MMCTS
(December 17, 2007). doi:10.1510/mmcts.2006.002568
Copyright © 2007 European Association for Cardio-thoracic Surgery
Procedure
Diaphragm plication in adult patients with diaphragm paralysis
Michel I. M. Versteegh* and
Andrew Tjon Jouk Tjien
Department of Cardio-thoracic Surgery, Leiden University Medical Center, K6-S, PO Box 9600, 2300 RC Leiden, The Netherlands
* Corresponding author: * Tel.: +31-71-5262355; fax: +31-71-5266359 m.i.m.versteegh{at}lumc.nl
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Summary
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Diaphragm paralysis in adults can cause severe dyspnea which results from the paradoxical movement of the diaphragm. Surgical plication can be done with excellent long-term results.
Key Words: Diaphragm paralysis • Neuralgic amyotrophy • Surgery for dyspnea • Surgical plication of the diaphragm
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Introduction
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Diaphragm paralysis in adults results from an acquired dysfunction of the phrenic nerve. Patients usually present with dyspnea on exertion; however, the severe and progressive dyspnea when bending over or changing to supine position is in most cases even more disturbing and almost pathognomonic for this disease. Patients eventually have to sleep in upright position and have to stop working. The progression of dyspnea is caused by a decline in lung volumes, i.e. vital capacity (VC) and forced expiratory volume in one second (FEV1). Also immersion in water (taking a bath or swimming) causes deterioration of dyspnea by the increased pressure on the abdomen.
Etiology
Phrenic nerve dysfunction can be caused by any disorder which affects nerve tissues, including trauma. Iatrogenic trauma during cardiac [1, 2] and oncological surgery of tumors involving the area of the phrenic nerve have to be mentioned. Diaphragm paralysis can also be part of a neuropathological entity called neuralgic amyotrophy. Although this can occur without any symptom at all, most of these patients have a history of a viral infection like a common cold or influenza and a sudden pain in the shoulder or neck region before the onset of progressive dyspnea [3, 5]. These patients typically suffer from a weakness of the arm, which eventually recovers. The recovery of diaphragmatic strength, however, is highly variable. If there is no sign of recovery at all after one year, the chances of complete recovery of muscle strength seems small.
Diagnosis
Diaphragm paralysis can be suspected on a chest X-ray (Photo 1). Pulmonary function tests in upright and supine position and a paradoxical diaphragm movement in a sniff-test with fluoroscopy or ultrasound are all that is needed to confirm the diagnosis.
Treatment
Surgical treatment by diaphragm plication has been described since 1985 in small series for unilateral paralysis and bilateral paralysis (Table 1). Some of these studies only or mainly concern patients after cardiac surgery with problems at weaning from ventilation. Follow-up in most studies is limited both in number of patients and in time.
We describe the technique performed until now in 28 patients of whom five had bilateral and 23 unilateral paralysis. The long-term effects of 17 of these procedures were presented at the 2006 EACTS/ESTS joint meeting and have recently been published. [7] (Table 2). All values of spirometry tests improved significantly resulting in a remarkable decrease of the loss of lung capacity going from upright to supine position. Also the dyspnea scores show a substantial and persistent improvement of dyspnea resulting in the possibility for the patients to return to a more or less normal way of life.
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Surgical procedure
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The surgical technique used in our center consists of a limited lateral thoracotomy through the 8th intercostal space (Schematic 1, Video 1). By this technique an excellent exposure of the diaphragm can be achieved (Video 2).
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Schematic 1 After opening the chest the top of the paralyzed diaphragm can be found cranial of the level of the hilum.
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Video 1 The thoracic cavity is opened through a limited lateral thoracotomy through the 8th intercostal space. The length of the incision is indicated here by the two dots.
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Video 2 By this incision the exposure of the diaphragm is excellent.
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It is very important to realize that the paralyzed diaphragm is usually very thin. Passing the needles has to be done with extreme care to avoid damaging the abdominal organs in which gentle traction on the diaphragm will help (Video 3).
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Video 3 A paralyzed diaphragm can be extremely thin. It is important to pull the diaphragm upward to avoid damage to the underlying organs.
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The uncut diaphragm is shortened first in the antero-posterior direction with a number of U-stitches (Mersilene® 2 without needle; Ethicon, Norderstedt, Germany – MMCTSLink 36), starting on the mediastinal or on the lateral side (Schematic 2, Video 4). There is no material used to reinforce the sutures. These sutures are tied as tight as possible (Schematic 3).
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Schematic 2 The first layer of stitches is used to shorten the diaphragm primarily in antero-posterior direction. No reinforcement at all is being used.
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Video 4 The diaphragm is plicated with a number of U-stitches.
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If the surgeon is not completely satisfied a second layer below the first can be placed (Video 5).
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Video 5 If the surgeon is not completely satisfied, he should place a second suture layer.
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Then another radial U-stitch is used to complete the shortening in lateral direction (Schematics 4 and 5, Video 6).
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Schematic 5 The shortening of the diaphragm in both directions results in redundant tissue in the center of the diaphragm.
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Video 6 After the plication in antero-posterior direction, a shortening in lateral direction adds even more tightness to the diaphragm.
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Redundant tissue is flattened both anteriorly and posteriorly to the plicature with running sutures (Ethibond® 2-0 with SH-needles; Ethicon – MMCTSLink 24 – (Schematic 6, Video 7). The result is a tense and firm diaphragm (Schematic 7, Video 7, Photo 2).
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Schematic 6 The redundant tissue is flattened to reduce adhesions in the thoracic cavity and to add additional strength to the repair.
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Video 7 Flattening the redundant tissue.
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If a patient has bilateral paralysis, both sides can be plicated in one surgical procedure, although we do recommend performing two separate procedures with an interval of approximately two months.
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Postoperative period
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Most patients can be extubated in the operating room. For all patients an ICU-bed was available which was used in about 50% of the patients for one night (first years of our experience). Sometimes patients develop a paralytic ileus for two or three days. Probably this is due to some blood in the abdominal cavity and in all our patients it did recover spontaneously. Almost all patients experience a feeling of tightness in the lower chest/upper abdominal area after the procedure. This feeling may never disappear completely.
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Discussion
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For this surgical procedure we made the choice for an open technique for several reasons. First, the advantages of a thoracoscopic technique are not as evident as is sometimes described. Although the incisions are smaller, the incidence and intensity of post-thoracotomy pain does not seem to be very different after a thoracoscopic procedure or a lateral thoracotomy. Secondly, a paralyzed diaphragm can be very thin and, as can be seen in the videos, extreme care has to be taken not to damage the abdominal organs just below this thin structure. Can this be safely performed with a thoracoscopic technique? It is obvious that it can be difficult to fully inspect the highly elevated dome of a paralyzed diaphragm. The third argument considers the tightness of the plication. We regard it of high importance that the diaphragm is made as tense as possible. We speculate that this is one of the reasons the beneficial effects of the plication in our patients hold on over the years. Because we do wonder if such a tense diaphragm can be achieved with a video-assisted technique lacking full tactile feedback, we made the choice to use the open procedure. Obviously, there are no head-to-head comparisons to date.
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Acknowledgements
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The authors would like to express their gratitude to Dr R. Smithuis, radiologist in Rijnland Ziekenhuis, Leiderdorp, The Netherlands for his help with the drawings.
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References
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- Higgs SM, Hussain A, Jackson M, Donnelly RJ, Berrisford RG. Long term results of diaphragmatic plication for unilateral diaphragm paralysis. Eur J Cardiothorac Surg 2002;21:294–297.[Abstract/Free Full Text]
- Kuniyoshi Y, Yamashiro S, Miyagi K, Uezu T, Arakaki K, Koja K. Diaphragmatic plication in adult patients with diaphragm paralysis after cardiac surgery. Ann Thorac Cardiovasc Surg 2004;10:160–166.[Medline]
- HÜttl TP, Wichmann MW, Reichart B, Geiger TK, Schildberg FW, Meyer G. Laparoscopic diaphragmatic plication: long-term results of a novel technique for postoperative phrenic nerve palsy. Surg Endosc 2004;18:547–551.[CrossRef][Medline]
- Mouroux J, Venissac N, Leo F, Alifano M, Guillot F. Surgical treatment of diaphragmatic eventration using video-assisted thoracic surgery: a prospective study. Ann Thorac Surg 2005;79:308–312.[Abstract/Free Full Text]
- Freeman RK, Wozniak TC, Fitzgerald EB. Functional and physiologic results of video-assisted thoracoscopic diaphragm plication in adult patients with unilateral diaphragm paralysis. Ann Thorac Surg 2006;81:1853–1857.[Abstract/Free Full Text]
- Stolk J, Versteegh MI. Long-term effect of bilateral plication of the diaphragm. Chest 2000;117:786–789.[CrossRef][Medline]
- Versteegh MIM, Braun J, Voigt PG, Bosman DB, Stolk J, Rabe KF, Dion RAE. Diaphragm plication in adult patients with diaphragm paralysis leads to long-term improvement of pulmonary function and level of dyspnea. Eur J Cardiothorac Surg 2007;32:449–456.[Abstract/Free Full Text]
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Summary
Introduction
