Left Hemidiaphragm Research Articles

Efficacy of ultrasonographic diaphragmatic parameters in distinguishing diaphragmatic dysfunction in cats.

Diaphragmatic dysfunction (DD) is often underdiagnosed in veterinary medicine. Various ultrasonographic diaphragmatic parameters, including diaphragmatic excursion (DE), diaphragmatic thickness (Tdi) and diaphragmatic thickening fraction (DTF), can be used to identify DD. We aimed to establish normal reference intervals in healthy cats, examine the effects of intrinsic factors on diaphragmatic parameters and evaluate the efficacy of these parameters in identifying DD in healthy and diseased cats. This prospective observational study was conducted on 22 healthy cats and 12 diseased cats using ultrasonographic techniques to evaluate DE, Tdi and DTF. The correlation between diaphragmatic parameters and intrinsic factors, including sex, age, body weight and body condition score, was analysed using Pearson correlation analysis. Cut-off values for healthy and diseased cats were established using receiver operating characteristic curve analysis. The mean DEs of the left and right hemidiaphragms were 0.66 ± 0.16 and 0.64 ± 0.18 cm, respectively. The mean Tdis in the end-inspiration phase were 0.13 ± 0.03 and 0.12 ± 0.03 cm for the left and right hemidiaphragms, respectively, whereas in the end-expiration phase the mean Tdi was 0.07 ± 0.03 cm for both hemidiaphragms. The DTF ranges for the left and right hemidiaphragms were 23.90-122.1% and 38.80-107%, respectively. Intrinsic factors had no significant impact on DE, Tdi and DTF. The DE measurements for the left hemidiaphragm were more accurate for evaluating diaphragmatic function. To distinguish between healthy and diseased cats, the cut-off value, sensitivity and specificity were 0.458 cm (area under the curve [AUC] 0.846), 75.00% and 86.36%, respectively, for the left hemidiaphragm and 0.423 cm (AUC 0.704), 41.67% and 100%, respectively, for the right hemidiaphragm. Normal reference values for DE, Tdi and DTF were established for healthy cats. DE, particularly in the left hemidiaphragm, obtained using routine ultrasonography, improves the efficacy of identifying DD and assists clinicians in the diagnosis and treatment of cats with cardiorespiratory disease.

Quantifying Normal Diaphragmatic Motion and Shape and their Developmental Changes via Dynamic MRI

BackgroundThe diaphragm is a critical structure in respiratory function, yet in-vivo quantitative description of its motion available in the literature is limited. Research QuestionHow to quantitatively describe regional hemi-diaphragmatic motion and curvature via free-breathing dynamic magnetic resonance imaging (dMRI)? Study Design and MethodsIn this prospective cohort study we gathered dMRI images of 177 normal children and young adults and segmented hemi-diaphragm domes in end-inspiration and end-expiration phases of the constructed 4D image. We selected 25 points uniformly located on each 3D hemi-diaphragm surface. Based on the motion and local shape of hemi-diaphragm at these points, we computed the velocities and sagittal and coronal curvatures in 13 regions on each hemi-diaphragm surface and analyzed the change in these properties with age and sex. ResultsOur cohort consisted of 94 Females, 6-20 years (12.09+3.73), and 83 Males, 6-20 years (11.88+3.57). We observed velocity range: ∼2mm/s to ∼13mm/s; Curvature range – Sagittal: ∼3m-1 to ∼27m-1; Coronal: ∼6m-1 to ∼20m-1. There was no significant difference in velocity between sexes, although the pattern of change in velocity with age was different for the two groups. Strong correlations in velocity were observed between homologous regions of right and left hemi-diaphragms. There was no significant difference in curvatures between sexes or change in curvatures with age. InterpretationRegional motion/curvature of the 3D diaphragmatic surface can be estimated using free-breathing dynamic MRI. Our analysis sheds light on here-to-fore unknown matters such as how the pediatric 3D hemi-diaphragm motion/shape varies regionally, between right and left hemi-diaphragms, between sexes, and with age.

The role of extradiaphragmatic muscles’ ultrasound on the diagnosis and follow-up of diaphragmatic dysfunction associated with cervical septic arthritis: A case report and literature review

Cervical septic arthritis can lead to complications such as epidural abscess, which may result in respiratory failure. We present a case of a 78-year-old male with cervical septic arthritis complicated by epidural abscess, leading to severe diaphragm dysfunction. Ultrasound evaluation revealed dysfunction of the left hemidiaphragm and compensatory activation of accessory respiratory muscles. Treatment included antibiotic therapy and corticosteroids, alongside respiratory support. After 21 days, improvements were observed in diaphragmatic function and respiratory muscle activation. Our findings highlight the importance of assessing both diaphragm and accessory respiratory muscles in cases of cervical septic arthritis with respiratory complications.

Auto-segmentation of hemi-diaphragms in free-breathing dynamic MRI of pediatric subjects with thoracic insufficiency syndrome.

In respiratory disorders such as thoracic insufficiency syndrome (TIS), the quantitative study of the regional motion of the left hemi-diaphragm (LHD) and right hemi-diaphragm (RHD) can give detailed insights into the distribution and severity of the abnormalities in individual patients. Dynamic magnetic resonance imaging (dMRI) is a preferred imaging modality for capturing dynamic images of respiration since dMRI does not involve ionizing radiation and can be obtained under free-breathing conditions. Using 4D images constructed from dMRI of sagittal locations, diaphragm segmentation is an evident step for the said quantitative analysis of LHD and RHD in these 4D images. In this paper, we segment the LHD and RHD in three steps: recognition of diaphragm, delineation of diaphragm, and separation of diaphragm along the mid-sagittal plane into LHD and RHD. The challenges involved in dMRI images are low resolution, motion blur, suboptimal contrast resolution, inconsistent meaning of gray-level intensities for the same object across multiple scans, and low signal-to-noise ratio. We have utilized deep learning (DL) concepts such as Path Aggregation Network and Dual Attention Network for the recognition step, Dense-Net and Residual-Net in an enhanced encoder-decoder architecture for the delineation step, and a combination of GoogleNet and Recurrent Neural Network for the identification of the mid-sagittal plane in the separation step. Due to the challenging images of TIS patients attributed to their highly distorted and variable anatomy of the thorax, in such images we localize the diaphragm using the auto-segmentations of the lungs and the thoraco-abdominal skin. We achieved an average±SD mean-Hausdorff distance of ∼3±3 mm for the delineation step and a positional error of ∼3±3 mm in recognizing the mid-sagittal plane in 100 3D test images of TIS patients with a different set of ∼430 3D images of TIS patients utilized for building the models for delineation, and separation. We showed that auto-segmentations of the diaphragm are indistinguishable from segmentations by experts, in images of near-normal subjects. In addition, the algorithmic identification of the mid-sagittal plane is indistinguishable from its identification by experts in images of near-normal subjects. Motivated by applications in surgical planning for disorders such as TIS, we have shown an auto-segmentation set-up for the diaphragm in dMRI images of TIS pediatric subjects. The results are promising, showing that our system can handle the aforesaid challenges. We intend to use the auto-segmentations of the diaphragm to create the initial ground truth (GT) for newly acquired data and then refining them, to expedite the process of creating GT for diaphragm motion analysis, and to test the efficacy of our proposed method to optimize pre-treatment planning and post-operative assessment of patients with TIS and other disorders.

Diagnostic Strategy in Idiopathic Diaphragmatic Paralysis

Unilateral diaphragmatic paralysis is a medical condition characterized by the impairment of either the right or left hemidiaphragm, resulting in an inability to contract effectively during inspiration. This condition may arise due to intrinsic diaphragmatic muscle dysfunction or a disruption in the neural input from the phrenic nerve to the affected hemidiaphragm. The etiology is diverse, with clinical manifestations varying from an absence of symptoms to severe respiratory compromise. This case study aims to review the assessment and management of unilateral diaphragmatic paralysis, highlighting the role of dynamic imaging techniques, such as diaphragmatic ultrasound, in the diagnosis, evaluation, and ongoing monitoring of patients with this condition.

Effectiveness of simultaneous bilateral visual diaphragm biofeedback under low back pain: influence of age and sex.

Introduction: The aim of the present study was to determine the effectiveness of simultaneous bilateral visual diaphragm biofeedback (BFB) from ultrasonography in conjunction with inspiratory muscle training (IMT) on diaphragmatic thickness during normal breathing and respiratory and clinical outcomes in patients with non-specific low back pain (NSLBP) and determine the influence of age and sex. Methods: A single-blind randomized clinical trial was carried out (NCT04582812). A total sample of 96 patients with NSLBP was recruited and randomized by sex-based stratification into IMT (n = 48) and BFB + IMT (n = 48) interventions over 8weeks. Bilateral diaphragmatic thickness at maximum inspiration (Tins) and expiration (Texp), respiratory pressures, lung function, pain intensity, bilateral pressure pain threshold (PPT), disability, and quality of life were measured at baseline and after 8weeks. Results: The BFB + IMT group showed significant differences (p < 0.05) with increased left hemidiaphragm thickness at Tins and Tins-exp (d = 0.38-053), and right and left PPT (d = 0.71-0.74) versus the IMT group. The interaction with sex was statistically significant (p = 0.007; F(1,81) = 7.756; ηp 2 = 0.087) and higher left hemidiaphragm thickness at Tins was predicted by the BFB + IMT group (R 2 = 0.099; β = 0.050; F(1,82) = 8.997; p = 0.004) and male sex (R 2 = 0.079; β = 0.045; F(1,81) = 7.756;p = 0.007). Furthermore, greater left hemidiaphragm thickness at Tins-exp was predicted by younger age (R 2 = 0.052; β = -0.001; F(1,82) = 4.540; p = 0.036). Discussion: The simultaneous bilateral visual diaphragm biofeedback by ultrasonography in conjunction with IMT was effective in both increasing the left diaphragmatic thickness during inspiration, which was positively influenced and predicted by male sex and younger age, and increasing the bilateral PPT of the paraspinal muscles in patients with NSLBP.

Combined Rupture of the Diaphragm and Urinary Bladder in Blunt Trauma Abdomen.

The authors examined a 25-year-old man with a combined rupture of the diaphragm and urinary bladder following blunt trauma to the abdomen. The presence of hematuria, suprapubic tenderness, and elevated serum urea and creatinine levels in this patient raised suspicion of urinary bladder rupture. Documentation of bowel gas shadows on the chest x-ray suggested underlying diaphragm injury. A computed tomogram of the thorax and abdomen confirmed the tear in the left hemidiaphragm with intrathoracic herniation of abdominal contents; however, it failed to detect the intraperitoneal urinary bladder rupture. Both the defects were identified and repaired during laparotomy. The sudden increase in intraabdominal pressure in blunt trauma to the abdomen often resulted in full-thickness tears of the diaphragm and the urinary bladder. Although radiological investigations were pivotal for assessing the damage to the internal organs, a methodical and thorough exploratory laparotomy was invaluable for successfully managing patients with blunt abdominal trauma.

Incidental finding of an arteriovenous malformation originating from the diaphragm: Case report and literature review

Arteriovenous malformations (AVMs) are defined as aberrant linkages between arteries and veins in the absence of a capillary network. This case report will discuss the incidental finding of an AVM likely originating from the diaphragm. A 65-year-old female presents for an umbilical hernia repair. Her past medical history is significant for HTN, type 2 diabetes mellitus, gastroesophageal reflux disease, and class 1 obesity. She has a past surgical history of hysteroscopy in 2020 and laparoscopy in 1996. She has no history of tobacco use, alcohol use, or recreational drug use. She is allergic to contrast. A computed tomography (CT) scan was ordered and incidentally showed a soft tissue mass in the left upper quadrant adjacent to the stomach and diaphragm, possibly a gastrointestinal stromal tumor (GIST) or splenule, in addition to diastasis of the abdominal wall. Biopsies of the esophagus, stomach, and duodenum from the esophagogastroduodenoscopy (EGD) were all benign. A nuclear medicine scan of the liver and spleen found an estimated 2.3 cm soft tissue nodule located between the fundus of the stomach and the left hemidiaphragm that does not demonstrate sulfa colloid uptake and is therefore not consistent with a splenule. This is the only incidence cited of an AVM originating from the diaphragm. We suspect that the origin of this AVM is the inferior phrenic artery. The decision for management for this case was to get a CT scan of the abdomen and chest to trace the path of the AVM and manage with surveillance.

Diaphragm Pacing Elicits Ventilatory Plasticity in a Rodent Model of Spinal Cord Injury

Cervical spinal cord injury (cSCI) often results in respiratory impairments requiring the use of chronic mechanical ventilation (MV). Diaphragm pacing (DP) is an emerging clinical intervention designed to combat the deleterious effects of chronic MV by electrically stimulating the diaphragm muscle to maintain ventilation. Anecdotal clinical evidence suggests a rehabilitative benefit of DP; however, current clinical practice is limited by a lack of controlled investigations. Thus, the purpose of this ongoing study was to determine if daily DP could be used as a rehabilitative tool following cSCI. We hypothesized that following cSCI, DP would 1) induce a long-lasting increase in tidal volume 60 minutes after stimulation, and 2) result in sustained improvements in tidal volume after four days of daily DP in awake, behaving rats. To test these hypotheses, we implanted custom electromyography electrodes in the mid-costal region of the left and right hemidiaphragms of male Sprague-Dawley rats. One week later, all animals received a left C2 hemisection (C2Hx; n=14) and a subset also received a left C4-6 dorsal rhizotomy (n=3). One week after injury, rats received stimulation on the paralyzed hemidiaphragm (biphasic 30Hz, 0.8mA, 80 μs pulse width) in phase with breathing (Pacing n=5, Rhizotomy n=3), or served as controls (n=6). We delivered DP to animals within plethysmography chambers in an intermittent pattern (5 minutes on/5 minutes off) for 1 hour/day over 4 consecutive days. Using whole body plethysmography, we recorded ventilation before, during, and for 60 minutes after to examine the acute effects of DP. Additionally, we measured ventilation during normoxia (21% FiO2) and respiratory challenge (10.5% FiO2, 7% FiCO2) before and after C2Hx, and 24 hours after four days of DP to assess the rehabilitative potential of pacing. DP increased tidal volume (% change from pre-pacing) compared to control animals during stimulation (P =0.021). Animals receiving DP displayed an elevated tidal volume compared to controls for at least 60 minutes after DP (P=0.015). When compared to control animals 24 hours after the completion of the pacing protocol, DP animals displayed an increased tidal volume (mL/breath/100g) during both normoxia (P =0.006) and respiratory challenge (P =0.019). In contrast, animals pre-treated with rhizotomy showed a similar tidal volume (mL/breath/100g) compared to controls (normoxia: P=0.597; respiratory challenge: P=0.191), suggesting that DP-induced ventilatory plasticity requires phrenic afferents. Taken together, our data suggest that diaphragm pacing has rehabilitative potential and elicits functional respiratory improvements in rodents following C2Hx. Acknowledgements: This work was supported by funding from the National Institute of Health, grant numbers: R00 HL143207-01 (KAS), UL1TR001436 (TCH) and the APTA Acute Care Physical Therapy Seed Grant (TCH). This is the full abstract presented at the American Physiology Summit 2024 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Massive diaphragmatic eventration: plication

Diaphragmatic eventration (DE) is a distinctive condition characterised by the abnormal elevation or displacement of a portion of the diaphragm, often leading to a protrusion of abdominal contents into the thoracic cavity. Unlike diaphragmatic hernias, eventrations involve a congenital or acquired weakness of the diaphragmatic muscle itself rather than a structural defect. Congenital eventrations typically arise from the incomplete development or muscular hypoplasia of the diaphragm, while acquired forms may result from trauma, surgery, or neurological disorders affecting the phrenic nerve. Clinical manifestations vary widely, with some individuals remaining asymptomatic, while others may experience respiratory difficulties, especially when lying down. The case involves a 65-year-old female with a history of breathlessness exacerbated in the lying position, improved when upright. Examination revealed low oxygen saturation, absent breath sounds on the left chest, and bowel sounds in that region. Chest X-ray and HRCT indicated bowel loops in the left chest due to eventration of the left hemidiaphragm. Surgical intervention involved thoracotomy, identifying a lax left hemidiaphragm, mobilising abdominal contents, and performing plication with proline 1-0. Closure was completed with an intercostal drainage (ICD) in the left thoracic cavity. Postoperative period was uneventful. This case emphasises the significance of prompt diagnosis and surgical intervention in managing DE, showcasing the effectiveness of thoracotomy, hemidiaphragm plication, and ICD placement.

Primary splenic abscess in an adult female patient: a case report

BackgroundPrimary splenic abscess is rare and typically presents in patients who are immunocompromised. We present a case of a 47-year-old apparently immunocompetent female patient who was diagnosed with primary splenic abscess from a Salmonella Typhimurium infection following emergency laparotomy.Case presentationA 47-year-old female patient presented with subjective fever and severe epigastric and left flank pain. She was treated empirically with intravenous piperacillin/tazobactam and gentamicin and was resuscitated with intravenous crystalloid infusion. A radiological diagnosis of splenic infarct secondary to splenic artery aneurysm superimposed with splenic abscess was presumed, however at emergency laparotomy, primary splenic abscess was identified. This abscess had eroded the left hemidiaphragm and had ruptured the splenic capsule leading to intra-abdominal pus in the pelvis which on culture grew Salmonella Typhimurium. A splenectomy and primary repair of the left hemidiaphragm were performed, with postoperative pancreatitis diagnosed following the procedure. After intensive care treatment, this patient made a full recovery.ConclusionThis case of primary splenic abscess was treated successfully with a combination of surgery (i.e.: splenectomy and surgical drainage), prolonged antimicrobial therapy, and intensive care in the perioperative period.

Robotic-enhanced hybrid ablation for persistent and long-standing atrial fibrillation: Early assessment of feasibility, safety, and efficacy

ObjectivesTo assess feasibility, safety, and early efficacy of robotic-enhanced epicardial ablation (RE-EA) as first stage of a hybrid approach to patients with persistent (PsAF) and long-standing atrial fibrillation (LSAF). MethodsSingle-center, retrospective analysis of patients with documented PsAF and LSAF who underwent RE-EA followed by catheter-guided endocardial ablation. Postoperatively, patients were monitored for major adverse events and underwent rhythm follow-up at 3 and 12 months. ResultsBetween January 2021 and June 2023, we performed RE-EA in 64 patients (73.5% male, CHA2DS2-VASc 2.7 ± 1.6, BMI 34.1 ± 6.3 kg/m2). Mean AF preoperative duration and left atrial volume index were, respectively, 85 months and 47.5 mL/m2. Through the robotic approach, the intended lesion set was completed in all patients without cardiopulmonary bypass support, conversion to thoracotomy/sternotomy, blood transfusions, or perioperative mortality. The average LOS was 1.7 days, with only 1 patient requiring intensive care unit admission and >65% of patients discharged within 24 hours. At follow-up, 2 (3.1%) patients experienced new left pleural effusion or hemidiaphragm paralysis requiring treatment. There were no readmissions related to AF, stroke, thromboembolic events, or deaths. The mean interval between the epicardial and endocardial stages of the procedure was 5.9 months. Rhythm follow-up showed AF resolution in 73.4% and 71.9% of patients at 3 and 12 months, respectively. ConclusionsRE-EA is a feasible and safe, first-stage approach for the treatment of patients with PsAF and LSAF. It improves exposure of the intended targets, favors short hospital stay, and facilitates return to activity with satisfactory AF treatment in the short term.

Computed tomographic diaphragmatic thickness: a promising method for the evaluation of diaphragmatic muscle in cardiopulmonary diseased cats.

Diaphragmatic dysfunction (DD) is defined as a weakening of the diaphragmatic muscle and can be an undetected cause of dyspnea. The objectives of this study were to explore the appropriate diaphragmatic location, measure diaphragmatic thickness (DT), evaluate the effect of intrinsic factors on DT, and compare DT between healthy and diseased cats, using 33 healthy cats and 15 diseased cats. A retrospective, analytical, case-control study using thoraco-abdominal feline computed tomography (CT) was performed. Two radiologists independently reviewed all images to verify inter- and intra-observer reliabilities and the best position for measuring DT. The effects of sex, age, and body weight were also studied, and cutoff values for detecting DT abnormalities were established. The results showed that the appropriate location for DT measurement was at the ventral border of the cranial endplate of the first lumbar vertebral body (L1) due to its highest intra- and inter-observer reliabilities. At this location, a significant difference in DT between the right and left hemidiaphragms (p = 0.01) was observed. Only sex had an impact on DT values. Interestingly, the DTs of cardiorespiratory-affected cats, both on the right and left sides, were significantly thinner than those of healthy cats. In conclusion, CT imaging is a reliable imaging method for determining diaphragmatic muscular atrophy. The ventral border of the cranial endplate of L1 is recommended for measuring the DT, and sex was the only factor affecting the DT measurement.

A rare case of asthmatic patient with left Chilaiditi's syndrome.

The following case report aims to highlight the rarity of the case in question, in which there is left Chilaiditi syndrome in a patient with bronchial asthma. The patient is a 79-year-old woman who arrived in January 2023 at my facility for episodes of recurrent dyspnea, chest heaviness, wheezing, eructation, dysphagia, epigastric abdominal pain associated with frequent episodes of bronchitis. He performed simple spirometry which showed mixed mild-moderate ventilatory deficit with reduction of small airway volumes, reduced peak expiratory flow and negative broncho reversibility tests for asthma. At 3 months, the patient returned to my attention with a chest radiograph showing marked elevation of the left hemidiaphragm with deviation of the cardiac shadow to the right. He repeated the spirometry which resulted in a clear improvement compared to the previous control with an important variation of the peak respiratory flow during ICS/LABA, the objective finding previously found disappeared, this indicating the presence of an underlying bronchial asthma. The radiological picture was identified by me as Left Chilaiditi Syndrome, as the patient had gastrointestinal symptoms which accompanied the procession of respiratory symptoms. The diagnostic suspicion must be early in these pathologies and the proton pump inhibitors and new generation alginates with the presence of hyaluronic acid and melatonin must also be included in the treatment of the symptoms, which have an important action on gastroesophageal reflux disease (GERD) secondary to this herniation of the viscera into the thoracic cavity. The rarity is represented by the left localization of the diaphragmatic pathology.

SAT174 Doege-Potter Syndrome In A Patient With Solitary Fibrous Tumor Of The Lung

Abstract Disclosure: N. Mon: None. S.S. Krishnasamy: None. Doege-Potter Syndrome is a non-islet cell tumor hypoglycemia (NICTH) due to a solitary fibrous tumor (SFT) with overexpression of Insulin-like growth factor 2 (IGF2). We report a case of refractory hypoglycemia in a patient with SFT of the lung. Case presentation: A 67-year-old homeless male with hypertension, chronic smoker presented with altered mental status after his blood glucose was found 34mg/dl by EMS. His confusion improved after D50W. He could not recall the event but he reported that he missed his dinner prior to the event. He denied taking any antidiabetic medications. He was diagnosed with left lung solitary fibrous tumor without metastases a week ago after he presented to ER with dyspnea, cough and wheezing. CT chest reported a 21x15.6x18.7 cm lesion with mass effect on the left hemidiaphragm, mediastinum shift to the right and occluded left lower lobe bronchi. Core needle biopsy of the mass revealed SFT with necrosis. He was discharged with Medrol dosepak 4mg daily for presumptive treatment of COPD exacerbation and a plan for elective surgery. While in the ER his BG improved to 136mg/dl after D50W. Few hours later BG dropped to 42mg/dl and D10W infusion was started. Physical exam was unremarkable except bilateral pedal edema. Work up showed BG 42mg/dl, Insulin 3.3 (2.6-24.9 uIU/mL), C peptide 0.39 (1.1-4.4ng/mL), Proinsulin 4.7 (&amp;lt;18.8pmol/L), beta-hydroxybutyrate &amp;lt;0.05 (0.02-0.27mmol/l), 8AM cortisol 10.7 (7.0-25.0 ug/dl), albumin 3.2mg/dl, HbA1c 5.8%, IGF1 53ng/mL (34-245ng/mL), IGF2 203ng/mL (267-616ng/mL) with a IGF2:IGF1 ratio of 3.8. In our patient, the IGF2:IGF1 ratio was not &amp;gt;10 since his IGF 2 was suppressed by the recent steroid use. The rest of the clinical and biochemical features strongly suggested NICTH. His preoperative evaluation showed new onset HFrEF with volume overload. He underwent staged percutaneous coronary interventions with stents placement. He was given hydrocortisone 50mg q6H then to q8H during hospitalization and discharged home with hydrocortisone 40mg TID. He underwent radical resection of lung tumor after optimization of his cardiac condition. He was on stress dose of steroid during surgery. Since he was on high dose steroid for &amp;gt; 3months, hydrocortisone dose was tapered slowly after the surgery. Final biopsy reported solitary fibrous tumor extending to parenchymal staple line. Tumor cells are positive for CD34 and STAT6, and negative for desmin, SMA, and SOX10. He recovered uneventfully and was discharged home with prednisone 5mg daily and follow up in endocrine clinic. Conclusion: NICTH is a rare paraneoplastic syndrome characterized by low levels of insulin, C-peptide, proinsulin, and beta-hydroxybutyrate. A ratio of IGF-2/IGF-1 more than 10 confirms NICTH; however, normal ratio cannot exclude the diagnosis and factors such as low IGFBP 3 or steroid therapy for other conditions need to be considered. Surgery is the mainstay of treatment. Presentation: Saturday, June 17, 2023

Report of a case of bochdalek hernia in an adult presenting as chronic cough: review of literature and discussion

Adult symptomatic bochdalek hernias (BH) are rare and account for 0.16%-6% of all diaphragmatic hernias. Chronic abdominal pain is commonest type of presentation. We have a patient of BH presented with chronic cough and breathlessness on exertion. Aim was to study clinical course and outcome of patient presented to our institute. We also would like to review relevant literature available online and compare it with our findings. 30-year-male from peripheral area had recurrent episodes of cough and breathlessness on exertion since 7 years. He was treated as a case of lower respiratory tract infection. We did chest radiogram which revealed presence of haziness in left lower zone with obliteration left costophrenic angle. His computerized tomography scan revealed defect of approximate size 43×45 mm in posterolateral aspect of left hemidiaphragm with omental herniation. Patient was operated by lap converted to open primary bochdalek hernia repair. His postoperative course was uneventful. Review of literature done revealed cough as a rare type of presentation. Laparoscopy is becoming emerging modality of treatment to do surgical correction. Adult onset diaphragmatic hernias have variable clinical manifestations. High index of clinical suspicion with imaging studies like contrast enhanced computed tomography (intravenous plus oral contrast) of chest and abdomen are required for timely diagnosis and treatment.

Volitional inspiration is mediated by two independent output channels in the primary motor cortex.

The diaphragm is a multifunctional muscle that mediates both autonomic and volitional inspiration. It is critically involved in vocalization, postural stability, and expulsive core-trunk functions, such as coughing, hiccups, and vomiting. In macaque monkeys, we used retrograde transneuronal transport of rabies virus injected into the left hemidiaphragm to identify cortical neurons that have multisynaptic connections with phrenic motoneurons. Our research demonstrates that representation of the diaphragm in the primary motor cortex (M1) is split into two spatially separate and independent sites. No cortico-cortical connections are known to exist between these two sites. One site is located dorsal to the arm representation within the central sulcus and the second site is lateral to the arm. The dual representation of the diaphragm warrants a revision to the somatotopic map of M1. The dorsal diaphragm representation overlaps with trunk and axial musculature. It is ideally situated to coordinate with these muscles during volitional inspiration and in producing intra-abdominal pressure gradients. The lateral site overlaps the origin of M1 projections to a laryngeal muscle, the cricothyroid. This observation suggests that the coordinated control of laryngeal muscles and the diaphragm during vocalization may be achieved, in part, by co-localization of their representations in M1. The neural organization of the two diaphragm sites underlies a new perspective for interpreting functional imaging studies of respiration and/or vocalization. Furthermore, our results provide novel evidence supporting the concept that overlapping output channels within M1 are a prerequisite for the formation of muscle synergies underlying fine motor control.

Management of diaphragmatic eventration in a low-income setting: A case report

Diaphragmatic eventration, is a rare pathology that is characterized by abnormal elevation of the diaphragm and abdominal contents residing within thoracic cavity, though separated from the lungs by the thin or membraneous diaphragm. It may be asymptomatic but may result in dyspnoea, heaviness in the chest and hearing of bowel sounds in the chest. We report a 63 year old man who presented to our service, 10 years history prior, of heaviness in the left hemithorax and whose chest x-ray revealed an abnormally elevated dome of the left hemidiaphragm in the chest (eventration). He was worked up for left thoracotomy, plication of the diaphragm with uneventful recovery postoperatively and disappearance of symptoms.

397. LEFT PILLAR PINCHING TECHNIQUE FOR MINIMALLY INVASIVE REPAIR OF PARA-CONDUIT HERNIA

Abstract Surgical repair of the para-conduit hernia provides an increasing challenge in the era of minimally invasive oesophagectomy. The key principles are preservation of the gastric conduit and its right gatro epiploic vascular arcade, and durable closure of the defect. Of various methods, posterior crural repair is difficult without mobilising and risking and kinking the conduit, while anterior repair of a big defect requires the adjunct of a mesh which carries its own risks of infection or erosion. There is no consensus on the appropriate surgical technique. We propose that the Left pillar of the hiatus be pinched to provide an effective repair. This is safe as dissection and suturing is well away from the conduit and arcade. We find the left pillar to be adequately mobile to allow repair, and the sutures sit in the tendinous portion of the left hemi diaphragm to provide durability. We provide 2 videos to describe the key steps in this technique and demonstrate that this technique is effective in both small and large defects, and acute and chronic para-conduit hernia. Link: https://1drv.ms/v/s!Anu-cyBTuGbsgbxtX8aLf2P1YEPl9g?e=fXz7Pm. Please contact me, shantjog@gmail.com if this link does not work and I will explore an alternative method to share the video. Many thanks.

Diagnosis and management of diaphragmatic pericardial hernia: A case report

Introduction: Diaphragmatic hernias can be congenital or acquired. Congenital diaphragmatic hernia is a relatively common malformation and can be diagnosed in the prenatal period using ultrasound. After birth, computed tomography is the most accurate diagnostic test and helps to assess the anatomical relationships between the viscera. Traumatic diaphragmatic hernia (TDH) is characterized by the passage of part of the abdominal contents into the thoracic cavity through trauma to the thoracoabdominal transition. Pericardial diaphragmatic hernia is a direct communication between the pericardium and the peritoneal cavity, through a defect in the diaphragm. It can be congenital or associated with diaphragmatic rupture after trauma. Case presentation: V.B, 57, complaining of chronic constipation, presented with hiatus hernia on chest X-ray and CT scan. The images showed herniation of fat content and intestinal loops into the chest through the anteromedial wall of the left hemidiaphragm, compressing the medial aspect of the lingula, with no evidence of complications. On April 6, 2023, she underwent diaphragmatic herniorrhaphy via the thoracic route. She returned for post-operative follow-up complaining of nausea, vomiting and asthenia. A new total abdominal tomography scan showed the presence of an anterior diaphragmatic hernia on the left. Subsequently, she underwent a thoracic surgical approach with a proposal to correct the diaphragmatic hernia. However, an inventory of the cavity revealed plication of the lateral diaphragm without herniation points. The decision was therefore made to open the pericardium, showing a diaphragmatic pericardial hernia, with a 0.5 cm ring containing the epipelon, transverse colon and stomach in the pericardium. Adhesions were lysed and the contents returned to the abdominal cavity. The patient evolved satisfactorily in the postoperative period. Discussion: Both diaphragmatic hernia and pericardial diaphragmatic hernia can be serious and require immediate medical intervention. They are rare pathologies that can be confused with other respiratory or cardiac diseases, making it difficult for doctors to diagnose them. Surgery is necessary to repair the hernia and reduce the risk of complications, which increase over time. Final considerations: In this case report, we have highlighted the complexity and importance of early and accurate diagnosis of diaphragmatic hernias, including the rare pericardial diaphragmatic hernia. Diaphragmatic hernia, whether congenital, acquired through trauma or associated with diaphragmatic rupture, can result in painful complications if not recognized and controlled. The clinical situation presented in this case, in which a pericardial diaphragmatic hernia was identified during the postoperative period of a thoracic diaphragmatic hernia, highlights the importance of continuous surveillance after surgical intervention.