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Chang M, Menegas S, Lee DU, Hammami MB, Sakiani S. A Rare Complication of Diaphragm Plication: Acute Liver Injury From Hepatic Compartment Syndrome. ACG Case Rep J 2023; 10:e01127. [PMID: 37654619 PMCID: PMC10468105 DOI: 10.14309/crj.0000000000001127] [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] [Received: 02/09/2023] [Accepted: 07/17/2023] [Indexed: 09/02/2023] Open
Abstract
Diaphragm plication is a surgical treatment of unilateral diaphragm paralysis, in which the affected diaphragm is sutured in place. Because the right diaphragm sits on top of the liver, right-sided diaphragm plication can injure the liver and lead to hepatic compartment syndrome resulting in acute liver injury. We report a case of a 59-year-old woman with a history of multilevel disk degeneration and alcohol use disorder who underwent right-sided diaphragm plication. After surgery, she complained of abdominal pain and was found to have severely elevated liver-associated enzymes and evidence of acute liver injury, which resolved with supportive care.
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Affiliation(s)
- Michael Chang
- University of Maryland School of Medicine, Baltimore, MD
| | | | - David Uihwan Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Muhammad Baraa Hammami
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Sasan Sakiani
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
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Beshay M, Abdel Bary M, Kösek V, Vordemvenne T, Mertzlufft F, Schulte am Esch J. Minimally-Invasive Diaphragmatic Plication in Patients with Unilateral Diaphragmatic Paralysis. J Clin Med 2023; 12:5301. [PMID: 37629343 PMCID: PMC10455218 DOI: 10.3390/jcm12165301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 08/07/2023] [Accepted: 08/12/2023] [Indexed: 08/27/2023] Open
Abstract
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.
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Affiliation(s)
- Morris Beshay
- Department of General Thoracic Surgery, University Hospital OWL, Campus Bielefeld-Bethel, 33617 Bielefeld, Germany
| | - Mohamed Abdel Bary
- Department of Cardiothoracic Surgery, South Valley University, Qena 83523, Egypt;
| | - Volkan Kösek
- Department of Thoracic Surgery, Klinik am Park, Klinikum, 44536 Luenen, Germany;
| | - Thomas Vordemvenne
- Department of Accident and Trauma Surgery, University Hospital OWL, Campus Bielefeld-Bethel, 33617 Bielefeld, Germany;
| | - Fritz Mertzlufft
- Forschungsverbund BioMedizin Bielefeld, OWL (FBMB e.V.), Maraweg 21, 33699 Bielefeld, Germany;
| | - Jan Schulte am Esch
- Department of General and Visceral Surgery, University Hospital OWL, Campus Bielefeld-Bethel, 33617 Bielefeld, Germany;
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Le UT, Titze L, Passlick B, Schmid S. [Robotic Diaphragm Plication]. Zentralbl Chir 2023; 148:S41-S47. [PMID: 36889335 DOI: 10.1055/a-2003-1100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2023]
Abstract
Acquired unilateral hemidiaphragm elevation is characterised by dyspnoea, which is typically aggravated when lying down, bending over or during swimming. The most common causes are idiopathic or due to injury to the phrenic nerve during cervical or cardio-thoracic surgery. To date, surgical diaphragm plication remains the only effective treatment. The aim of the procedure is to plicate the diaphragm to restore its tension and thus improve breathing mechanics, increase the available space for the lung and reduce compression from abdominal organs. In the past, various techniques using open and minimally invasive approaches have been described. Robot-assisted thoracoscopic diaphragm plication combines the advantages of a minimally invasive approach with excellent visualisation and freedom of movement. It was shown to be a safe technique which is easy to establish and can significantly improve pulmonary function.
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Affiliation(s)
- Uyen-Thao Le
- Klinik für Thoraxchirurgie, Universitätsklinikum Freiburg, Freiburg, Deutschland
| | - Laurin Titze
- Klinik für Thoraxchirurgie, Universitätsklinikum Freiburg, Freiburg, Deutschland
| | | | - Severin Schmid
- Klinik für Thoraxchirurgie, Universitätsklinikum Freiburg, Freiburg, Deutschland
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Robotic diaphragm plication: functional and surgical outcomes of a single-center experience. Surg Endosc 2023:10.1007/s00464-023-09942-7. [PMID: 36914782 DOI: 10.1007/s00464-023-09942-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 02/11/2023] [Indexed: 03/16/2023]
Abstract
BACKGROUND Diaphragm plication remains the only effective treatment for diaphragm paralysis. Robot-assisted thoracoscopic (RATS) diaphragm plication combines advantages of open and thoracoscopic techniques. We present our experiences focussing on lung-function improvement and surgical outcome. METHODS In this single-center retrospective study with comparative analysis, perioperative data of all patients who underwent RATS or thoracoscopic (VATS) diaphragm plication between 2015 and 2022 at our institution were assessed. Functional outcome was analysed with pre- and postoperative pulmonary function tests in sitting and supine position. RESULTS We included 43 diaphragm plications, of which 31 were performed via RATS. Morbidity in the RATS- and VATS-cohort were 13 and 8%, respectively (p = 0.64), without any major complication (Clavien-Dindo ≥ III, 0%). Surgical time for RATS diaphragm plication was reduced drastically with a median operating time for the first 16 patients of 136 min (range 84-185) and 84 min (range 56-122) for the most recent 15 patients (p < 0.0001). Pulmonary function testing after RATS-plication showed a mean increase in vital capacity (VC) of 9% (SD 8, p < 0.0001) and of 7% (SD 9, p = 0.0009) in forced expiratory volume in 1 s (FEV1) when sitting and 9% (SD 8, p < 0.0001) for VC as well as 10% (SD 8, p = 0.0001) for FEV1 when in supine position. CONCLUSION RATS diaphragm plication is a very safe and feasible approach, yielding good results in improving patients' pulmonary function. Further studies are required to elucidate possible advantages over VATS or open approaches.
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Lee MFH, Gan JY, Zhang M, Stokan MJ, Palme CE. The phrenic nerve; the forgotten nerve in head and neck surgery. ANZ J Surg 2023; 93:500-505. [PMID: 36792555 DOI: 10.1111/ans.18322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 01/08/2023] [Accepted: 01/31/2023] [Indexed: 02/17/2023]
Abstract
BACKGROUND Neck dissection is a commonly performed procedure for oncologic control of head and neck malignancy. With contemporary modified radical and selective neck dissections, haematoma, wound infection, tissue necrosis, chyle leak and injury involving the marginal mandibular, hypoglossal, vagus or accessory nerves are commonly described complications. Although the phrenic nerve courses within the surgical planes explored during a neck dissection and has a vital function in innervating the diaphragm, few studies have been performed to investigate the exact incidence of post-operative phrenic nerve paresis. This study aims to review the literature as to the rate of phrenic nerve injury following neck dissection. METHODS A systematic literature review was conducted from 2000 to 2022 including studies reporting on phrenic nerve paresis following neck dissection. RESULTS In total, 11 studies were included. The reported rate of immediate post-operative phrenic nerve paresis ranged from 0% to 5.3%, with an average rate of 0.613% (12/1959). The reported rate of phrenic nerve paresis at follow-up (1 month-127 months) ranged from 0% to 4.7%, with an average rate of 1.035% (5/483). There were no cases of bilateral phrenic nerve paresis reported in this period. CONCLUSIONS Phrenic nerve paresis is an uncommon complication following neck dissection, often asymptomatic and potentially underreported. Bilateral phrenic nerve paresis is exceedingly rare. Injury can be avoided by staying superficial to the prevertebral fascia when dissecting around the anterior scalene muscle. Routine phrenic nerve integrity monitoring is not commonly utilized but may aid intra-operative phrenic nerve identification or confirmation of function.
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Affiliation(s)
- Michael Fook-Ho Lee
- Department of Head and Neck Surgery, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia
| | - Jereme Yijin Gan
- Department of Head and Neck Surgery, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia
| | - Michael Zhang
- Department of Head and Neck Surgery, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia
| | - Murray James Stokan
- Department of Head and Neck Surgery, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia
| | - Carsten Erich Palme
- Department of Head and Neck Surgery, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia
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Khullar OV, Perez A, Dixon M, Binongo JN, Sancheti MS, Pickens A, Gillespie T, Force SD, Fernandez FG. Routine Implementation of Patient-Reported Outcomes Assessment Into Thoracic Surgery Practice. Ann Thorac Surg 2023; 115:526-532. [PMID: 35561801 DOI: 10.1016/j.athoracsur.2022.04.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 03/31/2022] [Accepted: 04/18/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Patient-reported outcomes (PROs) assessment is a necessary component of surgical outcome assessment and patient care. This study examined the success of routine PROs assessment in an academic-based thoracic surgery practice. METHODS PROs, measuring pain intensity, physical function, and dyspnea, were routinely obtained using the National Institutes of Health-sponsored Patient-Reported Outcomes Measurement Information System (PROMIS) on all thoracic surgery patients beginning in April 2018 through January 2021. Questionnaires were administered electronically through a web-based platform at home or during the office visit. Completion rates and barriers were measured. RESULTS A total of 9725 thoracic surgery office visits occurred during this time frame. PROs data were obtained in 6899 visits from a total of 3551 patients. The mean number of questions answered per survey was 22.4 ± 2.2. Overall questionnaire completion rate was 65.7%. A significant decline in survey completion was noted in April 2020, after which adjustments were made to allow for questionnaire completion through a mobile health platform. Overall monthly questionnaire completion rates ranged from 20% (April 2020) to 90% (October 2018). Mean T scores were dyspnea, 41.6 ± 12.3; physical function, 42.7 ± 10.5; and pain intensity, 52.8 ± 10.3. CONCLUSIONS PROs can be assessed effectively in a thoracic surgery clinic setting, with minimal disruption of clinical activities. Future efforts should focus on facilitating PROs collection from disadvantaged patient populations and scaling implementation across programs.
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Affiliation(s)
- Onkar V Khullar
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia.
| | - Aubriana Perez
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Meredith Dixon
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Jose N Binongo
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Manu S Sancheti
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Allan Pickens
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Theresa Gillespie
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Seth D Force
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Felix G Fernandez
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
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Tingquist ND, Gillaspie EA. Diaphragm Plication. Thorac Surg Clin 2023; 33:99-108. [DOI: 10.1016/j.thorsurg.2022.08.004] [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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An J, Dong Y, Li Y, Han X, Niu H, Zou Z, Wu J, Tian Y, Chen Z. CT-guided placement of microcoil end in the pleural cavity for video-assisted thoracic surgical resection of ground-glass opacity: a retrospective study. J Cardiothorac Surg 2022; 17:316. [PMID: 36527097 PMCID: PMC9758923 DOI: 10.1186/s13019-022-02048-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 11/27/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The aim of the study was to investigate and summarize the effectiveness and safety of CT-guided microcoil localization before video-assisted thoracic surgery (VATS) for the removal of ground-glass opacity (GGO). METHODS A total of 147 patients with GGO who were treated at our hospital between January 2019 and February 2021 were retrospectively analyzed. They were divided into two groups according to the final position at the end of the microcoil: intracavity (n = 78) and extracavity (n = 69), which were compared based on puncture complications and influence of the coil end position on VATS. RESULTS The proportions of supine and prone positions in the intracavity group were significantly higher than those in the extracavity group (82.1% vs. 66.7%, P < 0.05). The incidence of intrapulmonary hemorrhage, chest pain, and coil displacement in the intracavity group was significantly lower than that in the extracavity group (28.2% vs. 46.4%, 19.2% vs. 39.1%, 1.3% vs. 11.6%, P < 0.05, respectively); however, the incidence of pneumothorax was not significantly different (P > 0.05). The time of VATS and the rate of conversion to thoracotomy in the intracavity group were significantly lower than those in the extracavity group (103.4 ± 21.0 min vs. 112.2 ± 17.3 min, 0% vs. 5.8%, P < 0.05, respectively). CONCLUSION CT-guided placement of the microcoil is a practical, simple, and convenient localization method before VATS, with a high success rate and few complications. Furthermore, it is a better alternative method to place the end of the coil in the pleural cavity because of the lower complication rate, shorter VATS time, and lower rate of thoracotomy conversion.
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Affiliation(s)
- Jianli An
- Department of Interventional treatment, Qinhuangdao Municipal No. 1 Hospital, No. 258 Wenhua Road, Hebei Province 066000 Qinhuangdao, People’s Republic of China
| | - Yanchao Dong
- Department of Interventional treatment, Qinhuangdao Municipal No. 1 Hospital, No. 258 Wenhua Road, Hebei Province 066000 Qinhuangdao, People’s Republic of China
| | - Yanguo Li
- Department of Riadiology, Qinhuangdao Municipal No. 1 Hospital, No. 258 Wenhua Road, Hebei Province Qinhuangdao, People’s Republic of China
| | - Xiaoyu Han
- Department of Cardiovascular, Qinhuangdao Municipal No. 1 Hospital, No. 258 Wenhua Road, Hebei Province Qinhuangdao, People’s Republic of China
| | - Hongtao Niu
- Department of Interventional treatment, Qinhuangdao Municipal No. 1 Hospital, No. 258 Wenhua Road, Hebei Province 066000 Qinhuangdao, People’s Republic of China
| | - Zibo Zou
- Department of Interventional treatment, Qinhuangdao Municipal No. 1 Hospital, No. 258 Wenhua Road, Hebei Province 066000 Qinhuangdao, People’s Republic of China
| | - Jingpeng Wu
- Department of Interventional treatment, Qinhuangdao Municipal No. 1 Hospital, No. 258 Wenhua Road, Hebei Province 066000 Qinhuangdao, People’s Republic of China
| | - Ye Tian
- Department of Interventional treatment, Qinhuangdao Municipal No. 1 Hospital, No. 258 Wenhua Road, Hebei Province 066000 Qinhuangdao, People’s Republic of China
| | - Zhuo Chen
- Department of Interventional treatment, Qinhuangdao Municipal No. 1 Hospital, No. 258 Wenhua Road, Hebei Province 066000 Qinhuangdao, People’s Republic of China
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Gritsiuta AI, Gordon M, Bakhos CT, Abbas AE, Petrov RV. Minimally Invasive Diaphragm Plication for Acquired Unilateral Diaphragm Paralysis: A Systematic Review. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2022; 17:180-190. [PMID: 35549933 DOI: 10.1177/15569845221097761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Andrei I Gritsiuta
- Department of Surgical Services, 6595University of Pittsburgh Medical Center, PA, USA
| | - Matthew Gordon
- Department of Thoracic Medicine and Surgery, Division of Thoracic Surgery, 12314Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Charles T Bakhos
- Department of Thoracic Medicine and Surgery, Division of Thoracic Surgery, 12314Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Abbas E Abbas
- Department of Thoracic Oncology, 12321Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Roman V Petrov
- Department of Thoracic Medicine and Surgery, Division of Thoracic Surgery, 12314Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
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Abdel-Bary M, Rashad A, Elgendy H, Zaki M, Abdelhamid MY, Beshay M, Abdelaal KM. Clinical and sonographic evaluation of the diaphragm after plication in adults with unilateral eventration: a retrospective study. THE EGYPTIAN JOURNAL OF BRONCHOLOGY 2022. [DOI: 10.1186/s43168-021-00108-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
We aim to assess the role of diaphragm ultrasonography in evaluating the outcome of surgical diaphragmatic plication in adults with symptomatic unilateral diaphragmatic eventration.
Results
Forty patients with symptomatic unilateral diaphragmatic eventration underwent surgical diaphragmatic plication between 2015 and 2020. The etiology was idiopathic in 34 (85%) cases, and 37 (92.5%) of them were suffering from dyspnea. Diaphragm ultrasonography showed no diaphragmatic movement on the affected side in 10 (25%) patients and a paradoxical movement in 30 (75%) patients. Surgical diaphragmatic plication was done successfully in all cases. Postoperative complications were reported in 3 (7.5%) cases, with no mortality. There was a highly significant improvement in dyspnea at 1 week and 6 months follow-up. CXR showed a highly significant decrease in the mean height of eventration at 1 week 3.7 ± 1.2 cm (P < 0.001), and 6 months 2.6 ± 0.9 cm (P < 0.001), compared to preoperative values (10.1 ± 2.8 cm). diaphragm ultrasonography showed normal motility of the plicated cupola in all cases, and there was a highly significant decrease in the mean height of eventration at 1 week (3.1 ± 1.1 cm, P < 0.001), and 6 months (2.3 ± 0.5 cm, P < 0.001) compared to preoperative values (10.3 ± 2.2 cm). There was a highly significant increase in the diaphragm thickness at 1 week (2.7 ± 0.3 mm, P < 0.001), and 6 months (2.9 ± 0.2 mm, P < 0.001), compared to the preoperative value. There was a highly significant improvement in the degree of excursion 1 week (25 ± 4.3 mm, P < 0.001), and 6 months (28 ± 5.2 mm, P < 0.001), compared to the preoperative value (15 ± 6.2 mm). No fluid collection or surroundings organ injuries were detected. The mean FVC and FEV1 showed a highly significant improvement at 1 week (66.7 ± 6%, 78.2 ± 9.8%), and 6 months (68.8 ± 5.7%, 80.4 ± 10.3%), compared to the preoperative value (58.8 ± 8% and 70.9 ± 10.3%).
Conclusions
Surgical diaphragmatic plication is an effective and safe procedure that can be performed to treat symptomatic adults with unilateral diaphragmatic eventration. Diaphragm ultrasonography can be used as a simple bedside test to evaluate unilateral diaphragmatic eventration cases and their postoperative follow-up.
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11
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Schumacher L, Zhao D. Outcomes and technique of robotic diaphragm plication. J Thorac Dis 2021; 13:6113-6115. [PMID: 34795961 PMCID: PMC8575844 DOI: 10.21037/jtd-2019-rts-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 08/07/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Lana Schumacher
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Danjing Zhao
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
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12
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Kaufman MR, Chang EI, Bauer T, Rossi K, Elkwood AI, Paulin E, Jarrahy R. Phrenic Nerve Reconstruction for Effective Surgical Treatment of Diaphragmatic Paralysis. Ann Plast Surg 2021; 87:310-315. [PMID: 34397519 DOI: 10.1097/sap.0000000000002896] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Diaphragmatic paralysis due to phrenic nerve injury may cause orthopnea, exertional dyspnea, and sleep-disordered breathing. Phrenic nerve reconstruction may relieve symptoms and improve respiratory function. A retrospective review of 400 consecutive patients undergoing phrenic nerve reconstruction for diaphragmatic paralysis at 2 tertiary treatment centers was performed between 2007 and 2019. Symptomatic patients were identified, and the diagnosis was confirmed on radiographic evaluations. Assessment parameters included pulmonary spirometry (forced expiratory volume in 1 second and FVC), maximal inspiratory pressure, compound muscle action potentials, diaphragm thickness, chest fluoroscopy, and Short Form 36 Health Survey Questionnaire (SF-36) survey. There were 81 females and 319 males with an average age of 54 years (range, 19-79 years). The mean duration from diagnosis to surgery was 29 months (range, 1-320 months). The most common etiologies were acute or chronic injury (29%), interscalene nerve block (17%), and cardiothoracic surgery (15%). The mean improvements in forced expiratory volume in 1 second and FVC at 1 year were 10% (P < 0.01) and 8% (P < 0.05), respectively. At 2-year follow-up, the corresponding values were 22% (P < 0.05) and 18% (P < 0.05), respectively. Improvement on chest fluoroscopy was demonstrated in 63% and 71% of patients at 1 and 2-year follow-up, respectively. There was a 20% (P < 0.01) improvement in maximal inspiratory pressure, and compound muscle action potentials increased by 82% (P < 0.001). Diaphragm thickness demonstrated a 27% (P < 0.01) increase, and SF-36 revealed a 59% (P < 0.001) improvement in physical functioning. Symptomatic diaphragmatic paralysis should be considered for surgical treatment. Phrenic nerve reconstruction can achieve symptomatic relief and improve respiratory function. Increasing spirometry and improvements on Sniff from 1 to 2 years support incremental recovery with longer follow-up.
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Affiliation(s)
| | - Eric I Chang
- From the Institute for Advanced Reconstruction, Shrewsbury, NJ
| | - Thomas Bauer
- Department of Thoracic Surgery, Hackensack Meridian Health Jersey Shore University Medical Center, Neptune City, NJ
| | - Kristie Rossi
- From the Institute for Advanced Reconstruction, Shrewsbury, NJ
| | | | - Ethan Paulin
- Department of Thoracic Surgery, Hackensack Meridian Health Jersey Shore University Medical Center, Neptune City, NJ
| | - Reza Jarrahy
- Division of Plastic and Reconstructive Surgery, UCLA Medical Center, Los Angeles, CA
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Sarac S, Salturk C, Oruc O, Metin SK, Bayram S, Karakurt Z, Yalcınkaya I. Sleep-related breathing disorders in diaphragmatic pathologies. Sleep Breath 2021; 26:959-963. [PMID: 34191224 DOI: 10.1007/s11325-021-02422-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 05/02/2021] [Accepted: 06/15/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The diaphragm is the most significant muscle involved in breathing. There are very few studies and cases evaluating sleep-related breathing disorders in diaphragmatic pathologies. This study compares preoperative and postoperative polysomnography (PSG) and pulmonary function test (PFT) results in diaphragmatic pathologies. MATERIAL AND METHODS The study included 28 patients who underwent video-assisted mini-thoracotomy (VATS) due to diaphragm eventration and paralysis between January 2014 and October 2019. Pulmonary function tests (PFT) and polysomnography (PSG) were performed preoperatively in all patients, and PSG and PFT were repeated 2 months after the surgery. RESULTS Twenty-five of the 28 patients were found to have apnea-hypopnea index (AHI) ≥ 5 (89%). A significant decrease in the preoperative TST, stage 3, and REM periods was observed. Nineteen of these patients (76%) were supine isolated or supine dominant. There was a marked improvement in AHI and PFT values after the surgery. Only five patients required a PAP device. CONCLUSION Doctors should perform PSG in patients with diaphragm pathologies, and these patients should be operated on after considering the comorbidities when OSA is detected.
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Affiliation(s)
- Sema Sarac
- Department of Pulmonary Medicine, Istanbul Sureyyapasa Teaching and Training Hospital, University of Health Science, Maltepe, Istanbul, Turkey.
| | - Cuneyt Salturk
- Department of Pulmonary Medicine, Istanbul Sureyyapasa Teaching and Training Hospital, University of Health Science, Maltepe, Istanbul, Turkey
| | - Ozlem Oruc
- Department of Pulmonary Medicine, Istanbul Sureyyapasa Teaching and Training Hospital, University of Health Science, Maltepe, Istanbul, Turkey
| | - Serda Kanbur Metin
- Department of Chest Surgery, Istanbul Sureyyapasa Teaching and Training Hospital, University of Health Science, Istanbul, Turkey
| | - Serkan Bayram
- Department of Pulmonary Medicine, Istanbul Sureyyapasa Chest Diseases and Chest Surgery, Hospital Maltepe, Istanbul, Turkey
| | - Zuhal Karakurt
- Department of Pulmonary Medicine, Istanbul Sureyyapasa Teaching and Training Hospital, University of Health Science, Maltepe, Istanbul, Turkey
| | - Irfan Yalcınkaya
- Department of Chest Surgery, Istanbul Sureyyapasa Teaching and Training Hospital, University of Health Science, Istanbul, Turkey
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Kim DH, Sung SC, Kim H, Choi KH, Son BS, Park JM, Lee SK. Is the pleating technique superior to the invaginating technique for plication of diaphragmatic eventration in infants? J Pediatr Surg 2021; 56:995-999. [PMID: 32792164 DOI: 10.1016/j.jpedsurg.2020.07.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 07/10/2020] [Accepted: 07/13/2020] [Indexed: 11/21/2022]
Abstract
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.
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Affiliation(s)
- Do Hyung Kim
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Yangsan Hospital, Yangsan, Gyoungnam, Republic of Korea
| | - Si Chan Sung
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Yangsan Hospital, Yangsan, Gyoungnam, Republic of Korea
| | - Hyungtae Kim
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Yangsan Hospital, Yangsan, Gyoungnam, Republic of Korea
| | - Kwang Ho Choi
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Yangsan Hospital, Yangsan, Gyoungnam, Republic of Korea
| | - Bong Soo Son
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Yangsan Hospital, Yangsan, Gyoungnam, Republic of Korea
| | - Jong Myung Park
- Department of Thoracic and Cardiovascular Surgery, Busan Medical Center, Yeonje-gu, Busan, Republic of Korea
| | - Sung Kwang Lee
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Yangsan Hospital, Yangsan, Gyoungnam, Republic of Korea.
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15
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Goldberg L, Krauthammer A, Ashkenazi M, Soudack M, Tokatly Latzer I, Vardi A, Paret G. Predictors for plication performance following diaphragmatic paralysis in children. Pediatr Pulmonol 2020; 55:449-454. [PMID: 31589009 DOI: 10.1002/ppul.24539] [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] [Received: 05/18/2019] [Accepted: 09/23/2019] [Indexed: 11/11/2022]
Abstract
INTRODUCTION AND OBJECTIVES Diaphragmatic paralysis (DP) in children can result from various etiologies. Guidelines for patient selection for diaphragmatic plication (DPL) are lacking. Our objectives were to describe the etiologies of DP and to determine the risk factors and predictors for DPL in the pediatric population. METHODS Retrospective data were retrieved from departmental databases on patients with DP from the pediatric, cardiac, and neonatal intensive care departments of Safra Children's Hospital from 2010 to 2017. RESULTS DP was diagnosed in 88 patients, 29 with noncardiac surgery-related etiologies, for example, congenital, surgery, trauma, and shock and 59 with cardiac surgery-related etiologies. In total, 27 (31%) patients underwent DPL, and they had significant comorbidities involving respiratory, central nervous, and cardiovascular systems, higher lung injury scores, and lower weight compared with the patients who did not undergo DPL (P = .002, P = .002, P < .001, P = .012, and P = .013, respectively). A multivariate regression model revealed significant independent predictors for DPL, including morbidities of central nervous (odds ratio [OR = 9.651, P = .005), respiratory (OR = 4.875, P = .039), and cardiovascular systems (OR = 23.938, P = .001). CONCLUSIONS Etiologies of DP are very diverse in the pediatric population. Comorbidities of respiratory, central nervous, and cardiovascular systems are risk factors for plication requirement in respiratory support-dependent pediatric patients with DP. Early DPL should be considered in these patients.
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Affiliation(s)
- Lior Goldberg
- Department of Pediatric Critical Care Medicine, Sheba Medical Center, Tel Hashomer, Israel.,Sackler Faculty of Medicine, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Alexander Krauthammer
- Department of Pediatric Critical Care Medicine, Sheba Medical Center, Tel Hashomer, Israel.,Sackler Faculty of Medicine, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Moshe Ashkenazi
- Sackler Faculty of Medicine, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Pediatric Pulmonary Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Israel
| | - Michal Soudack
- Sackler Faculty of Medicine, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Pediatric Imaging Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Israel
| | - Itay Tokatly Latzer
- Department of Pediatric Critical Care Medicine, Sheba Medical Center, Tel Hashomer, Israel.,Sackler Faculty of Medicine, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amir Vardi
- Department of Pediatric Critical Care Medicine, Sheba Medical Center, Tel Hashomer, Israel
| | - Gideon Paret
- Department of Pediatric Critical Care Medicine, Sheba Medical Center, Tel Hashomer, Israel.,Sackler Faculty of Medicine, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Uchida T, Tanaka Y, Shimizu N, Kuroda S, Doi T, Hokka D, Okita Y, Maniwa Y. Diaphragmatic plication for iatrogenic respiratory insufficiency after cardiothoracic surgery. J Thorac Dis 2019; 11:3704-3711. [PMID: 31656642 DOI: 10.21037/jtd.2019.09.34] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The efficacy of diaphragmatic plication (DP) has been proven in many studies. However, there are few reports on DP for patients with severe respiratory conditions requiring mechanical ventilation. The study aim was to demonstrate the efficacy of DP for patients with severe respiratory insufficiency after cardiothoracic surgeries. Methods We retrospectively reviewed 10 patients who underwent DP for severe respiratory insufficiency due to postoperative diaphragmatic paralysis; eight of them required mechanical ventilation, and two needed high-flow oxygen therapy prior to DP. The symptoms, lung function, and elevation of the diaphragm were assessed before and after DP. Results All patients were successfully withdrawn from mechanical ventilation after DP and discharged without the need for oxygen therapy. The mean perioperative Medical Research Council (MRC) dyspnea scale (ATS/ERS 2004) score improved in 30 days (from 4 to 1.8) and in 90 days (from 4 to 0.6) after DP. Lung dynamic compliance was also ameliorated (mean improvement: 41.9 to 60.7 mL/cmH2O). Radiography revealed improved elevation of the diaphragm (mean improvement of 1.8 intercostal spaces, range, 1-2). Mean hospital stay after DP was 65.5 days (range, 25-187 days). One patient who underwent DP with endostapler-only suturing required re-operation because of staple line ruptures. Conclusions DP was found to be an effective form of treatment for patients with severe respiratory insufficiency after cardiothoracic surgery.
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Affiliation(s)
- Takahiro Uchida
- Division of Thoracic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yugo Tanaka
- Division of Thoracic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Nahoko Shimizu
- Division of Thoracic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Sanae Kuroda
- Division of Thoracic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Takefumi Doi
- Division of Thoracic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Daisuke Hokka
- Division of Thoracic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yutaka Okita
- Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yoshimasa Maniwa
- Division of Thoracic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
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17
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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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18
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Abstract
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.
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Affiliation(s)
- V D Parshin
- Sechenov First Moscow State Medical University of Healthcare Ministry of the Russian Federation, Burdenko Clinic of Faculty Surgery, Moscow, Russia
| | - M A Khetagurov
- Sechenov First Moscow State Medical University of Healthcare Ministry of the Russian Federation, Burdenko Clinic of Faculty Surgery, Moscow, Russia
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19
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Vats Plication of the Diaphragm a Descriptive Observational 10-Year Southampton Experience. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2017; 12:398-405. [DOI: 10.1097/imi.0000000000000441] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Objective The aim of the study was to report the safety and efficacy of video-assisted thoracoscopic (VATS) plication of the diaphragm at our institution between 2006 and 2016. Methods Adult patients selected on etiology and combination of investigations including plain chest x-ray, computed tomography of chest and abdomen, lung functions in supine and sitting positions, radiological/ultrasonic screening for diaphragmatic movement, and phrenic nerve conduction studies. We incorporated a triportal VATS and Endostitch device for plication, using CO2 insufflation to maximum 12 mm Hg. Bilateral simultaneous plication and high-risk patients were electively admitted to intensive therapy unit postoperatively. Results Thirty-five patients (24 males) had their diaphragm plicated. The mean age was 56.6 years (range = 23–76 years). The mean body mass index was 32.1 (range = 22.2–45.4). Twenty one were right, 13 left, 2 patients had VATS simultaneous bilateral plication, and 1 had sequential VATS bilateral plication. Paralysis was idiopathic in 17, posttraumatic in 5, postremoval of mediastinal tumor in 4, and postcardiac surgery in 3. All patients presented with lifestyle-limiting dyspnea and orthopnea, three were on nocturnal noninvasive ventilation. Five were diabetic and 16 were smokers. The mean supine forced expiratory volume in the first second was 62.5% of predicted. Twenty two were performed by VATS (63%), three converted to thoracotomy, and 13 were open limited thoracotomy (historic). The mean hospital stay was 4.5 days (range = 1–18, mode 2 days). Intensive therapy unit admission was required in six patients for mechanical ventilation 0 to 3 days. Five patients (14%) had no improvement in symptoms. There were no deaths, no 30-day readmissions, and no long-term neuralgia in this series. Conclusions We found minimal access VATS plication of the diaphragm to be feasible and safe, but no firm conclusions should be drawn from our limited resources. We report the feasibility of concomitant bilateral VATS plication of the diaphragm in two adults, and this was not previously reported in the adult population. There is a need for further good quality, prospective studies, and randomized controlled studies evaluating efficacy of VATS diaphragmatic plication.
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20
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Taberham RJ, Raza A, Alzetani A, Woo EB, Chamberlain MH, Koulaxouzidis G, Amer KM. Vats Plication of the Diaphragm a Descriptive Observational 10-Year Southampton Experience. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2017. [DOI: 10.1177/155698451701200605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Rhona J. Taberham
- Cardiovascular & Thoracic Centre, Southampton General Hospital, Southampton, UK
| | - Adnan Raza
- Cardiovascular & Thoracic Centre, Southampton General Hospital, Southampton, UK
| | - Aiman Alzetani
- Cardiovascular & Thoracic Centre, Southampton General Hospital, Southampton, UK
| | - Edwin B. Woo
- Cardiovascular & Thoracic Centre, Southampton General Hospital, Southampton, UK
| | | | | | - Khalid M. Amer
- Cardiovascular & Thoracic Centre, Southampton General Hospital, Southampton, UK
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Abstract
The existing thoracic surgical literature contains several retrospective and observational studies that include patient-reported outcomes. To deliver true patient-centered care, it will be necessary to universally gather patient-reported outcomes prospectively, including them in routine patient care, clinical registries, and clinical trials.
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Affiliation(s)
- Onkar V Khullar
- Section of General Thoracic Surgery, Emory University School of Medicine, 201 Dowman Drive, Atlanta, GA 30322, USA
| | - Felix G Fernandez
- Section of General Thoracic Surgery, Emory University School of Medicine, 201 Dowman Drive, Atlanta, GA 30322, USA.
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22
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Oruc O, Sarac S, Afsar GC, Topcuoglu OB, Kanbur S, Yalcinkaya I, Tepetam FM, Kirbas G. Is polysomnographic examination necessary for subjects with diaphragm pathologies? Clinics (Sao Paulo) 2016; 71:506-10. [PMID: 27652831 PMCID: PMC5004572 DOI: 10.6061/clinics/2016(09)04] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 06/28/2016] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES While respiratory distress is accepted as the only indication for diaphragmatic plication surgery, sleep disorders have been underestimated. In this study, we aimed to detect the sleep disorders that accompany diaphragm pathologies. Specifically, the association of obstructive sleep apnea syndrome with diaphragm eventration and diaphragm paralysis was evaluated. METHODS This study was performed in Süreyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital between 2014-2016. All patients had symptoms of obstructive sleep apnea (snoring and/or cessation of breath during sleep and/or daytime sleepiness) and underwent diaphragmatic plication via video-assisted mini-thoracotomy. Additionally, all patients underwent pre- and postoperative full-night polysomnography. Pre- and postoperative clinical findings, polysomnography results, Epworth sleepiness scale scores and pulmonary function test results were compared. RESULTS Twelve patients (7 males) with a mean age of 48 (range, 27-60) years and a mean body mass index of 25 (range, 20-30) kg/m2 were included in the study. Preoperative polysomnography showed obstructive sleep apnea syndrome in 9 of the 12 patients (75%), while 3 of the patients (25%) were regarded as normal. Postoperatively, patient complaints, apnea hypopnea indices, Epworth sleepiness scale scores and pulmonary function test results all demonstrated remarkable improvement. CONCLUSION All patients suffering from diaphragm pathologies with symptoms should undergo polysomnography, and patients diagnosed with obstructive sleep apnea syndrome should be operated on. In this way, long-term comorbidities of sleep disorders may be prevented.
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Affiliation(s)
- Ozlem Oruc
- Sureyyapasa Chest & Thoracic Surgery Training and Research Hospital, Chest Diseases, Istanbul, Turkey
- E-mail:
| | - Sema Sarac
- Sureyyapasa Chest & Thoracic Surgery Training and Research Hospital, Chest Diseases, Istanbul, Turkey
| | - Gulgun Cetintas Afsar
- Sureyyapasa Chest & Thoracic Surgery Training and Research Hospital, Chest Diseases, Istanbul, Turkey
| | - Ozgur Bilgin Topcuoglu
- Sureyyapasa Chest & Thoracic Surgery Training and Research Hospital, Neurology, Istanbul, Turkey
| | - Serda Kanbur
- Sureyyapasa Chest & Thoracic Surgery Training and Research Hospital, Thoracic Surgery, Istanbul, Turkey
| | - Irfan Yalcinkaya
- Sureyyapasa Chest & Thoracic Surgery Training and Research Hospital, Thoracic Surgery, Istanbul, Turkey
| | - Fatma Merve Tepetam
- Sureyyapasa Chest & Thoracic Surgery Training and Research Hospital, Allergy and Immunology, Istanbul, Turkey
| | - Gokhan Kirbas
- Faculty of Medicine Dicle University, Chest Diseases, Diyarbakir, Turkey
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Video-assisted minimally invasive diaphragmatic plication: feasibility of a recognized procedure through an uncharacteristic hybrid approach. Surg Endosc 2016; 31:1772-1777. [PMID: 27519592 DOI: 10.1007/s00464-016-5171-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 08/06/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Diaphragmatic plication is an approved surgical procedure for treatment of symptomatic diaphragmatic paralysis and eventration. We aim to define our minimally invasive technique of plication and objectively assess our surgical outcomes of the largest series reported in the literature so far, using pulmonary function tests. METHODS Symptomatic patients whom were planned to undergo plication using video-assisted mini-thoracotomy between December 2009 and December 2015 were the cohort of this retrospective study. Single camera port and a utility incision (3-4 cm) were used for access. Data of patient demographics with preoperative and postoperative spirometric results were collected for statistical comparison. RESULTS Procedure (30 left, 7 right) was completed in 37 (27 male, 10 female) patients. One patient was excluded because of insufficient objective postoperative comparison criteria due to previous permanent tracheostomy. Mean length of surgery was 48.8 ± 19.7 (range: 30-70) min. Postoperative overall morbidity was 8.3 %, with no mortality. The mean length of hospital stay was 3.1 ± 1.7 days. All patients except one (97.3 %) were asymptomatic on discharge and on follow-ups. Significant improvement in measurements of forced expiratory volume in 1st second was observed on postoperative measurements (P < 0.001), with a mean overall increase of 13 % in whole cohort. No recurrence was detected throughout a mean follow-up of 19 months. CONCLUSIONS Diaphragmatic plication via video-assisted mini-thoracotomy is an effective and curative surgical procedure which can be performed successfully with low morbidity rates. As it combines the rapidity and economical benefits of open thoracotomy with the advantages of video thoracoscopic procedures such as fast recovery and short postoperative hospital stay, it can be preferred as a safe and effective alternative hybrid method compared to standard open or closed techniques, for symptomatic patients with non-functional hemidiaphragm.
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Evman S, Tezel C, Vayvada M, Kanbur S, Urek S, Baysungur V, Yalçınkaya I. Comparison of Mid-Term Clinical Outcomes of Different Surgical Approaches in Symptomatic Diaphragmatic Eventration. Ann Thorac Cardiovasc Surg 2016; 22:224-9. [PMID: 27076066 DOI: 10.5761/atcs.oa.16-00018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE There is no data comparing different surgical techniques for diaphragmatic re-positioning for hemi-diaphragmatic eventration in adults. Our aim was to verify the potential pros and cons of two major surgical techniques in symptomatic eventration patients. METHODS Patients undergoing thoracotomy for diaphragmatic elevation repair either by un-opened (accordion placation) or by opened (double-breasted placation) diaphragmatic technique between January 2007 and August 2013 were analyzed retrospectively, and compared in terms of operative outcomes on 12th and 24th months. RESULTS Forty-two patients underwent accordion (n = 23) or double-breasted (n = 19) plication. Postoperative drainage was significantly increased (215 ± 66 ml vs. 114 ± 48 ml; P = 0.0082) in double-breasted group. Although the corrected diaphragm was radiologically better preserved in this group, this divergence showed no additional effect on postoperative pulmonary functions or the dyspnea score on 12th or 24th months. No complication particularly related to both techniques or recurrence was noted during follow-up of 28 ± 12 months. CONCLUSIONS Radiological prospect of corrected diaphragm is better preserved with double-breasted plication, but the significant and permanent improvement of respiratory functions was similar. Since the clinical outcome is equivalent, incision of the diaphragm is not essential.
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Affiliation(s)
- Serdar Evman
- Department of Thoracic Surgery, Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
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Mead AF, Petrov M, Malik AS, Mitchell MA, Childers MK, Bogan JR, Seidner G, Kornegay JN, Stedman HH. Diaphragm remodeling and compensatory respiratory mechanics in a canine model of Duchenne muscular dystrophy. J Appl Physiol (1985) 2014; 116:807-15. [PMID: 24408990 DOI: 10.1152/japplphysiol.00833.2013] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Ventilatory insufficiency remains the leading cause of death and late stage morbidity in Duchenne muscular dystrophy (DMD). To address critical gaps in our knowledge of the pathobiology of respiratory functional decline, we used an integrative approach to study respiratory mechanics in a translational model of DMD. In studies of individual dogs with the Golden Retriever muscular dystrophy (GRMD) mutation, we found evidence of rapidly progressive loss of ventilatory capacity in association with dramatic morphometric remodeling of the diaphragm. Within the first year of life, the mechanics of breathing at rest, and especially during pharmacological stimulation of respiratory control pathways in the carotid bodies, shift such that the primary role of the diaphragm becomes the passive elastic storage of energy transferred from abdominal wall muscles, thereby permitting the expiratory musculature to share in the generation of inspiratory pressure and flow. In the diaphragm, this physiological shift is associated with the loss of sarcomeres in series (∼ 60%) and an increase in muscle stiffness (∼ 900%) compared with those of the nondystrophic diaphragm, as studied during perfusion ex vivo. In addition to providing much needed endpoint measures for assessing the efficacy of therapeutics, we expect these findings to be a starting point for a more precise understanding of respiratory failure in DMD.
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Affiliation(s)
- A F Mead
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Kaufman MR, Elkwood AI, Colicchio AR, CeCe J, Jarrahy R, Willekes LJ, Rose MI, Brown D. Functional restoration of diaphragmatic paralysis: an evaluation of phrenic nerve reconstruction. Ann Thorac Surg 2013; 97:260-6. [PMID: 24266954 DOI: 10.1016/j.athoracsur.2013.09.052] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Revised: 09/10/2013] [Accepted: 09/13/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Unilateral diaphragmatic paralysis causes respiratory deficits and can occur after iatrogenic or traumatic phrenic nerve injury in the neck or chest. Patients are evaluated using spirometry and imaging studies; however, phrenic nerve conduction studies and electromyography are not widely available or considered; thus, the degree of dysfunction is often unknown. Treatment has been limited to diaphragmatic plication. Phrenic nerve operations to restore diaphragmatic function may broaden therapeutic options. METHODS An interventional study of 92 patients with symptomatic diaphragmatic paralysis assigned 68 (based on their clinical condition) to phrenic nerve surgical intervention (PS), 24 to nonsurgical (NS) care, and evaluated a third group of 68 patients (derived from literature review) treated with diaphragmatic plication (DP). Variables for assessment included spirometry, the Short-Form 36-Item survey, electrodiagnostics, and complications. RESULTS In the PS group, there was an average 13% improvement in forced expiratory volume in 1 second (p < 0.0001) and 14% improvement in forced vital capacity (p < 0.0001), and there was corresponding 17% (p < 0.0001) and 16% (p < 0.0001) improvement in the DP cohort. In the PS and DP groups, the average postoperative values were 71% for forced expiratory volume in 1 second and 73% for forced vital capacity. The PS group demonstrated an average 28% (p < 0.01) improvement in Short-Form 36-Item survey reporting. Electrodiagnostic testing in the PS group revealed a mean 69% (p < 0.05) improvement in conduction latency and a 37% (p < 0.0001) increase in motor amplitude. In the NS group, there was no significant change in Short-Form 36-Item survey or spirometry values. CONCLUSIONS Phrenic nerve operations for functional restoration of the paralyzed diaphragm should be part of the standard treatment algorithm in the management of symptomatic patients with this condition. Assessment of neuromuscular dysfunction can aid in determining the most effective therapy.
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Affiliation(s)
- Matthew R Kaufman
- Department of Surgery, Jersey Shore University Medical Center, Neptune, New Jersey; The Institute for Advanced Reconstruction, Shrewsbury, New Jersey.
| | - Andrew I Elkwood
- Department of Surgery, Jersey Shore University Medical Center, Neptune, New Jersey; The Institute for Advanced Reconstruction, Shrewsbury, New Jersey
| | - Alan R Colicchio
- Department of Neuroscience, Jersey Shore University Medical Center, Neptune, New Jersey
| | - John CeCe
- The Institute for Advanced Reconstruction, Shrewsbury, New Jersey
| | - Reza Jarrahy
- Department of Surgery, Ronald Reagan UCLA Medical Center, Los Angeles, California
| | | | - Michael I Rose
- Department of Surgery, Jersey Shore University Medical Center, Neptune, New Jersey; The Institute for Advanced Reconstruction, Shrewsbury, New Jersey
| | - David Brown
- Department of Physical Medicine and Rehabilitation, JFK Medical Center, Edison, New Jersey
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27
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Welvaart WN, Jak PMC, van de Veerdonk MC, Marcus JT, Ottenheijm CAC, Paul MA, Vonk Noordegraaf A. Effects of diaphragm plication on pulmonary function and cardiopulmonary exercise parameters. Eur J Cardiothorac Surg 2013; 44:643-7. [PMID: 23449864 DOI: 10.1093/ejcts/ezt094] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVES Paralysis of the diaphragm is an uncommon condition, which may result in dyspnoea on excertion and in orthopnea. In patients who have symptoms, the paralysed diaphragm is often plicated to prevent its paradoxical movement on inspiration. This procedure brings relief to many patients, but the mechanism for this improvement is not well understood. METHODS Nine symptomatic patients who underwent plication of a unilateral paralysed hemidiaphragm were prospectively evaluated. All patients underwent pulmonary function tests and cardiopulmonary exercise tests before surgery and repeated them after surgery. RESULTS Patients with hemidiaphragm paralysis before surgery were found to have lower tidal volumes at any given ventilation rate during exercise than normal subjects. A clear and consistent change was found in the manner in which patients increased their ventilation during exercise after surgery. All patients showed an increase in tidal volume for a given ventilation rate, which was significant. The plication procedure reduced the respiratory rate for any exercise level in all patients, and this effect was more pronounced during exercise. CONCLUSIONS In patients with hemidiaphragm paralysis who underwent a diaphragm plication exercise, tidal volumes increased and the ventilatory frequency decreased. Despite this improvement, maximal exercise capacity remained unaltered.
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Affiliation(s)
- Willem N Welvaart
- Department of Surgery, VU University Medical Center/Institute for Cardiovascular Research, Amsterdam, Netherlands
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28
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Sarwal A, Walker FO, Cartwright MS. Neuromuscular ultrasound for evaluation of the diaphragm. Muscle Nerve 2013; 47:319-29. [PMID: 23382111 DOI: 10.1002/mus.23671] [Citation(s) in RCA: 181] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2012] [Indexed: 12/17/2022]
Abstract
Neuromuscular clinicians are often asked to evaluate the diaphragm for diagnostic and prognostic purposes. Traditionally, this evaluation is accomplished through history, physical exam, fluoroscopic sniff test, nerve conduction studies, and electromyography (EMG). Nerve conduction studies and EMG in this setting are challenging, uncomfortable, and can cause serious complications, such as pneumothorax. Neuromuscular ultrasound has emerged as a non-invasive technique that can be used in the structural and functional assessment of the diaphragm. In this study we review different techniques for assessing the diaphragm using neuromuscular ultrasound and the application of these techniques to enhance diagnosis and prognosis by neuromuscular clinicians.
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Affiliation(s)
- Aarti Sarwal
- Department of Neurology, Wake Forest School of Medicine, Reynolds M, Medical Center Boulevard, Winston-Salem, North Carolina 27157, USA.
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29
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Visouli AN, Mpakas A, Zarogoulidis P, Machairiotis N, Stylianaki A, Katsikogiannis N, Tsakiridis K, Courcoutsakis N, Zarogoulidis K. Video assisted thoracoscopic plication of the left hemidiaphragm in symptomatic eventration in adulthood. J Thorac Dis 2013; 4 Suppl 1:6-16. [PMID: 23304437 DOI: 10.3978/j.issn.2072-1439.2012.s001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2012] [Accepted: 11/22/2012] [Indexed: 11/14/2022]
Abstract
Diaphragmatic eventration is a rare congenital developmental defect of the muscular portion of the diaphragm, which appears attenuated and membranous, maintaining its normal attachments and its anatomical continuity. It has been attributed to abnormal myoblast migration to the septum transversum and the pleuroperitoneal membrane. Eventration can be unilateral or bilateral, partial or complete. It is more common in males, and involves more often the left hemidiaphragm. Eventration results in diaphragmatic elevation (cephalad displacement). Most adults are asymptomatic and the diagnosis is incidentally made by chest radiography. The commonest symptom in the adults is dyspnoea, while orthopnoea, mild hypoxemia, tachypnoea, respiratory alkalosis, palpitations, and non specific gastrointestinal symptoms may be present. Surgery is indicated only in the presence of symptoms. The established surgical treatment is diaphragmatic plication. Various techniques and approaches have been employed. We present a simple surgical technique of a 3-port video assisted thoracoscopic plication of the left hemidiaphragm in the adult.
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30
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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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