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Kosse NJ, Galetin T, Schwarz SB, Mathes T, Koryllos A, Lopez-Pastorini A, Beckers F, Stoelben E. Results of the Diaphragmatic Plication Database: 10 Years' Experience. Thorac Cardiovasc Surg 2023; 71:483-489. [PMID: 34655069 DOI: 10.1055/s-0041-1735496] [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: 10/20/2022]
Abstract
BACKGROUND Unilateral diaphragmatic paralysis or paresis (UDP) in adults is an often overlooked disease which relevantly impairs the patient's lung function and quality of life. Particularly in idiopathic UDP, there is no evidence for conservative therapy and only little evidence for surgical therapy. METHODS The method involves retrospective single-center analysis of patients with UDP persistent for at least 1 year who were operated by diaphragmatic resection, plication, and augmentation with a polypropylene mesh. The patients were tested for lung and diaphragmatic function, six-minute walk test (6MWT), and blood gas analysis before, 3 and 12 months after surgery. RESULTS In total, 85 patients received surgery for UDP. The most frequent reasons for UDP were idiopathic (67%), iatrogenic (mainly cardiac and cervical spine surgery; 24%), and trauma (9%). The mean operation time was 84 ± 24 minutes, the length of hospital stay 8.4 ± 3.9 days, chest tubes were removed after 11.7 ± 4.1 days. Overall morbidity was 42%, mortality 0%. Forced expiratory volume in one second (FEV1) in supine position improved by 12.4% absolute, vital capacity by 11.8% absolute, and sniff nasal inspiratory pressure by 1.4 kPa 12 months after surgery (p <0.001 each). Total lung capacity increased by 6.8% absolute at 12 months (p = 0.001) The 6MWT distance improved by 45.9 m at 3 months and 50.9 m at 12 months (p = 0.001, each). CONCLUSION Surgical therapy for UDP is highly effective in the long term. The superiority over conservative treatments needs to be evaluated prospectively with standardized physiotherapeutic protocols. FEV1 in supine position and 6MWT are easy to perform tests and represent statistically and patient-relevant outcomes.
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Affiliation(s)
- Nils Jurriaan Kosse
- Department of Thoracic Surgery, University Witten Herdecke Faculty of Health, Witten, Germany
- Lung Clinic Merheim/Thoracic Surgery, Kliniken der Stadt Köln gGmbH, Koln, Germany
| | - Thomas Galetin
- Department of Thoracic Surgery, University Witten Herdecke Faculty of Health, Witten, Germany
- Lung Clinic Merheim/Thoracic Surgery, Kliniken der Stadt Köln gGmbH, Koln, Germany
| | - Sarah Bettina Schwarz
- Department of Pneumology, University Witten Herdecke Faculty of Health, Witten, Germany
- Lungclinic Merheim/Pneumology, Kliniken der Stadt Köln gGmbH, Koeln, Germany
| | - Tim Mathes
- Institut für Forschung in der operativen Medizin (IFOM), Universität Witten/Herdecke Fakultät für Gesundheit, Witten, Nordrhein-Westfalen, Germany
| | - Aris Koryllos
- Department of Thoracic Surgery, University Witten Herdecke Faculty of Health, Witten, Germany
- Lung Clinic Merheim/Thoracic Surgery, Kliniken der Stadt Köln gGmbH, Koln, Germany
| | - Alberto Lopez-Pastorini
- Department of Thoracic Surgery, University Witten Herdecke Faculty of Health, Witten, Germany
- Lung Clinic Merheim/Thoracic Surgery, Kliniken der Stadt Köln gGmbH, Koln, Germany
| | - Frank Beckers
- Department of Thoracic Surgery, St Vinzenz Hospital, Koeln, Germany
| | - Erich Stoelben
- Department of Thoracic Surgery, University Witten Herdecke Faculty of Health, Witten, Germany
- Lung Clinic Merheim/Thoracic Surgery, Kliniken der Stadt Köln gGmbH, Koln, Germany
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2
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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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3
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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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4
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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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5
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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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6
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Nardini M, Jayakumar S, Migliore M, Nosotti M, Paul I, Dunning J. Minimally Invasive Plication of the Diaphragm: A Single-Center Prospective Study. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2021; 16:343-349. [PMID: 34130535 DOI: 10.1177/15569845211011583] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Marco Nardini
- 9304 Department of Thoracic Surgery and Lung Transplantation, University of Milan, Italy.,4964 Department of Cardiothoracic Surgery, Royal Brompton and Harefield Hospitals, London, UK
| | - Shruti Jayakumar
- 156705 Department of Thoracic Surgery, James Cook University Hospital, Middlesbrough, UK
| | - Marcello Migliore
- 8903 Department of Thoracic Surgery, University Hospital of Wales, Cardiff, UK
| | - Mario Nosotti
- 9304 Department of Thoracic Surgery and Lung Transplantation, University of Milan, Italy
| | - Ian Paul
- 156705 Department of Thoracic Surgery, James Cook University Hospital, Middlesbrough, UK
| | - Joel Dunning
- 156705 Department of Thoracic Surgery, James Cook University Hospital, Middlesbrough, UK
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7
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Draeger H, Salman J, Aburahma K, Becker LS, Siemeni T, Boethig D, Sommer W, Avsar M, Bobylev D, Schwerk N, Müller C, Greer M, Gottlieb J, Welte T, Hoeper MM, Hinrichs JB, Tudorache I, Kühn C, Haverich A, Warnecke G, Ius F. Impact of unilateral diaphragm elevation on postoperative outcomes in bilateral lung transplantation - a retrospective single-center study. Transpl Int 2021; 34:474-487. [PMID: 33393142 DOI: 10.1111/tri.13812] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 11/17/2020] [Accepted: 12/27/2020] [Indexed: 12/18/2022]
Abstract
This study evaluated the impact of unilateral diaphragm elevation following bilateral lung transplantation on postoperative course. Patient data for all lung transplantations performed at our institution between 01/2010 and 12/2019 were reviewed. Presence of right or left diaphragm elevation was retrospectively evaluated using serial chest X-rays performed while patients were standing and breathing spontaneously. Right elevation was defined by a > 40 mm difference between right and left diaphragmatic height. Left elevation was present if the left diaphragm was at the same height or higher than the right diaphragm. In total, 1093/1213 (90%) lung transplant recipients were included. Of these, 255 (23%) patients exhibited radiologic evidence of diaphragm elevation (right, 55%; left 45%; permanent, 62%). Postoperative course did not differ between groups. Forced expiratory volume in 1 second, forced vital capacity and total lung capacity were lower at 1-year follow-up in patients with permanent than in patients with transient or absent diaphragmatic elevation (P = 0.038, P < 0.001, P = 0.002, respectively). Graft survival did not differ between these groups (P = 0.597). Radiologic evidence of diaphragm elevation was found in 23% of our lung transplant recipients. While lung function tests were worse in patients with permanent elevation, diaphragm elevation did not have any relevant impact on outcomes.
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Affiliation(s)
- Helge Draeger
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jawad Salman
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Khalil Aburahma
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Lena S Becker
- Department of Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Thierry Siemeni
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Dietmar Boethig
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Wiebke Sommer
- Department of Cardiac Surgery, Heidelberg Medical School, Heidelberg, Germany.,Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Hannover, Germany
| | - Murat Avsar
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Dmitry Bobylev
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Nicolaus Schwerk
- Department of Paediatrics, Hannover Medical School, Hannover, Germany
| | - Carsten Müller
- Department of Paediatrics, Hannover Medical School, Hannover, Germany
| | - Mark Greer
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Jens Gottlieb
- Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Hannover, Germany.,Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Tobias Welte
- Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Hannover, Germany.,Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Marius M Hoeper
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Jan B Hinrichs
- Department of Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Igor Tudorache
- Department of Cardiac Surgery, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Christian Kühn
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Axel Haverich
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany.,Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Hannover, Germany
| | - Gregor Warnecke
- Department of Cardiac Surgery, Heidelberg Medical School, Heidelberg, Germany.,Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Hannover, Germany
| | - Fabio Ius
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany.,Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Hannover, Germany
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8
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Patel DC, Berry MF, Bhandari P, Backhus LM, Raees S, Trope W, Nash A, Lui NS, Liou DZ, Shrager JB. Paradoxical Motion on Sniff Test Predicts Greater Improvement Following Diaphragm Plication. Ann Thorac Surg 2020; 111:1820-1826. [PMID: 33031777 DOI: 10.1016/j.athoracsur.2020.07.049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 07/25/2020] [Accepted: 07/30/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND Diaphragm plication (DP) improves pulmonary function and quality of life for those with diaphragm paralysis or dysfunction. It is unknown whether differing degrees of diaphragm dysfunction as measured by sniff testing affect results after plication. METHODS Patients who underwent minimally invasive DP from 2008 to 2019 were dichotomized based on sniff test results: paradoxical motion (PM) versus no paradoxical motion (NPM); the latter included normal, decreased, and no motion. Preoperative and postoperative pulmonary function testing (PFT) after DP was compared between groups. The impact of the diaphragm height index, a measure of diaphragm elevation, was also assessed. RESULTS A total of 26 patients underwent preoperative sniff testing, DP, and postoperative PFT. Including all patients, DP resulted in a 17.8% ± 5.5% improvement in forced expiratory volume in 1 second (P < .001), a 14.4% ± 5.3% improvement in forced vital capacity (P < .001), and a 4.7% ± 4.6% improvement in the diffusing capacity of carbon monoxide (P = .539). There were greater improvements in the PM group (n = 16) compared with the NPM group (n = 10) for forced expiratory volume in 1 second (27.2% ± 6.0% versus 3.9% ± 6.2%; P = .017) and forced vital capacity (28.1% ± 5.3% versus -0.5% ± 3.3%; P = .001). There was no difference in the change in the diffusing capacity of carbon monoxide between groups. There were no differences between patients with PM and NPM in the postoperative course or complications. No value for diaphragm height index predicted improvement in PFT after DP. CONCLUSIONS Patients with PM on sniff test have dramatically greater objective improvements in pulmonary function after plication compared with those without PM. Most patients without PM do not demonstrate improvement in standard PFT. Improvements in dyspnea require additional study.
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Affiliation(s)
- Deven C Patel
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Mark F Berry
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Prasha Bhandari
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Leah M Backhus
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California; Veterans Affairs Palo Alto Health System, Palo Alto, California
| | - Shehzaib Raees
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Winston Trope
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Abraham Nash
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Natalie S Lui
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Douglas Z Liou
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Joseph B Shrager
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California; Veterans Affairs Palo Alto Health System, Palo Alto, California.
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