Results of diaphragmatic plication for unilateral diaphragmatic paralysis

Minimally-Invasive Diaphragmatic Plication in Patients with Unilateral Diaphragmatic Paralysis

Background: Diaphragm eventration (DE) represents a frequent problem with consecutive major impacts on respiratory function and the quality of life of the patients. The role of diaphragmatic plication (DP) is still underestimated. The aim of the present study is to evaluate the efficacy of minimally-invasive surgical diaphragmatic plication for the management of unilateral diaphragmatic eventration, to the best of our knowledge, this is the largest series reported in the literature using a non-resectional technique. Methods: All patients with unilateral diaphragmatic paralysis admitted for diaphragmatic plication (DP) between January 2008 and December 2022 formed the cohort of this retrospective analysis. DP procedure was done to plicate the diaphragm without resection or replacement with synthetic materials. Patients were divided into two groups: Group I included patients who underwent DP through an open thoracotomy, and Group II included patients who underwent DP through video-assisted thoracoscopic surgery (VATS). Data from all patients were collected prospectively and subsequently analyzed retrospectively. Patients' characteristics, lung function tests, radiological findings, type of surgical procedures, complications, and postoperative follow-up were compared. The primary outcome measure was the postoperative result (deeper position of the paralyzed diaphragm) and improvement of dyspnea. The secondary outcome was lung function values over a long-term follow-up. Results: The study included a total of 134 patients who underwent diaphragmatic plication during the study period. 94 (71.7%) were males, mean age of 64 (SD ± 14.0). Group I (thoracotomy group) consisted of 46 patients (35 male). Group II (VATS-group) consisted of 88 patients (69 male). The majority of patients demonstrated impaired lung functions (n = 126). The mean length of diaphragmatic displacement was 8 cm (SD ± 113.8 cm). The mean duration of the entire procedure, including placement of the epidural catheter (EDC), was longer in group I than in group II (p = 0.016). This was also observed for the mean length of the surgical procedure itself (p = 0.031). Most patients in group I had EDC (n = 38) (p = 0.001). Patients in group I required more medication for pain control (p = 0.022). A lower position of the diaphragm was achieved in all patients (p < 0.001). The length of hospital stay was 7 (SD ± 4.5) days in group I vs. 4.5 (SD ± 3.2) days in group II (p = 0.036). Minor complications occurred in 3% (n = 4) in group I vs. 2% (n = 3) in group II. No mortality was observed in any of the groups. Postoperative follow-up of patients at 6, 12, and 24 months showed a significant increase in forced vital capacity (FVC) up to 25% (SD ± 10%-35%) (p = 0.019), in forced expiratory volume in 1 s (FEV1) up to 20% (SD ± 12%-38%) in both groups (p = 0.026), also in the diffusion capacity of carbon monoxide (DLCO) up to 15% (SD ± 10%-20%) was noticed in both groups. Chronic pain symptoms were noted in 13% (n = 6) in group I vs. 2% (n = 2) in group II (p = 0.014). Except for one patient in group II, no recurrence of DE was observed. Conclusions: Diaphragm plication is an effective procedure to reduce debilitating dyspnea and improve lung function in patients suffering from diaphragm eventration. Minimally invasive diaphragmatic plication using VATS procedures is a safe and feasible procedure for the management of unilateral diaphragmatic paralysis. VATS-DP is superior to open procedure in terms of pain management and length of hospital stay, hence, accelerated recovery is more likely. Careful patient selection is crucial to achieving optimal outcomes. Prospective studies are needed to validate these results.

Diaphragmatic paralysis post COVID-19 treated with robot-assisted plication reinforced with acellular dermal matrix: a report of two cases

Coronavirus disease 2019 (COVID-19) continues to be a disease of global importance, with an increasing array of sequelae attributed to infection by the severe acute respiratory syndrome coronavirus-2. One such complication that has been rarely documented thus far is diaphragmatic dysfunction. Here, we report the cases of 2 individuals who developed diaphragmatic paralysis post COVID-19, which failed to respond to conservative management. Both patients proceeded to undergo robot-assisted thoracoscopic plication of the diaphragm reinforced with a bovine acellular dermal matrix. In both cases, there was significant improvement in symptomatology, namely dyspnoea and fatigue. We conclude that robot-assisted diaphragmatic plication should be considered for the treatment of refractory diaphragmatic paralysis post COVID-19.

Phrenic Nerve Dysfunction Secondary to Cervical Neuroforaminal Stenosis: A Literature Review

BACKGROUND

Phrenic nerve dysfunction has been associated with cervical neuroforaminal stenosis in limited case reports and case-controlled studies. It is unclear if magnetic resonance imaging of the cervical spine should be included in the workup of patients with pulmonary dysfunction. A systematic review of the current literature was conducted on the topic to provide an outline of the body of knowledge and some guidance for neurosurgeons that receive these patient referrals.

METHODS

A systematic literature review was conducted through the PubMed database to identify articles related to phrenic nerve dysfunction secondary to cervical stenosis.

RESULTS

A total of 12 case reports were found. The median subject age was 64 years, 11 were male. Presenting symptoms included shortness of breath (n = 9), radiculopathy (n = 7), myelopathy (n = 5), reduced pulmonary function (n = 6), weakness (n = 4), and neck pain (n = 5). Ten of these patients underwent surgical intervention, all having improvements in their pulmonary and neurological symptoms at follow-up ranging from 10 days to 2 years.

CONCLUSIONS

Cervical stenosis, resulting in neuroforaminal stenosis, may be related to phrenic nerve dysfunction in select patients with idiopathic diaphragmatic paralysis or pulmonary dysfunction. Surgical decompression improves pulmonary and neurological symptoms.

Minimally Invasive Diaphragm Plication for Acquired Unilateral Diaphragm Paralysis: A Systematic Review

Objective: Diaphragm paralysis is a relatively uncommon entity that can be both congenital and acquired in nature. While commonly asymptomatic, it can also cause a significant decrease in pulmonary function and reserve, particularly in patients with underlying pulmonary diseases. Our aim was to summarize the current literature regarding the minimally invasive techniques used in the surgical correction of acquired diaphragm paralysis via traditional and robotic minimally invasive approaches. Methods: We conducted a systematic review of available literature using the Cochrane methodology and reported findings according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards. Results: A total of 6,561 citations were identified through initial database and reference searches, of which 90 articles met the inclusion criteria for review. After further assessment, 33 appropriate full-text studies were selected for the review. Of the selected publications, the majority represented case reports and single-center retrospective studies with level of evidence 4. Only 1 level 2b study (individual cohort study) was identified, comparing minimally invasive and open approaches. Conclusions: Each of the minimally invasive approaches has its unique benefits and disadvantages, which are summarized and delineated in this article. Ultimately, no preferred method of diaphragm plication for diaphragm paralysis can be recommended at this time based on clinical data. The choice of procedure and surgical approach continues to be selected based on the surgeon's experience and preference.

Phrenic nerve paralysis and phrenic nerve reconstruction surgery

Phrenic nerve injury results in paralysis of the diaphragm muscle, the primary generator of an inspiratory effort, as well as a stabilizing muscle involved in postural control and spinal alignment. Unilateral deficits often result in exertional dyspnea, orthopnea, and sleep-disordered breathing, whereas oxygen or ventilator dependency can occur with bilateral paralysis. Common etiologies of phrenic injuries include cervical trauma, iatrogenic injury in the neck or chest, and neuralgic amyotrophy. Many patients have no identifiable etiology and are considered to have idiopathic paralysis. Diagnostic evaluation requires radiographic and pulmonary function testing, as well as electrodiagnostic assessment to quantitate the nerve deficit and determine the extent of denervation atrophy. Treatment for symptomatic diaphragm paralysis has traditionally been limited. Medical therapies and nocturnal positive airway pressure may provide some benefit. Surgical repair of the nerve injury to restore functional diaphragmatic activity, termed phrenic nerve reconstruction, is a safe and effective alternative to static repositioning of the diaphragm (diaphragm plication), in properly selected patients. Phrenic nerve reconstruction has increasingly become a standard surgical treatment for diaphragm paralysis due to phrenic nerve injury. A multidisciplinary approach at specialty referral centers combining diagnostic evaluation, surgical treatment, and rehabilitation is required to achieve optimal long-term outcomes.

Minimally Invasive Plication of the Diaphragm: A Single-Center Prospective Study

OBJECTIVE

Plication of the diaphragm is a life-changing procedure for patients affected by diaphragm paralysis. Traditionally, this procedure is performed through a thoracotomy. Access to the diaphragm via this incision is poor and the indications for surgery are limited to patients who can actually sustain such an invasive approach and associated morbidities. A minimally invasive approach was developed to improve the surgical management of diaphragm paralysis.

METHODS

Patients underwent minimally invasive diaphragm plication either by video-assisted or robotic surgery through a 3-port technique with CO₂ insufflation. Patients were followed at the routine 6-week clinic and also by telephone consultation 6 to 12 months postoperatively. Data were collected on postoperative complications, postoperative pain or numbness, symptomatic improvement, and change to quality of life following surgery.

RESULTS

Forty-eight patients underwent 49 minimally invasive diaphragm plication. Median postoperative length of hospital stay was 4 days (range: 2 to 34 days) and there were no cases of mortality. Mean reduction in Medical Research Council dyspnea score per patient was 2.2 points (mode: 3 points). Twenty-eight patients (77.8%) reported a significant symptomatic improvement enabling improvements in quality of life, and 97.2% (n = 35) were satisfied with the surgical outcome.

CONCLUSIONS

Minimally invasive diaphragm plication is a safe procedure associated with prompt postoperative recovery. It is effective at reducing debilitating dyspnea and improving quality of life.

Treatment for bilateral diaphragmatic dysfunction using phrenic nerve reconstruction and diaphragm pacemakers

OBJECTIVES

Bilateral diaphragmatic dysfunction results in severe dyspnoea, usually requiring oxygen therapy and nocturnal ventilatory support. Although treatment options are limited, phrenic nerve reconstruction (PR) offers the opportunity to restore functional activity. This study aims to evaluate combination treatment with PR and placement of a diaphragm pacemaker (DP) compared to DP placement alone in patients with bilateral diaphragmatic dysfunction.

METHODS

Patients with bilateral diaphragmatic dysfunction were prospectively enrolled in the following treatment algorithm: Unilateral PR was performed on the more severely impacted side with bilateral DP implantation. Motor amplitudes, ultrasound measurements of diaphragm thickness, maximal inspiratory pressure, forced expiratory volume, forced vital capacity and subjective patient-reported outcomes were obtained for retrospective analysis following completion of the prospective database.

RESULTS

Fourteen male patients with bilateral diaphragmatic dysfunction confirmed on chest fluoroscopy and electrodiagnostic testing were included. All 14 patients required nocturnal ventilator support, and 8/14 (57.1%) were oxygen-dependent. All patients reported subjective improvement, and all 8 oxygen-dependent patients were able to discontinue oxygen therapy following treatment. Improvements in maximal inspiratory pressure, forced vital capacity and forced expiratory volume were 68%, 47% and 53%, respectively. There was an average improvement of 180% in motor amplitude and a 50% increase in muscle thickness. Comparison of motor amplitude changes revealed significantly greater functional recovery on the PR + DP side.

CONCLUSIONS

PR and simultaneous implantation of a DP may restore functional activity and alleviate symptoms in patients with bilateral diaphragmatic dysfunction. PR plus diaphragm pacing appear to result in greater functional muscle recovery than pacing alone.

Is the pleating technique superior to the invaginating technique for plication of diaphragmatic eventration in infants?

BACKGROUNDS

The pleating technique is widely used in plication but is difficult to perform with thoracoscopy because of its complex procedure and the limited surgical space. Thus, the invaginating technique was introduced to facilitate thoracoscopic surgery and is now widely used in video-assisted thoracoscopic surgery (VATS) plication. However, the usefulness of the invaginating technique in children has not been established because of the lack of data on long-term outcomes after surgery using the technique.

METHODS

From March 2007 to December 2017, 21 patients who were surgically treated for congenital diaphragmatic eventration and phrenic nerve palsy after congenital cardiac surgery were divided into 2 groups according to the surgical method used (pleating technique: 10 patients, invaginating technique: 11 patients). We evaluated the patients for postoperative outcomes and recurrence of diaphragmatic eventration over 5 years. Postoperative recurrence of diaphragmatic eventration was confirmed by calculating the ratio of the eventration level between the eventrated and normal diaphragms.

RESULTS

In the 21 patients who underwent diaphragmatic plication, the pleating and invaginating techniques were used in 10 and 11 patients, respectively. The mean follow-up duration was 63.4 ± 48.4 months (pleating group [P] vs invaginating group [I]: 89.1 ± 52.4 vs 40.1 ± 30.8 months, p = 0.022). The mean eventration rates in the 21 patients was 26.7% ± 9.1% (P vs I: 26.6% ± 6.1% vs 26.9% ± 11.3%, p = 0.945) before operation and -2.1% ± 7.3% (-2.8% ± 7.5% vs -1.5% ± 7.4%, p = 0.695) in the immediate postoperative period. From the first to the fifth postoperative year, no recurrence of diaphragmatic eventration was found in any of the groups during the follow-up.

CONCLUSIONS

The invaginating technique was easier to perform but showed a similar long-term result as compared with the pleating technique in terms of the growth and development of the chest cavity in the pediatric patients in this study. Thus, we recommend that the invaginating technique be applied in VATS plication for children as an alternative to the pleating technique.

LEVEL OF EVIDENCE

Level III.

[Diaphragm relaxation surgery]

AIM

To develop examination algorithm and to determine the indications for various options for surgical treatment.

MATERIAL AND METHODS

It is presented analysis of surgical treatment of 25 patients with unilateral diaphragm relaxation for the period from 1963 to 2016. There were 15 men and 10 women aged from 39 to 65 years. Diagnosis included predominantly radiological methods. All patients were operated openly through thoracotomy. Procedure consisted of creation of new diaphragmatic cupola at the usual level with two flaps of diaphragm and prosthesis between them. In 12 (48%) patients who were operated before 1990 xenopericardial patch was used. Further, synthetic materials (Teflon, polypropylene) were preferred.

RESULTS

Postoperative morbidity and mortality was 20% (n=6) and 4% (n=1) respectively. Long-term results were followed-up within terms from 8 months to 12 years. Recurrent relaxation was absent. Most of patients had improved dyspnea, increased vital capacity and FEV1 in long-term period. Certain and general values of SF-36 life quality questionnaire were high in long-term postoperative period and similar to those in general population.

Best Approach and Benefit of Plication for Paralyzed Diaphragm

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

Thoracoscopic plication for idiopathic eventration of the bilateral diaphragm: Report of a case

INTRODUCTION

Diaphragmatic eventration, defined as permanent elevation of the diaphragm without defects, is a rare anomaly in adults. Trauma, neoplasms, infection, and degenerative disease are the most common causes of this condition, whereas idiopathic eventration of the diaphragm is relatively infrequent.

PRESENTATION OF CASE

We herein present the rare case of an 85-year-old female with idiopathic eventration of the bilateral diaphragm. The patient demonstrated a rapidly progressive course with dyspnea; therefore, thoracoscopic surgery of the unilateral diaphragm was performed. She subsequently withdrew from home oxygen therapy, which had introduced preoperatively, and exhibited a significant improvement in her pulmonary function for one year after the operation.

DISCUSSION

Various approaches for diaphragmatic plication have been reported, including open (transthoracic or transabdominal) and minimally invasive methods, such as thoracoscopic or laparoscopic plication. We consider thoracoscopic plication to be an effective minimally invasive method, although single-lung ventilation is required.

CONCLUSION

We experienced a case in which thoracoscopic plication of the unilateral diaphragm resulted in adequate objective improvements in the pulmonary function in a patient with idiopathic eventration of the bilateral diaphragm.

Diaphragmatic hernia after liver transplantation in children: case series and review of the literature

A diaphragmatic hernia (DH) is a rare complication of pediatric liver transplantation (LT), with multiple factors implicated in the pathophysiology. It is a potentially life-threatening condition in the absence of early recognition and surgical treatment. A DH after LT has been reported in 16 patients in 7 case series. We report 10 cases from our institution and review the published literature to understand the underlying pathophysiology. The study sample included all children (<18 years of age) who underwent LT from October 1989 to August 2013 at our center and subsequently presented with a DH. Among 4433 LT procedures performed in this time period, 1032 were for children. Ten DH cases were recognized, and risk factors were assessed. The mean age at diagnosis was 4.9 years, all patients with a DH received left lateral segment split grafts, and the mean graft weight was 248 ± 41 g with a mean graft-to-recipient body weight ratio (GBWR) of 3% ± 1.22% (range = 1.7%-5.0%). The mean cold ischemia time was 510.7 ± 307.6 minutes (range = 60-900 minutes). Six patients had a primary abdominal muscle closure, 3 had a temporary Silastic mesh closure, and 1 had a skin closure only. Postoperative ascites and pleural effusion did not appear to be significant risk factors. All 10 children presented with a right posterolateral DH, with 1 also having a left DH. The small bowel was herniated in the majority. All patients underwent prompt surgical intervention without complications. An early age, a split graft, and a high GBWR may be risk factors for a DH. A high index of suspicion and prompt surgical intervention minimize complications.

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

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

[Diaphragmatic palsy and dysfunction: from physiology to surgery]

The clinical presentations of diaphragm dysfunctions vary according to etiologies and unilateral or bilateral diseases. Elevation of the hemidiaphragm from peripheral origins, the most frequent situation, requires a surgical treatment only in case of major functional impact. Complete morphological and functional analyses of the neuromuscular chain and respiratory tests allow the best selection of patients to be operated. The surgical procedure may be proposed only when the diaphragm dysfunction is permanent and irreversible. Diaphragm plication for eventration through a short lateral thoracotomy, or sometimes by videothoracoscopy, is the only procedure for retensioning the hemidiaphragm. This leads to a decompression of intrathoracic organs and a repositioning of abdominal organs without effect on the hemidiaphragm active contraction. Morbidity and mortality rates after diaphragm plication are very low, more due to the patient's general condition than to surgery itself. Functional improvements after retensioning for most patients with excellent long-term results validate this procedure for symptomatic patients. In case of bilateral diseases, very few bilateral diaphragm plications have been reported. Some patients with diaphragm paralyses from central origins become permanently dependent on mechanical ventilation whereas their lungs, muscles and nerves are intact. In patients selected by rigorous neuromuscular tests, a phrenic pacing may be proposed to wean them from respirator. Two main indications have been validated: high-level tetraplegia above C3 and congenital alveolar hypoventilation from central origin. After progressive reconditioning of the diaphragm muscles following phrenic pacing at thoracic level, more than 90% of patients can be weaned from respirator within a few weeks. This weaning improves the quality of life with more physiological breathing, restored olfaction, better sleep and better speech. The positive impact of diaphragm stimulation has also been evaluated in other degenerative neurological diseases, particularly the amyotrophic lateral sclerosis. For either central or peripheral diaphragm dysfunctions, a successful surgical treatment lies on a strict preoperative selection of patients.

Diaphragmatic plication offers functional improvement in dyspnoea and better pulmonary function with low morbidity

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was as follows: In adults with unilateral diaphragmatic paralysis, does diaphragmatic plication offer functional improvement in dyspnoea, better pulmonary function tests (PFTs) and return to activity? A total of 126 papers were found using the reported search, of which 13 represented the best evidence to answer the clinical question. The authors, date and country of publication, patient group studied, surgical approach, study type, relevant outcomes and results of these articles are tabulated. Those articles reporting improvement in PFTs following plication, documented this benefit in the following parameters: mean forced vital capacity (range 17-40%), forced expiratory volume at 1 sec (range 21-27%), functional residual capacity (range 20-21%) and total lung capacity (range 16-19%). The percentage of postoperative improvement in shortness of breath as measured by a dyspnoea score was reported to be between 90 and 96% in the thoracotomy group and 100% in the Video Assisted Thoracoscopic Surgery (VATS) group, the dyspnoea score that was used in all the studies was a visual analogue scale between 0 and 10 where 0 is no dyspnoea and 10 is the worst dyspnoea a patient can have. One of the studies reported postoperative normalization in ventilation perfusion scan (VQ) scan parameters when compared with the preoperative mismatch. Complication rate was similar between the two groups, while the mortality rate was 4% in the thoracotomy group and 0% in the VATS group. The total number of patients included in all the studies combined was 161. All reports included in this review are observational studies (one cohort study and the remainder being case series); therefore, the risk of selection, information and publication biases are high and conclusions should be implemented with caution. We conclude that diaphragmatic plication can improve the functional status, shortness of breath and PFTs of patients with unilateral diaphragm paralysis. Patients undergoing a VATS approach appear to have more advantages in objective and subjective measures (including PFTs, dyspnoea score, length of hospital stay and postoperative complications). Further research with high-quality study designs is advised, focussing mainly on the long-term benefits and assessment of health-related quality of life.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

[Surgical treatment of diaphragmatic eventrations and paralyses]

Surgical treatment of eventration or paralysis of the diaphragm is symptomatic and non curative, and depends on whether the dysfunction is of peripheral or central origin. Elevation of a hemidiaphragm of peripheral origin, the most frequent situation, needs surgical treatment only in case of major functional effects (effort or positional dyspnoea, cardiac or digestive symptoms, or pain) that persists despite optimal conservative management. Selection of candidates for surgery depends on a thorough morphological and functional investigation of the neuromuscular and respiratory components. Surgical plication of the diaphragm through a lateral thoracotomy or by video-thoracoscopy is a recognized, safe and effective procedure. Its low morbidity and mortality, which are mainly associated with co-morbid factors, and its long-lasting functional benefit of around 100%, show that it is an effective procedure. In the case of bilateral dysfunction, occasional cases of bilateral plication have been reported. Some cases of diaphragmatic paralysis of central causation result in a life of ventilator dependence, even though the peripheral neuromuscular and respiratory systems are intact. In selected cases, following a complete functional investigation, phrenic nerve pacing may be attempted to achieve ventilator weaning. To date, there are two validated indications for this technique: Tetraplegia above C3 and alveolar hypoventilation of central cause. After thoracic implantation, a progressive reconditioning of the diaphragmatic muscle allows weaning from the ventilator in a few weeks in more than 90% of patients. Their quality of life is greatly improved thanks to independence from the ventilator, more physiological respiration, restoration of smell and better speech. Whether the diaphragmatic dysfunction is peripheral or central in origin, the success of surgical treatment depends on rigorous preoperative selection of patients.

Diaphragmatic eventration

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

Ipsilateral diaphragmatic motion and lung function in long-term pneumonectomy patients

BACKGROUND

The physiologic advantages of preserving phrenic nerve integrity and normal diaphragmatic motion (DM) during the course of pnemonectomy are incompletely understood. This study was conducted to investigate potential benefits of this strategy on postoperative lung function.

METHODS

Among 523 consecutive patients who underwent pneumonectomy for lung cancer between January 1992 and September 2001, 117 were alive at the time of study (March to December 2006) and thus had 5 years' minimum follow-up. Of those, 17 were excluded and 12 could not have magnetic resonance imaging (MRI), leaving 88 patients available for study. Diaphragmatic motion was assessed by MRI during deep breathing, and patients were classified as having normal and synchronous diaphragmatic motion (n = 44) or abnormal diaphragmatic motion (immobile or paradoxical, n = 44). These findings were correlated with expiratory volume measurements, gas exchange (arterial blood gases), and exercise tolerance (6-minute walk test).

RESULTS

The mean follow-up time was 9.3 years. Patients with abnormal DM were younger than patients with normal DM and were more likely to have had a right or an extended pneumonectomy (p < 0.01). Despite comparable preoperative lung function, patients with abnormal DM had significantly worse postoperative lung volumes (forced expiratory voume in 1 second, forced vital capacity, lung diffusion capacity for carbon monoxide; p < 0.01) and exercise capacity (6-minute walk test, percent predicted, p < 0.05) than patients with normal DM.

CONCLUSIONS

Because the long-term effects of a paralyzed hemidiaphragm in pneumonectomy patients are characterized by significant alterations in lung function, all surgeons doing this type of work should take every precaution to avoid technical errors that could lead to phrenic nerve injury or interruption.

Diaphragm plication in adult patients with diaphragm paralysis leads to long-term improvement of pulmonary function and level of dyspnea

OBJECTIVE

There is still controversy about the feasibility and long-term outcome of surgical treatment of acquired diaphragm paralysis. We analyzed the long-term effects on pulmonary function and level of dyspnea after unilateral or bilateral diaphragm plication.

METHODS

Between December 1996 and January 2006, 22 consecutive patients underwent diaphragm plication. Before surgery, spirometry in both seated and supine positions and a Baseline Dyspnea Index were assessed. The uncut diaphragm was plicated as tight as possible through a limited lateral thoracotomy. Patients with a follow-up exceeding 1 year (n=17) were invited for repeat spirometry and assessment of changes in dyspnea level using the Transition Dyspnea Index (TDI).

RESULTS

Mean follow-up was 4.9 years (range 1.2-8.7). All spirometry variables showed significant improvement. Mean vital capacity (VC) in seated position improved from 70% (of predicted value) to 79% (p<00.03), and in supine position from 54% to 73% (p=0.03). Forced expiratory volume in 1s (FEV1) in supine position improved from 45% to 63% (p=0.02). Before surgery the mean decline in VC changing from seated to supine position was 32%. At follow-up this had improved to 9% (p=0.004). For FEV1 these values were 35% and 17%, respectively (p<0.02). TDI showed remarkable improvement of dyspnea (mean+5.69 points on a scale of -9 to +9).

CONCLUSION

Diaphragm plication for single- or double-sided diaphragm paralysis provides excellent long-term results. Most patients were severely disabled before surgery but could return to a more or less normal way of life afterwards.

Mid-term follow-up in patients with diaphragmatic plication after surgery for congenital heart disease

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.

Intraoperative diaphragmatic plication during coronary artery bypass

Diaphragmatic paralysis following coronary artery bypass grafting (CABG), while often benign, can sometimes require plication. This paper describes the first reported case of intraoperative (CABG) pulmonary plication for a patient with prior diaphragmatic paralysis.

Functional and Physiologic Results of Video-Assisted Thoracoscopic Diaphragm Plication in Adult Patients With Unilateral Diaphragm Paralysis

BACKGROUND

Plication of the hemidiaphragm for unilateral diaphragm paralysis is infrequently performed in adults. Barriers to diaphragm plication have included the perceived need for thoracotomy and uncertainty of the potential benefits. The purpose of this investigation was to assess the effects of video-assisted thoracoscopic diaphragm plication in symptomatic adult patients with unilateral diaphragm paralysis.

METHODS

Patients with unilateral diaphragm paralysis underwent an evaluation that included a chest radiograph, fluoroscopic sniff test, pulmonary spirometry, and the Medical Research Council (MRC) dyspnea score. Patients with symptomatic unilateral diaphragm paralysis present for at least 6 months were offered video-assisted thoracoscopic diaphragm plication. Patients who underwent diaphragm plication as well as those who declined surgery were reassessed at 6 months with a chest radiograph, spirometry, and the MRC dyspnea score.

RESULTS

Twenty-five patients underwent left (19) or right (6) diaphragm plication through video-assisted thoracoscopic diaphragm plication (22) or thoracotomy (3). There were no operative deaths. Mean hospital length of stay for diaphragm plication was 3.7 days for video-assisted thoracoscopic diaphragm plication and 5.4 days for thoracotomy. After diaphragm plication, mean forced vital capacity, forced expiratory volume at 1 second, functional residual capacity, and total lung capacity improved by 17%, 21.4%, 20.3%, and 16.1%, respectively (p < 005) at 6 months. Mean MRC dyspnea scores also significantly improved in the operative cohort (p < 0001). Seventeen patients in the surgical cohort had returned to work at 6 months. Seven patients treated without surgery displayed a trend toward more frequent hospitalizations and deteriorating pulmonary spirometry and MRC dyspnea scores during the follow-up period.

CONCLUSIONS

Plication of the hemidiaphragm using minimally invasive techniques produced significant improvements in patients' functional status, pulmonary spirometry, and MRC dyspnea scores. Video-assisted thoracoscopic diaphragm plication should be considered appropriate therapy in symptomatic adult patients with unilateral diaphragm paralysis.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Determinants of diaphragm motion in unilateral diaphragmatic paralysis

Cranial displacement of a hemidiaphragm during sniffs is a cardinal sign of unilateral diaphragmatic paralysis in clinical practice. However, we have recently observed that isolated stimulation of one phrenic nerve in dogs causes the contralateral (inactive) hemidiaphragm to move caudally. In the present study, therefore, we tested the idea that, in unilateral diaphragmatic paralysis, the pattern of inspiratory muscle contraction plays a major role in determining the motion of the inactive hemidiaphragm. We induced a hemidiaphragmatic paralysis in six anesthetized dogs and assessed the contour of the diaphragm during isolated unilateral phrenic nerve stimulation and during spontaneous inspiratory efforts. Whereas the inactive hemidiaphragm moved caudally in the first instance, it moved cranially in the second. The parasternal intercostal muscles were then severed to reduce the contribution of the rib cage muscles to inspiratory efforts and to enhance the force generated by the intact hemidiaphragm. Although the change in pleural pressure (DeltaPpl) was unaltered, the cranial displacement of the paralyzed hemidiaphragm was consistently reduced. A pneumothorax was finally induced to eliminate DeltaPpl during unilateral phrenic nerve stimulation, and this enhanced the caudal displacement of the inactive hemidiaphragm. These observations indicate that, in unilateral diaphragmatic paralysis, the motion of the inactive hemidiaphragm is largely determined by the balance between the force related to DeltaPpl and the force generated by the intact hemidiaphragm.

Long term results of diaphragmatic plication for unilateral diaphragm paralysis

OBJECTIVES

To examine whether diaphragmatic plication is an effective and lasting treatment option for non-malignant diaphragmatic paralysis.

METHODS

Nineteen patients who had undergone diaphragm plication (1983-1990) were recalled for interview, pulmonary function testing and chest X-ray.

RESULTS

There were 13 men and six women aged 24-73 (mean 55). Diaphragm paralysis was idiopathic (n=9), postsurgical (n=3), related to cervical spondylosis (n=4) and neck injury (n=2). Patients presented with breathlessness (18/19) or orthopnoea (1/19). Symptoms had lasted 3-60 months (mean 24 months). All patients had a raised hemidiaphragm on chest X-ray with paradoxical movement on ultrasound. Mean preoperative FVC was 71% predicted (range 38-93, SD 12.9) and mean FEV(1) was 67% predicted (range 33-90, SD 10.8). Supine lung volumes were 81% (mean) of sitting values. There were six right plications and 13 left. There were no postoperative deaths. One patient required re-plication. Follow-up (18/19 of original operated patients) ranged from 7-14 years (mean 10 years). Three patients had died of unrelated causes and one patient failed to attend long term follow-up, leaving 15 patients of the original 19 operated on. Positional change in lung volumes was not affected by surgery at early (6 week) or late (>5 year) follow-up. FVC, FEV(1), FRC and TLC improved by 10.1*, 11.8*, 16.9* and 9.2*%, respectively, at early follow-up and 11.8*, 15.4*, 26 and 13.3*% at late follow-up (*P<0.005 signed rank). Dyspnoea scores at long term follow-up improved 1 point (n=5), 2 points (n=5) and 3 points (n=2), remained unchanged (n=1) or dropped 1 point (n=2). Of the 15 patients followed up all but one who had been employed returned to work. 14/15 patients expressed satisfaction with their surgery.

CONCLUSION

Diaphragm plication is an effective procedure with lasting results.

Diaphragmatic dysfunction after pediatric orthotopic liver transplantation

BACKGROUND

Pediatric orthotopic liver transplantation (OLT) has a low mortality. Some children, however, have an adverse outcome defined as a prolonged ventilatory support requirement and protracted pediatric intensive care unit (PICU) stay. The aim of this study was to determine if that adverse outcome related to the child's condition pre-OLT and/or the development of a pleural effusion or diaphragmatic dysfunction.

METHODS

The study included 210 children with a median age at transplantation of 45.5 months (range 0.2-252 months). Fourteen had undergone retransplantation. The duration of ventilatory support (intermittent positive pressure ventilation [IPPV]) and PICU admission and development of a pleural effusion and/or diaphragmatic dysfunction were documented for each child. The patients were divided into three groups according to whether they had acute liver failure (ALF), chronic liver disease at home (CHOM), or chronic liver failure sufficiently ill to be in the hospital awaiting transplantation (CHOSP).

RESULTS

The 36 children with ALF were of similar age to the 138 CHOM and 36 CHOSP children but required longer IPPV (P<0.0001) and PICU stay (P<0.0001). Overall, 17 children developed diaphragmatic dysfunction and 138 pleural effusions; affected children required longer IPPV and PICU stay (P<0.01). Regression analysis demonstrated that diaphragmatic dysfunction, but not pleural effusion development, was associated with prolonged ventilation (P<0.01) and protracted PICU stay (P<0.05). Other risk factors were ALF (P<0.01), retransplantation (P<0.01), and young age (P<0.05).

CONCLUSION

Diaphragmatic dysfunction adversely influences PICU morbidity after OLT. Early assessment of diaphragmatic function, and if necessary aggressive management, might improve outcome.

Magnetic phrenic nerve stimulation to assess diaphragm function in children following liver transplantation

BACKGROUND: An accurate and practical test of diaphragm function in children in the intensive care unit is desirable. Diaphragm dysfunction can occur after liver transplantation and may be a contributory factor in the respiratory complications after the procedure. OBJECTIVE: Our aim was to assess if magnetic stimulation (MS) of the phrenic nerves could be used to assess diaphragm strength in children receiving intensive care. SETTING: Pediatric intensive care unit. PATIENTS: Eight supine, ventilated, sedated children (mean age, 7.3; range, 0.6-15 yrs) were studied within 12 hrs of liver transplantation. INTERVENTIONS: MS was performed using either 90-mm double circular coils or 43-mm figure of eight coils placed over the phrenic nerves on the anterior aspect of the neck. Measurements: The produced diaphragm force was assessed by measuring the transdiaphragmatic pressure (Pdi) with balloons in the mid-esophagus and stomach. During MS, the endotracheal tube was briefly occluded by using a pneumatic valve. MAIN RESULTS: Supramaximal diaphragm force responses were obtained in all subjects; mean Pdi, 7.8 (sd, 3.1) cmH(2)O for left, 5.2 (sd, 3.4) cmH(2)O for right, and 14.8 (sd, 9.2) cmH(2)O for bilateral stimulation. Bland and Altman analysis indicated close agreement between esophageal and airway pressure during MS (mean difference, -0.76 [sd, 0.99] cmH(2)O for left stimulation, 0.81 [sd, 1.25] cmH(2)O for right stimulation, and -0.63 [sd, 1.55] cmH(2)O for bilateral stimulation). In three children, there was a >50% difference between the Pdi generated after left and right unilateral MS and the results of MS indicated complete right hemidiaphragm paralysis in one child. CONCLUSION: MS of the phrenic nerves provides a practical technique for assessing diaphragm function in children receiving intensive care. Measurement of airway pressure during MS may provide a noninvasive technique for assessing diaphragm strength when the use of balloon catheters is contraindicated.

Surgical Management of Eventration of Diaphragm in an Elderly Patient

A 70-year-old woman with eventration of the left dome of the diaphragm, presented with features of acute respiratory distress. She was successfully treated by emergency plication of the diaphragm. Computed tomography of the chest was useful for diagnosis.

Long-term effect of bilateral plication of the diaphragm

STUDY OBJECTIVES

To assess the feasibility and clinical outcome of bilateral plication of the diaphragm in patients with bilateral diaphragmatic paralysis (BDP) caused by neuralgic amyotrophy (NA), a mononeuritis of the phrenic nerves.

DESIGN

Prospective, case-control study over a 1-year period.

SETTING

A university hospital in The Netherlands.

PATIENTS

Six patients who presented with BDP caused by NA.

METHODS

The diagnosis of BDP was based on the absence of muscle response after cervical magnetic stimulation of both phrenic nerves. Three patients did not undergo surgery but were observed for a period of 2 years, and the other three patients underwent a limited lateral thoracotomy at the eighth intercostal space. Plication was performed by U-stitches until the diaphragm was as tight as possible. Vital capacity (VC) and arterial blood gas was measured during follow-up.

RESULTS

One month postoperatively, mean VC measured in the supine position was significantly improved by 17%, and this effect was sustained for 12 months. Arterial PO(2) increased by 45%. VC and blood gas levels did not improve in the three patients that were only observed during the 2-year period. All three surgical patients could sleep in the supine position after the operation.

CONCLUSION

Bilateral plication of the diaphragm for NA-induced paralysis results in improvement of ventilation and blood gas exchange, allowing patients to sleep in the supine position without dyspnea.

Large eventration of diaphragm in an elderly patient treated with emergency plication

Total eventration of the hemidiaphragm is a rare condition in adults. We report a 75-year-old woman with large eventration of the right diaphragm who required an emergency plication because of acute progressive respiratory distress. The symptom disappeared immediately after operation. Even in asymptomatic elderly patients with eventration, close follow-up is recommended.

Successful plication for postoperative diaphragmatic paralysis in an adult

Diaphragmatic paralysis developed in an adult after a cardiac operation. The patient suffered from recurrent fevers and could not be weaned from mechanical ventilatory support. Diaphragmatic plication was performed and enabled rapid and sustained weaning from respiratory support.

Diaphragmatic plication for unilateral diaphragmatic paralysis: a 10-year experience

Unilateral paralysis of the diaphragm due to nonmalignant disease is an uncommon disorder previously thought to have benign implications. Some patients, however, experience dyspnea and orthopnea with impairment of pulmonary function. Unilateral diaphragmatic plication was performed on 17 patients (16 men and 1 woman with a mean age of 53.7 years [range, 28 to 74 years]) during the last 10 years. Preoperatively each patient was shown to have paradoxical movement of the paralyzed diaphragm on sniffing and to have a reduction in forced vital capacity and lung volumes. These reductions were greater when the patient was in the supine position. All patients had moderate hypoxemia (mean arterial oxygen tension, 73.1 +/- 10.9 mm Hg). Plication was performed by imbricating the diaphragm in layers through a thoracotomy incision. After plication, all patients showed both subjective and objective improvement. Six patients were reassessed 5 or more years after plication (range, 5 to 7 years), and the improvement was maintained. Diaphragmatic plication is a safe and effective procedure for adult patients with dyspnea due to unilateral diaphragmatic paralysis; furthermore, the initial improvement is maintained.