharge to assess diaphragm function. Results: A total of 87 patients were suspected of DP based on clinical signs. DP was diagnosed in 61 patients on fluoroscopy. The median time from index operation to diagnosis was 10 (1–59) days. Diaphragm plication was done among 52 patients and not done in nine patients. Bedside ultrasonography using echo machine was 96.7% sensitive and 96.15% specific in diagnosing DP. Early plication (<14 days) significantly reduced the need for nasal continuous positive airway pressure (65% vs. 96%, P = 0.02), duration of mechanical ventilation (12 vs. 25 days, P = 0.018), intensive care unit (ICU) stay (25 days vs. 39 days, P = 0.019), and hospital stay (30 days vs. 46 days, P = 0.036). Conclusion : Hoover's sign and raised hemidiaphragm on chest X-ray are the most specific clinical signs to suspect unilateral DP. Bedside ultrasonography using an echo machine is a good diagnostic investigation comparable to fluoroscopy. Early plication facilitates weaning from the ventilator and thereby decreases the ICU stay and hospital stay.
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Affiliation(s)
- Divyakant Parmar
- Department of Cardiac Anesthesia, U.N. Mehta Institute of Cardiology and Research Center, Ahmedabad, Gujarat, India
| | - Jigar Panchal
- Department of Cardiac Anesthesia, U.N. Mehta Institute of Cardiology and Research Center, Ahmedabad, Gujarat, India
| | - Neha Parmar
- Department of Physiotherapy, U.N. Mehta Institute of Cardiology and Research Center, Ahmedabad, Gujarat, India
| | - Pankaj Garg
- Department of Cardiovascular and Thoracic Surgery, U.N. Mehta Institute of Cardiology and Research Center, Ahmedabad, Gujarat, India
| | - Amit Mishra
- Department of Pediatric Cardiac Surgery, U.N. Mehta Institute of Cardiology and Research Center, Ahmedabad, Gujarat, India
| | - Jigar Surti
- Department Cardiac Anesthesia, U.N. Mehta Institute of Cardiology and Research Center, Ahmedabad, Gujarat, India
| | - Kartik Patel
- Department of Cardiovascular and Thoracic Surgery, U.N. Mehta Institute of Cardiology and Research Center, Ahmedabad, Gujarat, India
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Hosokawa T, Shibuki S, Tanami Y, Sato Y, Ko Y, Nomura K, Oguma E. Extracardiac Complications in Intensive Care Units after Surgical Repair for Congenital Heart Disease: Imaging Review with a Focus on Ultrasound and Radiography. J Pediatr Intensive Care 2020; 10:85-105. [PMID: 33884209 DOI: 10.1055/s-0040-1715483] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 06/24/2020] [Indexed: 12/24/2022] Open
Abstract
Pediatric patients show various extracardiac complications after cardiovascular surgery, and radiography and ultrasound are routinely performed in the intensive care unit to detect and evaluate these complications. This review presents images of these complications, sonographic approach, and timing of occurrence that are categorized based on their extracardiac locations and include complications pertaining to the central nervous system, mediastinum, thorax and lung parenchyma, diaphragm, liver and biliary system, and kidney along with pleural effusion and iatrogenic complications. This pictorial review will make it easier for medical doctors in intensive care units to identify and manage various extracardiac complications in pediatric patients after cardiovascular surgery.
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Affiliation(s)
- Takahiro Hosokawa
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| | - Saki Shibuki
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| | - Yutaka Tanami
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| | - Yumiko Sato
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| | - Yoshihiro Ko
- Department of Cardiovascular Surgery, Saitama Children's Medical Center, Saitama, Japan
| | - Koji Nomura
- Department of Cardiovascular Surgery, Saitama Children's Medical Center, Saitama, Japan
| | - Eiji Oguma
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
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Unilateral diaphragmatic paralysis associated with surgical mitral valve repair in dogs. J Vet Cardiol 2020; 29:33-39. [PMID: 32408112 DOI: 10.1016/j.jvc.2020.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 02/25/2020] [Accepted: 03/04/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVES Unilateral diaphragmatic paralysis (UDP) due to phrenic nerve injury is a potential complication of thoracic surgery. This study evaluated the prevalence of UDP associated with surgical mitral valve repair (MVR) and its effect on surgical outcomes in dogs. ANIMALS, MATERIALS AND METHODS Two hundred ninety-four dogs that underwent MVR were included in the study. A retrospective review of medical records was performed for dogs surviving surgery. Diagnosis of UDP was based on preoperative and postoperative thoracic dorsoventral radiographs. RESULTS A total of 284 dogs survived until the day after surgery. The prevalence of UDP on the day after surgery, on the day of discharge, and after the first postoperative month was 30%, 24%, and 9%, respectively. One case of UDP was observed at 3 months after surgery. Unilateral diaphragmatic paralysis was exhibited by nine of the 21 patients that died in the hospital. The proportion of patients with UDP was higher in dogs that died of respiratory failure than in dogs that died of other causes (p = 0.002). Most dogs whose deaths were suspected to have been related to respiratory failure also had pre-existing respiratory diseases. The occurrence of UDP did not relate to the lengths of stay in the intensive care unit or the hospital. CONCLUSIONS Our findings suggest that UDP is a common complication in dogs after MVR and that the prevalence of UDP decreases with time after surgery. Unilateral diaphragmatic paralysis is a risk factor for postoperative death, especially in patients with pre-existing respiratory disease.
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Thoracic versus abdominal approach to correct diaphragmatic eventration in children. J Pediatr Surg 2020; 55:245-248. [PMID: 31761454 DOI: 10.1016/j.jpedsurg.2019.10.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 10/26/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Plication of diaphragm (DP) for eventration (DE) can be done using thoracic or abdominal approaches. The purpose of our study was to compare outcomes between these approaches based on our experience and on systematic literature review. METHODS Retrospective records of children <16 years who underwent DP (single-center, 2004-2018) were recorded and analyzed. Systematic review and meta-analysis of related studies was undertaken. Data are reported as median (range). RESULTS Eighty-nine cases were identified in thoracic (Congenital = 5, Acquired = 84) and 13 (Congenital = 10, Acquired = 3) in abdominal group aged 5.88 (0.36-184.44) and 10.0 (0.12-181.8) months. Improvement in diaphragm level post-DP was significantly higher in abdominal [2(0-4)] than chest [1.5(0-5)] group (p = 0.04). On Cox regression analysis, there was a non-significant trend to a longer time to extubation in the chest group (Hazard ratio (HR) = 0.539[0.208-1.395], p = 0.203). Patients operated transthoracically left intensive care unit after a significantly longer time (HR = 0.339[0.119-0.966], p = 0.043). Patients operated transabdominally tended to be fed later, although this was not significant (HR = 1.801[0.762-4.253], p = 0.043). On Kaplan-Meier analysis, there was a non-significant trend to a lower rate of recurrence in the abdominal group (HR = 0.3196[0.061-1.675], p = 0.1876). In the meta-analysis including three published studies as well as our data (total n = 181, Thoracic = 139, Abdominal = 42), no difference was found in the incidence of recurrence amongst the 2 groups (RD = -0.04, 95%CI = -0.25, 0.18, p = 0.74). CONCLUSION This is one of the largest reports on outcomes of children undergoing DP for DE. There is no significant difference in recurrence rate, even though all recurrences in our series (15.7%) were in the acquired cases operated using a thoracic approach. TYPE OF STUDY Treatment Retrospective Comparative Study. LEVEL OF EVIDENCE Level III.
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Abstract
BACKGROUND Diaphragm dysfunction following surgery for congenital heart disease is a known complication leading to delays in recovery and increased post-operative morbidity and mortality. We aimed to determine the incidence of and risk factors associated with diaphragm plication in children undergoing cardiac surgery and evaluate timing to repair and effects on hospital cost and length of stay. METHODS We conducted a multi-institutional retrospective observational cohort study. Forty-three hospitals from the Pediatric Health Information System database were included, and a total of 112,110 patients admitted between January 2004 and December 2014 were analysed. RESULTS Patients less than 18 years of age who underwent cardiac surgery were included. Risk Adjustment for Congenital Heart Surgery was utilized to determine procedure complexity. The overall incidence of diaphragm dysfunction was 2.2% (n = 2513 out of 112,110). Of these, 24.0% (603 patients) underwent diaphragm plication. Higher complexity cardiac surgery (Risk Adjustment for Congenital Heart Surgery 5-6) and age less than 4 weeks were associated with a higher likelihood of diaphragm plication (p-value < 0.01). Diaphragmatic plication was associated with increased hospital length of stay (p-value < 0.01) and increased medical cost. CONCLUSIONS Diaphragm plication after surgery for congenital heart disease is associated with longer hospital length of stay and increased cost. There is a strong correlation of prolonged time to plication with increased length of stay and medical cost. The likelihood of plication increases with younger age and higher procedure complexity. Methods to improve early recognition and treatment of diaphragm dysfunction should be developed.
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Komori M, Hoashi T, Shimada M, Kitano M, Ohuchi H, Kurosaki K, Ichikawa H. Impact of Phrenic Nerve Palsy on Late Fontan Circulation. Ann Thorac Surg 2019; 109:1897-1902. [PMID: 31733188 DOI: 10.1016/j.athoracsur.2019.09.064] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 09/18/2019] [Accepted: 09/19/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Although adverse effects of phrenic nerve palsy (PNP) on early Fontan circulation have been reported, detailed late impact remains unclear. METHODS Of 218 patients undergoing extracardiac total cavopulmonary connection between 1995 and 2008, 160 who all underwent cardiac catheter examination, spirometry, and exercise capacity testing 10 years after the operation were enrolled. The cohort was divided into 2 groups: with (N = 21) or without PNP (control group, N = 139). The patients with PNP were further divided into the recovered PNP group (n = 10) and the persistent PNP group (n = 11). All but 2 patients who developed PNP (90.9%) underwent diaphragmatic plication. There was no difference in hemodynamic indices at pre-Fontan evaluation among the three groups. RESULTS Ten years after the Fontan procedure, the averaged forced vital capacity was 81% ± 18% of predicted in the control group, 86% ± 17% in the recovered PNP group, and 56% ± 12% in the persistent PNP group (P < .001). Peak oxygen consumption was linearly correlated to the forced vital capacity (r = 0.222, P = .009). There was no significant difference in the peak oxygen consumption between groups. Significant veno-venous collaterals into the diaphragm from lower body to pulmonary vein(s) or atria more frequently developed in patients who underwent diaphragmatic plication compared with those who did not (P < .001). CONCLUSIONS Persistent PNP resulted in reduced forced vital capacity; however, its influence on exercise intolerance could not be identified. Diaphragmatic plication should be reserved for patients who experience clinically significant respiratory or hemodynamic sequelae of PNP.
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Affiliation(s)
- Motoki Komori
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Research Center, Suita, Osaka, Japan
| | - Takaya Hoashi
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Research Center, Suita, Osaka, Japan.
| | - Masatoshi Shimada
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Research Center, Suita, Osaka, Japan
| | - Masataka Kitano
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Research Center, Suita, Osaka, Japan
| | - Hideo Ohuchi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Research Center, Suita, Osaka, Japan
| | - Kenichi Kurosaki
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Research Center, Suita, Osaka, Japan
| | - Hajime Ichikawa
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Research Center, Suita, Osaka, Japan
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El-Masri N, Saj F, Wehbe T, Nasrallah G, Ejbeh S. Management of phrenic nerve palsy following cardiac surgery. J Card Surg 2018; 33:534-538. [PMID: 30014534 DOI: 10.1111/jocs.13772] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Phrenic nerve palsy (PNP) is a potential complication of cardiac surgery. It may prolong ventilation and hospitalization and result in significant morbidity and mortality. The diagnosis and management of PNP following cardiac surgery is reviewed.
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Affiliation(s)
- Noura El-Masri
- The Lebanese University School of Medicine, Al-Hadath, Lebanon
| | - Fatima Saj
- The Lebanese University School of Medicine, Al-Hadath, Lebanon
| | - Tarek Wehbe
- The Lebanese Canadian and The Notre Dame University Hospitals, Department of Hematology, Jounieh, Lebanon
| | - Georges Nasrallah
- The Notre Dame University Hospital, Chief of Cardiothoracic Anesthesia, Jounieh, Lebanon
| | - Sarkis Ejbeh
- The Notre Dame University Hospital, Chief of Cardiothoracic Surgery, Jounieh, Lebanon
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Alowayshiq H, Shaban A, Khaymaf D, Alarfaj M, Alfuraian H, Assiri K. Early hemi-diaphragmatic plication following intraoperative phrenic nerve transection during complete AV canal repair. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2018. [DOI: 10.1016/j.epsc.2017.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Floh AA, Zafurallah I, MacDonald C, Honjo O, Fan CPS, Laussen PC. The advantage of early plication in children diagnosed with diaphragm paresis. J Thorac Cardiovasc Surg 2017; 154:1715-1721.e4. [PMID: 28712584 DOI: 10.1016/j.jtcvs.2017.05.109] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 04/25/2017] [Accepted: 05/31/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND In this single-center study, we sought to determine the frequency of phrenic nerve injury leading to diaphragm paresis (DP) in children following open cardiac surgery over the last 10 years, and to identify possible variables that predict the need for plication and associated clinical outcomes. METHODS Patients diagnosed with DP were identified from departmental databases and a review of clinical diaphragm ultrasound images. A cohort was analyzed for predictors of diaphragm plication and associations with clinical outcomes. Cumulative proportion graphs modeled the association between plication and length of stay. RESULTS DP was diagnosed in 161 of 6448 patients (2.5%) seen between January 2002 and December 2012. All diagnoses but 1 were confirmed by ultrasound. Plication of the diaphragm was performed in 30 patients (19%); compared with patients who did not undergo plication, these patients were younger (median age, 10 days vs 138 days; P < .001), more likely to have undergone deep hypothermic circulatory arrest (47% vs 18%; P = .005), had a longer duration of positive pressure ventilation (median, 15 days vs 7 days; P < .001), and had longer lengths of stay in both the intensive care unit (median, 23 days vs 8 days; P < .0001) and the hospital (median, 37 days vs 15 days; P < .0001). Early plication was associated with reduction in all intervals of care. CONCLUSIONS Early plication should be considered for patients with diaphragm paresis requiring prolonged respiratory support after cardiac bypass surgery. Longer follow-up evaluation is required to better define the long-term implications of plication.
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Affiliation(s)
- Alejandro A Floh
- Department of Critical Care Medicine and Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada.
| | - Intikhab Zafurallah
- Paediatric Intensive Care and KIDS Retrieval Service, Birmingham Children's Hospital, Birmingham, United Kingdom
| | - Cathy MacDonald
- Department of Radiology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Osami Honjo
- Division of Cardiovascular Surgery and Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Chun-Po S Fan
- Cardiovascular Data Management Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Peter C Laussen
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
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15
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Kozlov Y, Novozhilov V. Thoracoscopic Plication of the Diaphragm in Infants in the First 3 Months of Life. J Laparoendosc Adv Surg Tech A 2015; 25:342-7. [DOI: 10.1089/lap.2014.0205] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Yury Kozlov
- Department of Neonatal Surgery, Municipal Pediatric Hospital, Irkutsk, Russia
- Department of Pediatric Surgery, Irkutsk State Medical Academy of Continuing Education, Irkutsk, Russia
- Department of Pediatric Surgery, Irkutsk State Medical University, Irkutsk, Russia
| | - Vladimir Novozhilov
- Department of Neonatal Surgery, Municipal Pediatric Hospital, Irkutsk, Russia
- Department of Pediatric Surgery, Irkutsk State Medical Academy of Continuing Education, Irkutsk, Russia
- Department of Pediatric Surgery, Irkutsk State Medical University, Irkutsk, Russia
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Fujishiro J, Ishimaru T, Sugiyama M, Arai M, Uotani C, Yoshida M, Miyakawa K, Kakihara T, Iwanaka T. Thoracoscopic plication for diaphragmatic eventration after surgery for congenital heart disease in children. J Laparoendosc Adv Surg Tech A 2014; 25:348-51. [PMID: 25536425 DOI: 10.1089/lap.2014.0260] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE The aim of this study was to clarify the role of thoracoscopic plication for diaphragmatic eventration after surgery for congenital heart disease (CHD) in children. PATIENTS AND METHODS We retrospectively reviewed the medical charts of pediatric patients who had undergone thoracoscopic plication of diaphragmatic eventration after surgery for CHD between 2008 and 2013 at our department. RESULTS Five patients were identified during the study period. The median age and body weight of the patients were 7.6 months and 6.6 kg, respectively. The associated CHDs were pulmonary artery atresia in 3 patients, truncus arteriosus in 1 patient, and double-outlet right ventricle in 1 patient. Four patients needed preoperative mechanical respiratory support. At operation, all the patients received CO2 insufflation (4 mm Hg), and single-lung ventilation was attempted in 3 patients using a bronchial blocker. A sufficient operative field was maintained by CO2 insufflation in all the patients regardless of single-lung ventilation. The procedure was not converted to open operation in any patient. Postoperative extubation was performed in the operating room in 1 patient, on the day of operation in 2 patients, and on postoperative Days 1 and 2 in 2 patients. Air embolism was not observed in any of the patients. Diaphragmatic eventration did not recur in any of the patients after thoracoscopic plication. CONCLUSIONS Thoracoscopic plication is a safe and effective procedure for pediatric diaphragmatic eventration after surgery for CHD. Considering the sufficient operative field maintained by CO2 insufflation, single-lung ventilation using a bronchial blocker would be unnecessary for this procedure. With its safety and good outcome, early thoracoscopic plication is a good treatment option for pediatric patients with symptomatic diaphragmatic eventration after surgery for CHD.
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Affiliation(s)
- Jun Fujishiro
- Department of Pediatric Surgery, Faculty of Medicine, The University of Tokyo , Tokyo, Japan
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17
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Thoracoscopic and laparoscopic plication of the hemidiaphragm is effective in the management of diaphragmatic eventration. Pediatr Surg Int 2014; 30:19-24. [PMID: 24100524 DOI: 10.1007/s00383-013-3418-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/25/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE Diaphragmatic plication by minimally invasive surgery is thought to allow for a quick recovery and has been performed on small children. Here, we report our experience with different plication procedures to discuss how to choose among these different plication procedures in endoscopic surgery for pediatric patients with diaphragmatic eventration. PATIENTS AND METHODS We retrospectively analyzed clinical data of 27 pediatric patients (21 boys, 6 girls; median age: 12.7 months, range 2 months-3 years) admitted to our hospital between November 2008 and July 2013. Three different plication procedures were used: the "reefing the mainsail" technique (8 patients), "invaginating the diaphragmatic dome" technique (10 patients), and "pleating" technique (9 patients). Indications included ventilator dependency (7.41 %), respiratory distress (22.22 %), chronic lung lobe collapse (11.11 %), persistent atelectasis with recurrent pneumonias (18.52 %), and asymptomatic severe eventration (40.74 %). RESULTS Descending distance of diaphragm after surgery ranged from 1 to 4.5 intercostal spaces (mean distance: 2.65 intercostal spaces). All patients recovered well postoperatively, except for one patient with a pneumothorax. Two patients who required respiratory support before the operation no longer required it within 7 d after surgery. Follow-up ranged from 1 to 35 months. Clinical results were satisfactory with obvious improvement in symptoms and a slight re-elevation within a distance of one intercostal space. CONCLUSION For pediatric patients with diaphragmatic eventration, different endoscopic surgeries and plication procedures all yielded satisfactory results. We believe that the choice of one procedure over the other depends only on the surgeon's experience.
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Smith BM, Ezeokoli NJ, Kipps AK, Azakie A, Meadows JJ. Course, Predictors of Diaphragm Recovery After Phrenic Nerve Injury During Pediatric Cardiac Surgery. Ann Thorac Surg 2013; 96:938-42. [DOI: 10.1016/j.athoracsur.2013.05.057] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Revised: 05/07/2013] [Accepted: 05/17/2013] [Indexed: 11/30/2022]
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Wilson MN, Bergeron LM, Kakade A, Simon LM, Caspi J, Pettitt T, Kluka EA. Airway Management following Pediatric Cardiothoracic Surgery. Otolaryngol Head Neck Surg 2013; 149:621-7. [DOI: 10.1177/0194599813498069] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives (1) Review airway management in pediatric patients undergoing cardiothoracic surgery (CTS); (2) determine the incidence of airway-related complications of CTS in this population. Design Case series with chart review. Setting Tertiary care children’s hospital. Patients Children undergoing CTS over a 4-year period. Methods Patients who underwent CTS at a single, tertiary care, children’s hospital between June 1, 2007, and May 31, 2011, were retrospectively reviewed; those <18 years who had open CTS were included. Statistical analysis examined relationships of intubation duration, complications, and need for tracheotomy while comparing patient characteristics, comorbidities, and types of surgery. Results Eight hundred seventy-five primary surgeries in 745 patients met inclusion criteria. Mean postoperative intubation duration was 7.2 days and median 3 days. On univariate analysis, significantly longer postoperative intubation requirements were found in patients younger in age, with congenital comorbidities or prematurity, with preoperative ventilation requirements, and those with early postoperative complications. Multivariate analysis found younger age, presence of congenital comorbidities, preoperative intubation requirements, and early postoperative complications each lengthen ventilation requirements. Four patients developed vocal cord paralysis and 5 developed phrenic nerve palsy. Nineteen patients required tracheotomy. Conclusions In this large cohort, CTS in the pediatric population is associated with few long-term or permanent airway-related complications. Patients who are younger in age and those with congenital comorbidities, preoperative ventilation requirements, or early postoperative complications required longer periods of postoperative intubation.
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Affiliation(s)
- Meghan N. Wilson
- Department of Otolaryngology Head & Neck Surgery, Louisiana State University Health Science Center, New Orleans, Louisiana, USA
| | - Lauren M. Bergeron
- Department of Otolaryngology Head & Neck Surgery, Louisiana State University Health Science Center, New Orleans, Louisiana, USA
| | | | - Lawrence M. Simon
- Department of Otolaryngology Head & Neck Surgery, Louisiana State University Health Science Center, New Orleans, Louisiana, USA
- Children’s Hospital of New Orleans, New Orleans, Louisiana, USA
| | - Joseph Caspi
- Children’s Hospital of New Orleans, New Orleans, Louisiana, USA
- Department of Surgery, Division of Pediatric Cardiothoracic Surgery, Louisiana State University Health Science Center, New Orleans, Louisiana, USA
| | - Timothy Pettitt
- Children’s Hospital of New Orleans, New Orleans, Louisiana, USA
- Department of Surgery, Division of Pediatric Cardiothoracic Surgery, Louisiana State University Health Science Center, New Orleans, Louisiana, USA
| | - Evelyn A. Kluka
- Department of Otolaryngology Head & Neck Surgery, Louisiana State University Health Science Center, New Orleans, Louisiana, USA
- Children’s Hospital of New Orleans, New Orleans, Louisiana, USA
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Georgiev S, Konstantinov G, Latcheva A, Mitev P, Mitev I, Lazarov S. Phrenic nerve injury after paediatric heart surgery: is aggressive plication of the diaphragm beneficial? Eur J Cardiothorac Surg 2013; 44:808-12. [DOI: 10.1093/ejcts/ezt110] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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21
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Tsakiridis K, Visouli AN, Zarogoulidis P, Machairiotis N, Christofis C, Stylianaki A, Katsikogiannis N, Mpakas A, Courcoutsakis N, Zarogoulidis K. Early hemi-diaphragmatic plication through a video assisted mini-thoracotomy in postcardiotomy phrenic nerve paresis. J Thorac Dis 2013; 4 Suppl 1:56-68. [PMID: 23304442 DOI: 10.3978/j.issn.2072-1439.2012.s007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Accepted: 11/26/2012] [Indexed: 11/14/2022]
Abstract
New symptom onset of respiratory distress without other cause, and new hemi-diaphragmatic elevation on chest radiography postcardiotomy, are usually adequate for the diagnosis of phrenic nerve paresis. The symptom severity varies (asymptomatic state to severe respiratory failure) depending on the degree of the lesion (paresis vs. paralysis), the laterality (unilateral or bilateral), the age, and the co-morbidity (respiratory, cardiac disease, morbid obesity, etc). Surgical treatment (hemi-diaphragmatic plication) is indicated only in the presence of symptoms. The established surgical treatment is plication of the affected hemidiaphragm which is generally considered safe and effective. Several techniques and approaches are employed for diaphragmatic plication (thoracotomy, video-assisted thoracoscopic surgery, video-assisted mini-thoracotomy, laparoscopic surgery). The timing of surgery depends on the severity and the progression of symptoms. In infants and young children with postcardiotomy phrenic nerve paresis the clinical status is usually severe (failure to wean from mechanical ventilation), and early plication is indicated. Adults with postcardiotomy phrenic nerve paresis usually suffer from chronic dyspnoea, and, in the absence of respiratory distress, conservative treatment is recommended for 6 months -2 years, since improvement is often observed. Nevertheless, earlier surgical treatment may be indicated in non-resolving respiratory failure. We present early (25(th) day postcardiotomy) right hemi-diaphragm plication, through a video assisted mini-thoracotomy in a high risk patient with postcardiotomy phrenic nerve paresis and respiratory distress. Early surgery with minimal surgical trauma, short operative time, minimal blood loss and postoperative pain, led to fast rehabilitation and avoidance of prolonged hospitalization complications. The relevant literature is discussed.
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Affiliation(s)
- Kosmas Tsakiridis
- Cardiothoracic Department, St Luke's Hospital, Panorama, Thessaloniki, Greece
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22
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Tantawy AEE, Imam S, Shawky H, Salah T. Diaphragmatic Nerve Palsy After Cardiac Surgery in Children in Egypt. World J Pediatr Congenit Heart Surg 2013; 4:19-23. [DOI: 10.1177/2150135112454444] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction: Diaphragmatic paralysis (DP) due to phrenic nerve injury is a complication which occurs in association with congenital cardiac surgery and may be a life-threatening event in infants and young children. Information about this complication is still scarce from the developing countries. Methods: Retrospective study evaluated the incidence of DP among 414 patients who underwent congenital cardiac surgery in Abo Elriesh Children’s Specialized Hospital, Cairo University, Egypt, in the duration from April 2009 to December 2011. Results: Incidence of DP was 3.6% (15 of 414 cases). Median age of affected patients was 10 months (ranged from 1 month to 13 years). Diagnosis of DP was observed after ventricular septal defect repair (3.9%), Glenn anastomosis (8.6%), Tetralogy of Fallot repair (4.3%), Senning operation (10%), arterial switch operation (3.2%), Fontan procedure (33%), coarctation of the aorta repair (7%), and pulmonary artery banding (6.4%). Diaphragmatic plication was performed in 4 of 15 cases. Patients with DP had significantly prolonged mechanical ventilation duration as compared to unaffected patients (median 120, range 48-600 vs 4, range 0-48 hours, P < .000). They also had a higher incidence of nosocomial pneumonia in 8 of 15 (53%) cases, longer duration of intensive care unit stay (median 15, range 4-62 days, P < .006), and significant mortality in 7 of 15 (46%; P < .004). Mortality among patients who underwent diaphragm plication was 1 of 4 (25%). Conclusion: Diaphragmatic paralysis is a relatively rare complication of congenital cardiac surgery in children. Its occurrence is associated with increased morbidity and mortality. A high index of clinical suspicion, utilization of bedside diagnostic tools, and a policy of early plication for certain patients may lead to improved outcomes.
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Affiliation(s)
| | - Soha Imam
- Department of Pediatrics, Cairo University, Cairo, Egypt
| | - Hisham Shawky
- Department of Thoracic and Cardiovascular Surgery, Cairo University, Cairo, Egypt
| | - Tarek Salah
- Department of Thoracic and Cardiovascular Surgery, Cairo University, Cairo, Egypt
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23
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Hsu KH, Chiang MC, Lien R, Chu JJ, Chang YS, Chu SM, Wong KS, Yang PH. Diaphragmatic paralysis among very low birth weight infants following ligation for patent ductus arteriosus. Eur J Pediatr 2012; 171:1639-44. [PMID: 22763604 DOI: 10.1007/s00431-012-1787-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2012] [Accepted: 06/19/2012] [Indexed: 11/30/2022]
Abstract
Management of diaphragmatic paralysis (DP) among newborn infants remains controversial, especially for very low birth weight (VLBW) infants following ligation for patent ductus arteriosus (PDA). This study aimed to characterize the impact of DP after PDA ligation among VLBW infants. Clinical characteristics of DP cases treated with either diaphragmatic plication or conservative methods were described as well. The medical records of VLBW infants who underwent PDA ligation in Chang Gung Memorial Hospital between January 2000 and December 2011 were retrospectively reviewed, and DP was suspected if postligation chest X-rays showed an elevation of the left diaphragm as confirmed by a chest ultrasonograph. For each DP case, three other infants that received PDA ligation with proximate birth dates and who were closely matched in terms of gestational age (±1 week) and birth weight (±10 %) were selected as the control group. A total of eight preterm infants were diagnosed as having DP and 24 infants were selected as the control group. The affected infants usually presented with respiratory distress and extubation failure. The study demonstrated that, among our patient population, DP was associated with a significantly longer duration of ventilator dependency (56.1 ± 16.0 vs. 29.8 ± 17.7 days, p = 0.001) and a higher incidence of severe bronchopulmonary dysplasia (87.5 vs. 23 %, p = 0.002). For selective infants with DP-related ventilatory failure after PDA ligation, surgical plication may facilitate extubation. Diaphragmatic paralysis should be evaluated carefully among VLBW infants receiving PDA ligation because of its adverse impact on ventilator dependency and correlation to a higher incidence of severe bronchopulmonary dysplasia.
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Affiliation(s)
- Kai-Hsiang Hsu
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital at Linkou, 12th Fl., Bldg. L, 5-7 Fu-Shin Street, Gueishan, Taoyuan 33305, Taiwan
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24
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Massello W, Matshes EW, Pinckard JK. Shaken Infants Die of Neck Trauma, Not of Brain Trauma. Acad Forensic Pathol 2011. [DOI: 10.23907/2011.047a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Talwar S, Agarwala S, Mittal CM, Choudhary SK, Airan B. Diaphragmatic palsy after cardiac surgical procedures in patients with congenital heart. Ann Pediatr Cardiol 2011; 3:50-7. [PMID: 20814476 PMCID: PMC2921518 DOI: 10.4103/0974-2069.64370] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Paralysis of diaphragm on one or, exceptionally, both sides is a common cause of delayed recovery and excessive morbidity following pediatric cardiac surgery. The consequences of this complication after all forms of congenital heart surgery in newborns and young infants can be potentially serious. The impact of diaphragmatic palsy on the physiology after single ventricle palliations is particularly significant. It is necessary for all professionals taking care of children with heart disease to be familiar with the etiology, diagnosis, and management of this condition. Early recognition and prompt management of diaphragmatic palsy can potentially reduce the duration of mechanical ventilation and intensive care in those who develop this complication. This review summarizes the anatomy of the phrenic nerves, reasons behind the occurrence of diaphragmatic palsy, and suggests practical guidelines for management.
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Affiliation(s)
- Sachin Talwar
- Cardiothoracic Centre and Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
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26
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Hemidiaphragmatic paralysis in preterm neonates: a rare complication of peripherally inserted central catheter extravasation. J Pediatr Surg 2011; 46:E17-21. [PMID: 21763820 DOI: 10.1016/j.jpedsurg.2011.03.065] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2011] [Revised: 03/21/2011] [Accepted: 03/28/2011] [Indexed: 11/20/2022]
Abstract
Unilateral diaphragmatic paralysis was diagnosed in 2 preterm neonates born at 29 and 25 weeks of gestation, respectively. In both instances, the pathophysiology was phrenic nerve injury after extravasation of parenteral nutrition fluid. Misplacement and infection were predisposing factors. Diaphragmatic movement analysis by time-motion-mode ultrasonography was helpful in achieving a diagnosis. The first neonate required a diaphragmatic placation, whereas the other infant was managed nonoperatively. These cases confirm a rare etiology of diaphragmatic paralysis and possible spontaneous recovery. In neonates with very low birth weight, general anesthesia and thoracic surgery may be associated with a high morbidity, suggesting that nonoperative medical treatment, when possible, is preferable if the neonate does not require supplemental oxygen.
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27
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A Prospective Study of Temporal Course of Phrenic Nerve Palsy in Children After Cardiac Surgery. J Clin Neurophysiol 2011; 28:222-6. [DOI: 10.1097/wnp.0b013e3182121601] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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28
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Oktem S, Cakir E, Uyan ZS, Karadag B, Hamutcu RE, Kiyan G, Akalin F, Karakoc F, Dagli E. Diaphragmatic paralysis after pediatric heart surgery: usefulness of non-invasive ventilation. Int J Pediatr Otorhinolaryngol 2010; 74:430-1. [PMID: 20096939 DOI: 10.1016/j.ijporl.2010.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2009] [Revised: 12/22/2009] [Accepted: 01/05/2010] [Indexed: 11/19/2022]
Abstract
Diaphragmatic paralysis after cardiac surgery is an important complication especially in infants. We report a child who developed diaphragmatic paralysis, atelectasis, bronchomalasia and respiratory failure following cardiac surgery. Ventilatory support alleviated respiratory distress in this child. This report illustrates the usefulness of invasive and non-invasive ventilatory support for a pediatric patient with diaphragmatic paralysis.
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Affiliation(s)
- Sedat Oktem
- Division of Pediatric Pulmonology, Marmara University, Istanbul, Turkey
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Abstract
AIMS To describe the clinical course of infants recovering spontaneously from diaphragmatic paralysis due to perinatal phrenic nerve injury as well as those that underwent plication of the diaphragm. METHODS Between 1990 and 2006, 14 newborns admitted to the Neonatal Intensive Care Unit (NICU) of the Wilhelmina Children's Hospital in Utrecht, The Netherlands, were diagnosed with diaphragmatic paralysis due to obstetric phrenic nerve injury. The clinical and follow-up data were studied retrospectively. RESULTS Four infants recovered spontaneously and could be weaned from mechanical ventilation within nine days without further treatment. Plication of the diaphragm was performed in 10 infants because of failure to wean from ventilatory support or serious persistent respiratory distress. Time between birth and plication ranged from 10 to 51 days, with a median of 19 days. Satisfactory respiratory outcome was achieved in 86% of the cases. CONCLUSIONS The minority of infants suffering from diaphragmatic paralysis due to perinatal phrenic nerve injury recovers spontaneously. Infants who fail to wean from ventilatory support and undergo early plication have a quick recovery and can be extubated successfully within a few days.
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Affiliation(s)
- Claire A I Stramrood
- Selective Utrecht Medical Master, University Medical Center Utrecht, Utrecht University, The Netherlands
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30
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Ross Russell RI, Helms PJ, Elliott MJ. A prospective study of phrenic nerve damage after cardiac surgery in children. Intensive Care Med 2008; 34:728-34. [DOI: 10.1007/s00134-007-0977-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2007] [Accepted: 09/02/2007] [Indexed: 09/29/2022]
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31
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Baker CJ, Boulom V, Reemtsen BL, Rollins RC, Starnes VA, Wells WJ. Hemidiaphragm plication after repair of congenital heart defects in children: Quantitative return of diaphragm function over time. J Thorac Cardiovasc Surg 2008; 135:56-61. [DOI: 10.1016/j.jtcvs.2007.09.031] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2007] [Revised: 08/16/2007] [Accepted: 09/20/2007] [Indexed: 11/28/2022]
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Lemmer J, Stiller B, Heise G, Alexi-Meskishvili V, Hübler M, Weng Y, Berger F. Mid-term follow-up in patients with diaphragmatic plication after surgery for congenital heart disease. Intensive Care Med 2007; 33:1985-92. [PMID: 17554521 DOI: 10.1007/s00134-007-0717-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2006] [Accepted: 04/06/2007] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Diaphragmatic palsy (DP) is a rare but severe complication after surgery for congenital heart disease. Transthoracic diaphragmatic plication is an effective means of treatment for those with respiratory impairment due to DP, but little is known about the mid-term effects of diaphragmatic plication. DESIGN We performed a study in 24 patients with history of DP. Diaphragm movement was assessed using ultrasound. Patients with DP who were old enough were additionally followed-up with lung function and exercise testing. A group of patients with similar age, diagnoses and operations served as controls. RESULTS Ultrasound showed that in the majority of cases with history of DP the paralysed diaphragm was static, independently of whether it was plicated or not. Patients with DP had a more restrictive lung function pattern (VC: 54.3 vs. 76.4% predicted, p<0.001; FEV(1): 58.4 vs. 86.2% predicted, p<0.001) and a lower exercise capacity compared with the control group (peak VO2: 24.5 vs. 31.3 ml/kg/min, p=0.03). Comparing patients with and without plication for DP, only a tendency towards lower lung function values in patients after diaphragmatic plication, but no differences regarding exercise capacity, could be found. CONCLUSIONS Our results provide evidence that DP is a serious surgical complication with a reduction in lung function and exercise capacity, even at mid-term follow-up; however, diaphragmatic plication, a useful tool in treating post-surgical DP in children with respiratory impairment, seems to be without mid-term risk in terms of recovery of phrenic nerve function, lung function values, and exercise capacity.
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Affiliation(s)
- Julia Lemmer
- Department of Congenital Heart Disease, Deutsches Herzzentrum Berlin, Augustenburger Platz 1, 13353 Berlin, Germany.
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Sivakumar K, Krishnan P, Pieris R, Francis E. Hybrid approach to surgical correction of tetralogy of Fallot in all patients with functioning Blalock Taussig shunts. Catheter Cardiovasc Interv 2007; 70:256-64. [PMID: 17503508 DOI: 10.1002/ccd.21126] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND In total surgical correction of tetralogy of Fallot (TOF) with functioning Blalock Taussig shunts (BTS), shunt take down increased surgical time, bleeding, and might injure phrenic and recurrent laryngeal nerve and thoracic duct. OBJECTIVES A routine hybrid approach using transcatheter BTS closure immediately before total surgical correction of TOF in all patients might reduce these problems. We analyze the safety and feasibility of this approach. METHODS Transcatheter BTS closure was achieved using single or multiple stainless steel embolization coils, Amplatzer vascular plugs, or duct occluders. When coils were released without control by bioptome forceps, coil migration in larger shunts was prevented by proximal or distal balloon occlusion. RESULTS This routine hybrid strategy was followed in 22 consecutive patients aged 1-13 years over 4-year-period and 21 procedures were successful. Among the 16 patients attempted with coils, 13 had successful closure, 2 needed Amplatzer duct occluder devices, and 1 sent for surgical shunt takedown due to acute angulation of the shunt. New Amplatzer vascular plugs were used in six patients. Bioptome was used in six patients and proximal or distal balloon occlusion of flow was used in three patients. Four patients had closure of associated aortopulmonary or chest wall collaterals. CONCLUSION Hybrid approach using routine transcatheter closure of all BTS immediately before surgical correction of TOF shunts with coils/plugs/devices is safe, feasible, and reproducible.
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Miller SG, Brook MM, Tacy TA. Reliability of two-dimensional echocardiography in the assessment of clinically significant abnormal hemidiaphragm motion in pediatric cardiothoracic patients: Comparison with fluoroscopy. Pediatr Crit Care Med 2006; 7:441-4. [PMID: 16738495 DOI: 10.1097/01.pcc.0000227593.63141.36] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assess the utility and reliability of echocardiographic assessment of hemidiaphragm motion abnormalities in pediatric cardiothoracic patients. DESIGN Retrospective observational study, with post hoc blinded assessment of echocardiographic and fluoroscopic results. SETTING Tertiary care center. PATIENTS Thirty-six consecutive pediatric cardiothoracic patients with suspected hemidiaphragm paralysis were identified and included in the study. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The results of both echocardiographic and fluoroscopic studies on all patients were included. In addition, blinded review of study results were performed. The sensitivity and specificity of fluoroscopy in identifying hemidiaphragms that needed plication were 100% and 74%, respectively. The positive predictive value was 55%; negative predictive value was 100%. Comparing reported diagnoses with blinded review of the studies showed poor agreement; reviewers agreed with 89% diagnosed as normal, 44% of paralyzed, and 76% of paradoxical hemidiaphragms. The sensitivity and specificity of echo in identifying hemidiaphragms that needed plication were 100% and 81%, respectively. The positive predictive value and negative predictive value were 66% and 100%. Comparing reported diagnoses with blinded review, reviewers agreed with 97% diagnosed as normal, 81% of paralyzed, and 100% of paradoxical hemidiaphragms. Echocardiography was less accurate in discriminating between paralyzed and paradoxical diaphragm motion. Echocardiography was specific for paradoxical motion, since both patients identified by echocardiography were confirmed by fluoroscopy, but it was not sensitive. In nine patients, echo showed paralyzed motion that was identified by fluoroscopy as paradoxical. CONCLUSIONS This study supports the use of echocardiography in the assessment of diaphragm function. When the diaphragms are clearly visualized by echo, as they are in the majority of cases, the addition of an additional fluoroscopic study adds no clinical value. The differentiation between paralyzed and paradoxical motion is unreliable by both imaging modalities.
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Affiliation(s)
- Stephen G Miller
- Division of Pediatric Cardiology, University of California at San Francisco, USA
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Lemmer J, Stiller B, Heise G, Hübler M, Alexi-Meskishvili V, Weng Y, Redlin M, Amann V, Ovroutski S, Berger F. Postoperative phrenic nerve palsy: early clinical implications and management. Intensive Care Med 2006; 32:1227-33. [PMID: 16741696 DOI: 10.1007/s00134-006-0208-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2005] [Accepted: 04/26/2006] [Indexed: 01/07/2023]
Abstract
OBJECTIVE We examined the clinical impact of diaphragmatic palsy (DP) as a result of phrenic nerve injury following cardiothoracic surgery, specifically its effects on morbidity and mortality, early regeneration capacity of the phrenic nerve, and role of surgical diaphragmatic plication. METHODS A retrospective case control study was performed in 74 children with DP and 74 matched controls after cardiothoracic surgery within the past 14 years. RESULTS Following 5,128 surgical procedures in children (aged under 18 years) we found an incidence of DP of 1.4%. There were no differences in mortality between the groups, and the cause of death was not related to DP or plication in any of the patients. However, patients with diaphragm impairment had significantly longer duration of mechanical ventilation (median 3 days vs. 1), ICU stay (7 days vs. 3.5), duration of hospital stay (16 days vs. 12), and for antibiotic treatment (16 days vs. 7). Because of prolonged respiratory problems 40 children (54%) underwent surgical diaphragmatic plication to flatten the diaphragm in its inspiratory position. In children with DP younger age was a strong predictor for plication (median 3.8 months vs. 12.1). CONCLUSIONS Especially in newborns and young infants with DP the length of mechanical ventilation, ICU stay, and hospital stay are prolonged. Early spontaneous recovery of the phrenic nerve is rare. In cases of respiratory impairment early transthoracic diaphragmatic plication is an effective means of treatment.
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Affiliation(s)
- Julia Lemmer
- Department of Congenital Heart Disease, Deutsches Herzzentrum Berlin, Augustenburger Platz 1, 13353 Berlin, Germany.
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Dagan O, Nimri R, Katz Y, Birk E, Vidne B. Bilateral diaphragm paralysis following cardiac surgery in children: 10-years' experience. Intensive Care Med 2006; 32:1222-6. [PMID: 16741697 DOI: 10.1007/s00134-006-0207-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2005] [Accepted: 04/26/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To review the incidence and complications of conservative management of bilateral diaphragm paralysis following pediatric cardiac surgery. DESIGN AND SETTING Retrospective clinical review based on computerized database with daily follow-up in a pediatric cardiac intensive care unit in a tertiary care center. PATIENT AND PARTICIPANTS: Were reviewed the data on nine patients with bilateral diaphragm paralysis from the 3,214 consecutive children (0.28%) after operations performed between 1995 and 2004. MEASUREMENTS AND RESULTS A fluoroscopy-confirmed diagnosis of bilateral diaphragm paralysis was made in all nine patients. Mechanical ventilation was required for 14-62 days; maximum time to recovery was 7 weeks. Three patients underwent unilateral plication. Patients with a complicated postoperative course required longer mechanical ventilation. All patients were managed with a nasotracheal tube. One patient had minor subglottic stenosis. All patients survived. CONCLUSIONS Bilateral diaphragm paralysis can be managed conservatively with good prognosis and minor complications. The recovery time is relatively short, less than 7 weeks.
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Affiliation(s)
- Ovadia Dagan
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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Hoskote A, Cohen G, Goldman A, Shekerdemian L. Tracheostomy in infants and children after cardiothoracic surgery: indications, associated risk factors, and timing. J Thorac Cardiovasc Surg 2005; 130:1086-93. [PMID: 16214524 DOI: 10.1016/j.jtcvs.2005.03.049] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2005] [Revised: 02/26/2005] [Accepted: 03/14/2005] [Indexed: 11/30/2022]
Abstract
BACKGROUND Respiratory insufficiency in children after cardiothoracic surgery delays weaning from the ventilator and prolongs intensive care unit stay. There is little consensus as to the indications for tracheostomy and its safety in this population. METHODS We reviewed our institutional experience in 37 consecutive infants and children (median age, 8.6 months; weight, 7.2 kg) requiring a tracheostomy after cardiothoracic surgery between January 1998 and December 2001, with follow-up to June 2003. RESULTS Twenty-four children underwent tracheostomy after corrective (n = 15) or palliative (n = 9) surgery for congenital heart disease, 8 had undergone thoracic transplantation, and 5 had undergone thoracic surgery. Median duration of pretracheostomy ventilation was 30 days, and median total duration of ventilation was 73 days. Tracheostomy was performed earlier in patients undergoing transplantation (median of 20 days postoperatively), with a duration of ventilation of 34 days. No patient experienced mediastinitis, and a wound infection in 1 child was the only identified complication. Twenty-two children survived to hospital discharge, of whom 15 have since been decannulated; 6 still have a tracheostomy in situ and 1 has been lost to follow-up. A number of preoperative and postoperative factors were identified in this cohort. These were preoperative respiratory insufficiency, a history of neonatal ventilation, the need for cardiac reoperations, diaphragmatic paralysis, tracheobronchomalacia, neurological comorbidity, and associated chromosomal abnormalities. CONCLUSION Tracheostomy can be performed safely and without increased risk of complications in infants and children early after cardiothoracic surgery. The presence of identifiable factors in patients in whom weaning has been unsuccessful should alert clinicians to early consideration of tracheostomy.
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Affiliation(s)
- Aparna Hoskote
- Cardiothoracic Unit, Great Ormond Street Hospital for Children, London, United Kingdom
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Willis BC, Graham AS, Wetzel R, L Newth CJ. Respiratory inductance plethysmography used to diagnose bilateral diaphragmatic paralysis: a case report. Pediatr Crit Care Med 2004; 5:399-402. [PMID: 15215015 DOI: 10.1097/01.pcc.0000124019.99266.b6] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To report the use of respiratory inductance plethysmography in the diagnosis and management for a case of bilateral diaphragmatic paralysis after repeated sternotomies in a 23-month-old child. DESIGN Case report. SETTING A 15-bed pediatric cardiothoracic intensive care unit in an academic children's hospital. INTERVENTIONS The patient could not be weaned from the ventilator after a repeat sternotomy for pulmonary artery reconstruction. Pulmonary function test results were within normal limits, and plain film radiography, ultrasonography, and fluoroscopy were unable to establish a definitive diagnosis. Evaluation of thoracoabdominal synchrony was undertaken using respiratory inductance plethysmography (RespiTrace). The work of breathing was assessed using esophageal manometry to obtain the pressure-rate product. RESULTS During spontaneous breathing, complete thoracoabdominal asynchrony was noted, with clockwise Konno-Mead loops and associated phase angles of nearly 180 degrees. The pressure-rate product was 120 cm H(2)O/min, indicating elevated work of breathing. The pressure-rate product decreased dramatically, as indicated by measurement and observation, in response to increased levels of continuous positive airway pressure. CONCLUSIONS The diagnosis of bilateral diaphragmatic paralysis can be confirmed by measurement of thoracoabdominal synchrony. Therapeutic and diagnostic application of continuous positive airway pressure may predict response to diaphragmatic plication. Controlled trials comparing measurement of thoracoabdominal synchrony with standard methods for the early diagnosis of diaphragmatic paralysis are needed.
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Affiliation(s)
- Brigham C Willis
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA 90027, USA.
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Eren S, Ceviz N, Alper F. Congenital diaphragmatic eventration as a cause of anterior mediastinal mass in the children: imaging modalities and literature review. Eur J Radiol 2004; 51:85-90. [PMID: 15186890 DOI: 10.1016/s0720-048x(03)00143-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2003] [Revised: 05/14/2003] [Accepted: 05/16/2003] [Indexed: 11/22/2022]
Abstract
Congenital eventration of the diaphragm, as a cause of mediastinal mass, is an unusual condition and it may be unilateral or bilateral. Although this entity is frequently asymptomatic and firstly detected on the chest radiography, it may be difficult to distinguish a partial eventration from the other diaphragmatic lesions or mediastinal pathologies on the chest radiographs. US may present valuable information about diaphragm integrity with eventration content or the other diaphragmatic pathologies. Although the other imaging modalities such as fluoroscopy, computed tomography, and MR imaging may be performed as adjunct techniques in cases of the diagnosis still in doubt, they are frequently unnecessary after US. Our goal is to present imaging features and management of this entity together with a literature review.
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Affiliation(s)
- Suat Eren
- Department of Radiology, Faculty of Medicine, Atatürk University, Erzurum, Turkey.
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Imai T, Shizukawa H, Imaizumi H, Matsumoto H. Transient phrenic nerve palsy after cardiac operation in infants. Clin Neurophysiol 2004; 115:1469-72. [PMID: 15134717 DOI: 10.1016/j.clinph.2004.01.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2004] [Indexed: 11/20/2022]
Abstract
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.
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Affiliation(s)
- Tomihiro Imai
- Department of Neurology, Sapporo Medical University School of Medicine, South 1, West 16, Chuo-ku, Sapporo 060-8543, Japan.
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Hüttl TP, Wichmann MW, Reichart B, Geiger TK, Schildberg FW, Meyer G. Laparoscopic diaphragmatic plication: long-term results of a novel surgical technique for postoperative phrenic nerve palsy. Surg Endosc 2004; 18:547-51. [PMID: 15108692 DOI: 10.1007/s00464-003-8127-8] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
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.
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Affiliation(s)
- T P Hüttl
- Department of Surgery, Klinikum Grosshadern, University of Munich, Marchioninistrasse 15, 81377 Munich, Germany.
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Abstract
BACKGROUND Diaphragm paralysis after cardiac surgery may be secondary to phrenic nerve injury by ice, electrocautery, or dissection. Although most are asymptomatic, some patients, particularly children, have significant respiratory compromise. Video-assisted plication may offer more rapid improvement and recovery than thoracotomy in pediatric patients. METHODS We performed five procedures. The diaphragm was elevated, clamped, oversewn, and tacked down into the pleural gutter. The procedure was performed on 2 infants after repair of total anomalous pulmonary venous connection, on 1 child after the Fontan procedure, on 1 child after repair of tetralogy of Fallot, and on 1 child with congenital eventration. Indications included ventilator dependency, post-Fontan protein losing enteropathy with elevated venous pressures and chronic right lower lobe collapse, persistent atelectasis with recurrent pneumonias, and asymptomatic severe eventration. RESULTS Ventilator-dependent patients were extubated after 2 and 3 days. The remaining patients were immediately extubated. One patient was discharged the day of surgery and 2 were discharged at 1 and 3 days postoperatively. The remaining 2 were discharged on postoperative day 30 and 45 after continued issues with feeding and prematurity. The child with the eventration had rapid expansion and growth of the left lung over the next few weeks with a normal chest radiograph 3 weeks later. The child with recurrent pneumonia reexpanded her left lower lobe and remains free of infection. There were no wound infections, lung or vascular injuries, or complications from the procedure. All the patients had successful flattening of the hemidiaphragm as documented by chest radiograph, with successful lung reexpansion. CONCLUSIONS Video-assisted plication of paralyzed diaphragms is effective and safe, involves less morbidity, and has quicker recovery times than traditional open techniques.
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Affiliation(s)
- Michael H Hines
- Department of Cardiothoracic Surgery, Brenner Children's Hospital, Wake Forest University/Baptist Medical Center, Winston-Salem, North Carolina 27157, USA.
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LoTempio MM, Shapiro NL. Tracheotomy tube placement in children following cardiothoracic surgery: indications and outcomes. Am J Otolaryngol 2002; 23:337-40. [PMID: 12430124 DOI: 10.1053/ajot.2002.126854] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To review the indications for and outcomes of children requiring tracheotomy tube placement following cardiothoracic surgery, charts were reviewed retrospectively at a tertiary care center for fifteen children who had undergone tracheotomy tube placement following cardiothoracic surgery between 1994 and 2000. Outcomes Measure: Morbidity and/or mortality associated with tracheotomy tube placement in this patient population, duration of tracheotomy tube, and rate of decannulation. RESULTS Fifteen out of approximately 3000 children undergoing cardiothoracic surgery required tracheotomy tube placement over a 6-year period. Indications included diaphragmatic paresis (DP) (7 patients), vocal cord paresis (VP) alone (3 patients), DP and VP (2 patients), subglottic stenosis (SS) and DP (1 patient), VP and SS (2 patients), and cerebrovascular infarct (1 patient). The mean age at the time of tracheotomy tube placement was 36.5 months (range, 0.75-108 months). The mean duration of intubation between cardiothoracic procedure and tracheotomy was 31.6 days (range, 0-72 days). Six patients were successfully decannulated following a mean of 7.4 months of tracheotomy tube dependence. All 6 decannulated patients had DP necessitating tracheotomy and ventilatory support. Eight patients continue to be tracheotomy tube-dependent, and one patient died of unrelated causes. There was no short-term or long-term morbidity or mortality associated with tracheotomy tube placement. CONCLUSION Tracheotomy tube placement is rarely indicated following cardiothoracic surgery in children. The most common indication is DP, which is usually transient. Most children will eventually be candidates for decannulation.
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Affiliation(s)
- Maria M LoTempio
- Division of Head and Neck Surgery, UCLA School of Medicine, 10833 LeConte Avenue, Los Angeles, CA 90095-1624, USA
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Simansky DA, Paley M, Refaely Y, Yellin A. Diaphragm plication following phrenic nerve injury: a comparison of paediatric and adult patients. Thorax 2002; 57:613-6. [PMID: 12096205 PMCID: PMC1746380 DOI: 10.1136/thorax.57.7.613] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND A study was undertaken to evaluate whether adults differ from children in the indications and outcome of diaphragmatic plication following phrenic nerve injury. METHODS A retrospective study was performed of 21 patients, 10 below the age of 5 and 11 older than 37 years. The indication for surgery for all the children was failure to wean from ventilatory support. The indications for surgery in the adult group were ventilator dependency (n=4) and symptomatic dyspnoea (n=7). All patients had at least one imaging study confirming diaphragmatic paralysis. The American Thoracic Society (ATS) dyspnoea scale, pulmonary function tests, and quantitative pulmonary perfusion scans were used as evaluation parameters. At surgery the diaphragm was centrally plicated. RESULTS One child died immediately after surgery due to irreversible heart failure and two children died within 2 months of surgery from ongoing complications of their original condition. These three patients were considered as selection failures. Seven children were weaned from ventilatory support within a median of 4 days (range 2-140). Only one of four ventilated adults was successfully weaned. Seven adults who underwent surgery for chronic symptoms had a marked subjective improvement of 2-3 levels in the ATS dyspnoea scale. Pulmonary function studies in the seven symptomatic adults showed a 40% improvement above baseline. Severely asymmetrical perfusion scans reverted to a normal pattern after plication. CONCLUSIONS Diaphragmatic plication offers a significant benefit to children with diaphragmatic paralysis and should be performed early to facilitate weaning from mechanical ventilation. While plication is of limited benefit in weaning ventilated adults, it results in significant subjective and objective lifetime improvement in non-ventilated symptomatic adults.
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Affiliation(s)
- D A Simansky
- Department of Thoracic Surgery, Sheba Medical Center, Tel Hashomer affiliated with Sackler Faculty of Medicine of Tel Aviv University, Israel
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Ip P, Chiu CSW, Cheung YF. Risk factors prolonging ventilation in young children after cardiac surgery: Impact of noninfectious pulmonary complications. Pediatr Crit Care Med 2002; 3:269-274. [PMID: 12780968 DOI: 10.1097/00130478-200207000-00013] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE: To determine risk factors for prolonged ventilation after cardiac surgery in young children and assess the impact of noninfectious pulmonary complications on ventilatory duration. DESIGN: Retrospective case series analysis. SETTING: A tertiary pediatric cardiac center. PATIENTS: Clinical records of 222 consecutive children aged </=3 yrs undergoing cardiac surgery for congenital heart disease were reviewed. Fifteen patients, consisting of six premature babies and nine who died within 72 hrs of surgery, were excluded. MEASUREMENTS AND MAIN RESULTS: The demographic data, preoperative risk factors, surgical procedures performed, intraoperative variables, and postoperative complications of the remaining 207 children were reviewed. Univariate analysis was performed to compare patients who required prolonged ventilation (>72 hrs) to those who could be extubated at </=72 hrs, and multivariate analyses were performed to identify significant determinants on ventilatory duration and impact of noninfectious complications. Of the 182 patients undergoing open heart surgery, 45 (25%) required prolonged ventilation for a median of 8 days. The latter were significantly younger in age and lighter in weight and were more likely to have Down syndrome, preoperative pulmonary hypertension and ventilatory support, undergone more complex surgery requiring longer bypass and circulatory arrest time, postoperative cardiovascular and pulmonary complications, and extubation failure (all p values <.01). Of the 25 patients who had closed heart surgery, five (20%) required prolonged ventilation for a median of 14 days. The latter were more likely to require preoperative ventilation, have undergone more complex surgery, had postoperative cardiovascular and pulmonary complications, and had extubation failure (all p values <.05). Cox proportional hazard regression identified body weight (p <.001), Down syndrome (p =.02), need for preoperative ventilation (p <.001), complexity of surgery (p <.001), cardiovascular complications (p <.001), and infective (p <.001) and noninfective (p <.001) pulmonary complications to be significant factors that determined the ventilatory duration. Noninfectious pulmonary complications occurred in 31.9% (58/182) and 20% (5/25) of patients after open and closed heart surgery, respectively. In the absence of other risk factors, the median time to extubation was similar between patients with and without noninfectious complications (1 vs. 0.8 day). However, in the presence of other risk factors, noninfectious pulmonary complications prolonged the median time to extubation from 8 to 18 days. Logistic regression identified Down syndrome (p =.005), preoperative ventilation (p =.001), complexity of surgery (p =.006), and bypass time (p =.005) as risk factors for development of noninfectious pulmonary complications. CONCLUSIONS: Noninfectious pulmonary complications that occurred commonly after cardiac surgery in young children prolong ventilatory duration only in the presence of other risk factors, with which it acts in a synergistic fashion.
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Affiliation(s)
- Patrick Ip
- Division of Paediatric Cardiology (PI, YFC), Department of Paediatrics and Division of Cardiothoracic Surgery, Department of Surgery, Grantham Hospital, The University of Hong Kong, Hong Kong, People's Republic of China
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Mogayzel PJ, Colombani PM, Crawford TO, Yang SC. Bilateral diaphragm paralysis following lung transplantation and cardiac surgery in a 17-year-old. J Heart Lung Transplant 2002; 21:710-2. [PMID: 12057707 DOI: 10.1016/s1053-2498(01)00385-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Bilateral diaphragm paralysis is a rare complication of lung transplantation. This report describes the development of chronic respiratory failure due to bilateral diaphragm paralysis following bilateral lung transplantation and closure of a patent foramen ovale. This patient required prolonged mechanical ventilation post-operatively; however, he eventually had adequate recovery of diaphragm function to wean from mechanical ventilation.
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Affiliation(s)
- Peter J Mogayzel
- Eudowood Division of Pediatric Respiratory Sciences, Johns Hopkins Hospital, Baltimore, Maryland 21287, USA.
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Affiliation(s)
- Masahito Sato
- Second Department of Surgery, Kansai Medical University, Osaka, Japan
| | - Yoshinori Hamada
- Second Department of Surgery, Kansai Medical University, Osaka, Japan
| | - Koshiro Hioki
- Second Department of Surgery, Kansai Medical University, Osaka, Japan
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Amin Z, McElhinney DB, Strawn JK, Kugler JD, Duncan KF, Reddy VM, Petrossian E, Hanley FL. Hemidiaphragmatic paralysis increases postoperative morbidity after a modified Fontan operation. J Thorac Cardiovasc Surg 2001; 122:856-62. [PMID: 11689788 DOI: 10.1067/mtc.2001.118506] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVES After a Fontan procedure, forward pulmonary blood flow is augmented during inspiration because of negative intrathoracic pressure. Total pulmonary blood flow is higher during inspiration. With hemidiaphragmatic paralysis, inspiratory augmentation of pulmonary flow is lost or diminished. The objective of this study was to compare early postoperative morbidity after the modified Fontan operation in patients with and without hemidiaphragmatic paralysis. METHODS A case-control analysis was performed comparing 10 patients with documented hemidiaphragmatic paralysis against 30 patients without paralysis who were matched for diagnosis, fenestration, and age. The following early postoperative outcomes were assessed: duration of ventilator support, duration of hospital stay, incidence of ascites, prolonged effusions, and readmission. RESULTS Preoperatively, there were no significant differences between the 2 groups. However, among the postoperative outcomes, the duration of hospital stay (25.4 +/- 16.6 days vs 10.8 +/- 6.3 days; P =.03), incidence of ascites (70% vs 3%; P <.001), prolonged pleural effusions (60% vs 13%; P =.007), and readmission (50% vs 7%; P =.007) were significantly greater in patients with hemidiaphragmatic paralysis than in those without hemidiaphragmatic paralysis. CONCLUSIONS Hemidiaphragmatic paralysis after the modified Fontan operation is associated with an increase in early morbidity. Care should be taken to avoid injury to the phrenic nerve. Patients with prolonged effusions should be evaluated for hemidiaphragmatic paralysis.
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Affiliation(s)
- Z Amin
- Joint Division of Pediatric Cardiology, University of Nebraska, Omaha 68114, USA.
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Escande B, Cerveau C, Kuhn P, Astruc D, Daemgen F, Messer J. [Phrenic nerve paralysis of obstetrical origin: favorable course using continuous positive airway pressure]. Arch Pediatr 2000; 7:965-8. [PMID: 11028205 DOI: 10.1016/s0929-693x(00)90012-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Isolated diaphragmatic paralysis due to obstetrical factors is rare and therapeutic management modalities are not quite clear. CASE REPORT A neonate born by breech delivery presented with respiratory distress due to isolated paralysis of the right hemidiaphragm. The clinical course was progressive, his condition worsening with oxygen supplementation. Continuous positive airway pressure (CPAP) delivered via a nasal cannula was started in the one-month-old child, inducing gradual improvement towards recovery at the age of two months and a half. CONCLUSION Non-invasive nasal CPAP should be proposed for the treatment of phrenic nerve obstetrical palsy before introducing more invasive ventilation techniques. Surgical plication should be delayed until the child reaches the age of at least three months.
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Affiliation(s)
- B Escande
- Pédiatrie II, médecine néonatale et réanimation pédiatrique, hôpital de Hautepierre, Strasbourg, France
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Abstract
A case of acquired diaphragmatic paralysis in an extremely low birth weight infant complicated by respiratory failure, recurrent atelectasis, and pneumonia is described. Diaphragmatic plication led to a rapid improvement in pulmonary function and allowed for discontinuation of mechanical ventilation in less than 1 week. Therapeutic options for acquired diaphragmatic paralysis, including the rationale for early operative intervention, in this patient population are discussed.
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Affiliation(s)
- P G Gallagher
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA
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