Diaphragmatic Plication: Retrospective Study with 54 Patients

Sezai Çelik, Serhan Tanju, İsa Döngel, Onur Gürer, Alper Toker

Cardiothoracic Surgery Department, Medicana Hospitals, Istanbul, Turkey;.
Thoracic Surgery Department, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey..

DOI: 10.4236/ojts.2013.33019                

Abstract

Objective: This study seeks to evaluate the results of surgery performed according to the etiological causes of diaphragmatic eventration or paralysis. Method: Files of 54 patients (35 males, 19 females; mean age: 39.1 ± 3.01 years) who had undergone diaphragm plication between January 2005 and June 2011 in two clinics located in Istanbul were studied in terms of pulmonary spirometry, applied surgical procedure, duration of hospitalization, morbidity, and mortality. Results: In diaphragm plications, observed etiologies were isolated diaphragmatic eventration without phrenic nerve injury (Group 1) in 20 (37%) patients due to blunt thoracic trauma; Group 2 (thymoma in 19 (35.2%) patients; lung cancer in 7 (12.9%) patients; mediastinal tumor in 3 (5.6%) patients) and congenital heart surgery (Group 3) in 5 (9.3%) patients. The mean time to plication was 7.4 months in Group 1. The mean duration of hospitalization was 4 days in Group 1, 6.2 days in Group 2, 11.8 days in Group 3. Mean forced vital capacity, forced expiratory volume at 1 second improved by 17%, 20.3%, respectively (p < 0.005) in Group 1. In Group 1, mean dyspnea-related hospital admission before plication was 2.4 times. At the end of 6 months after plication mean dyspnea-related hospital admission was 0 time. All of them returned to daily activities or their job within 6 months in Group 1. Postoperative mortality was observed in 2 (3.7%) patients in Group 3 while the overall complication rates were 24%. The morbidity rates were 8%, 27.5%, 60%, respectively; and the mortality rates were 0%, 0%, 40%, respectively. Conclusion: As a result, it could be suggested that early and timely performed plications for diaphragmatic eventration improves functional status and assesses a shorter lenght of stay. On the other hand,simultaneously performed plications in intraoperative phrenic nerve resections can be performed with acceptable morbidity and no mortality. In diaphragmatic paralysis due to congenital heart surgery, morbidity and mortality rate is still high.

Keywords

Diaphragm Plication; Paralysis; Eventration; Phrenic Nerve Resection

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	T. W. Shields, “Diaphragmatic Function, Diaphragmatic Paralysis, and Eventration of the Diaphragm,” In: T. W. Shields, J. Locicero and R. B. Ponn, Eds., General Thoracic Surgery, Vol. 1, 6th Edition, Lippincott, Williams and Wilkins, Philadelphia, 2004, pp. 740-745.
[2]	J. M. Piehler, P. C. Pairolero, D. R.Gracey and P. E. Bernatz, “Unexplained Diaphragmatic Paralysis: A Harbinger of Malignant Disease?” The Journal of Thoracic and Cardiovascular Surgery, Vol. 84, No. 6, 1982, pp. 861-864.
[3]	M. Ribet and J. L. Linder, “Plication of the Diaphragma for Unilateral Eventration or Paralysis,” European Journal Cardio-Thorac Surgery, Vol. 6, No. 7, 1992, pp. 357-360.
[4]	R. W. Light, “Disorders of the Pleura, Mediastinum, and Diaphragm,” In: E. Braunwald, A. C. Fauci, D. L. Casper, et al., Eds., Harrison’s Principles of Internal Medicine, 15th Edition, McGraw-Hill, New York, 2001, pp. 1513-1516.
[5]	T. P. Hüttl, M. W. Wichmann, B. Reichart, T. K. Geiger, et al., “Paralysis of the Diaphragm Is a Severe Complication of Cardiothoracic Surgery Carrying Significant Morbidity and Mortality,” Surgery Endoscopy, Vol. 18, No. 3, 2004, pp. 547-551. doi:10.1007/s00464-003-8127-8
[6]	T. Tiryaki, Z. Livanelioglu and H. Atayurt, “Eventration of the Diaphragm,” Asian Journal Surgery, Vol. 29, No. 1, 2006, pp. 8-10. doi:10.1016/S1015-9584(09)60285-2
[7]	P. Gatzinsky and V. Lepore, “Surgical Treatment of a Large Eventration of the Left Diaphragm,” European Journal Cardio-Thoracic Surgery, Vol. 7, No. 5, 1993, pp. 271-274. doi:10.1016/1010-7940(93)90216-X
[8]	C. D. Wright, J. G. Williams, C. M. Ogilvie and R. J. Donnelly, “Results of Diaphragmatic Plication for Unilateral Diaphragmatic Paralysis,” The Journal of Thoracic Cardiovascular Surgery, Vol. 90, No. 2, 1985, pp. 195-198.
[9]	F. Oguzkaya, M. Bilgin, Y. Akcali, C. Kahraman and A. Sahin, “Diaphragmatic Plication in Unilateral Diaphragmatic Paralysis or Evantration in Adults,” Türk Gogüs Kalp ve Damar Cerrahisi Dergisi, Vol. 6,1998, pp. 63-67.
[10]	D. A. Simansky, M. Paley, Y. Refaely and A. Yellin, “Diaphragm Plication Following Phrenic Nerve Injury: A Comparison of Paediatric and Adult Patients,” Thorax, Vol. 57, No. 7, 2002, pp. 613-616. doi:10.1136/thorax.57.7.613
[11]	B. R. Celli, “Respiratory Management of Diaphragm Paralysis,” Seminars Respiratory Critical Care Medicine, Vol. 23, No. 3, 2002, pp. 275-281. doi:10.1055/s-2002-33036
[12]	S. Celik, M. Celik, B. Aydemir, C. Tunckaya, T. Okay and I. Dogusoy, “Long-Term Results of Diaphragmatic Plication in Adults with Unilateral Diaphragm Paralysis,” Journal of Cardiothoracic Surgery, Vol. 5, 2010, p. 111. doi:10.1186/1749-8090-5-111
[13]	K. Tsakiridis, A. N. Visouli, P. Zarogoulidis, N. Machairiotis, et al., “Early Hemi-Diaphragmatic Plication through a Video-Asisted Mini-Thoracotomy in Postcardiotomy Phrenic Nerve Paresis,” Journal of Thoracic Disease, Vol. 4, No. 1, 2012, pp. 56-58.
[14]	K. Kondo and Y. Monden, “Therapy for Thymic Epithelial Tumors: A Clinical Study of 1320 Patients from Japan,” Annals of Thoracic Surgery, Vol. 76, No. 3, 2003, pp. 878-884.
[15]	K. Nakagawa, H. Asamura, Y. Matsuno, K. Suzuki, H. Kondo, A. Maeshima, et al., “Thymoma: A Clinicopathologic Study Based on the New World Health Organization Classification,” Journal of Thoracic Cardiovascular Surgery, Vol. 126, No. 4, 2003, pp. 1134-1140. doi:10.1016/S0022-5223(03)00798-0
[16]	M. Yano, H. Sasak, S. Moriyama, O. Kawano, Y. Hikosaka, A. Masaoka and Y. Fujii, “Preservation of Phrenic Nerve Involved by Stage III Thymoma,” Annals of Thoracic Surgery, Vol. 89, No. 5, 2010, pp. 1612-1619. doi:10.1016/j.athoracsur.2010.01.057
[17]	T. Tokunaga, N. Sawabata, Y. Kadota, T. Utsumi, M. Minami, et al. “Efficacy of Intra-Operative Unilateral Diaphragm Plication for Patients Undergoing Unilateral Phrenicotomy during Extended Surgery,” European Journal of Cardio-Thoracic Surgery, Vol. 38, No. 5, 2010, pp. 600-603. doi:10.1016/j.ejcts.2010.03.012
[18]	S. Shawn, M. D. Groth, S. Rafael and M. D. Andrade, “Diaphragm Plication for Eventration or Paralysis: A Review of the Literature,” Annals of Thoracic Surgery, Vol. 89, No. 6, 2010, pp. 2146-2150. doi:10.1016/j.athoracsur.2010.03.021
[19]	A. L. J. Arreola, U. Bauersfeld, U. G. Stauffer, O. Baenziger and V. Bernet, “Incidence and Treatment of Diaphragmatic Paralysis after Cardiac Surgery in Children,” European Journal of Cardio-Thoracic Surgery, Vol. 27, No. 1, 2005, pp. 53-57. doi:10.1016/j.ejcts.2004.10.002
[20]	Q. Mok, R. Ross-Russel, D. Mulvey and E. A. Shinebourne, “Phrenic Nerve Injury in Infants and Children Undergoing Cardiac Surgery,” British Heart Journal, Vol. 65, No. 5, 1991, pp. 287-292. doi:10.1136/hrt.65.5.287
[21]	A. E. El Tantawy, S. Imam, H. Swaky and T. Salah, “Diaphragmatic Nerve Palsy after Cardiac Surgery in Children in Egypt. Outcome and Debate in Management,” World Journal of Pediatrics & Congenital Heart Surgery, Vol. 4, No. 1, 2013, pp. 19-23. doi:10.1177/2150135112454444