Diaphragmatic Plication Research Articles

Congenital partial diaphragmatic eventration presenting with Chilaiditi’s sign: a case report

BackgroundChilaiditi’s sign is an incidental radiographic finding, associated with intestinal disposition located between liver and right diaphragm. It is considered as an acquired rather than a congenital condition and the prevalence ranges from 1.18% to 2.4% according to recent adult retrospective studies. The aspects of this rare entity with regards to a 7-month-old male initially misdiagnosed as diaphragmatic hernia is discussed.Case presentationA 4-month-old Caucasian male was misdiagnosed with a congenital diaphragmatic hernia owing to previous hospitalization with complaints of respiratory tract infection. On admission 3 months later, he was free of any signs and symptoms of intestinal obstruction or respiratory distress. Thorax computed tomography revealed Chilaiditi’s sign. A diagnostic laparoscopy was regarded necessary to evaluate the anatomical details. The most prominent finding was the lack of muscle fibers and almost transparent appearance of the medial aspect of the partially eventrated right hemidiaphragm. Owing to delicate anatomical presentation, diaphragmatic plication was considered hazardous. The patient is doing well and under follow-up.ConclusionsIt is obvious that Chilaiditi’s sign is not always a completely incidental finding of no consequence, and may indicate an underlying congenital diaphragmatic pathology, clearly defined by laparoscopic evaluation in this case.

Congenital Diaphragmatic Eventration: Should we Maintain Surgical Treatment? A Retrospective Multicentric Cohort Study

BackgroundThe aims of this study were to describe the characteristics of children with congenital diaphragmatic eventration (CDE) and compare the outcomes of surgical and conservative treatment of pediatric CDE in France. MethodsRetrospective study on cohort data conducted in 22 paediatric surgery departments, including patients less than 16 years of age diagnosed with CDE between 2010 and 2021. Patients with surgical or conservative treatment were compared. Results139 patients were included, with a median age of 8 [1–16] months. CDE occurred in boys in 68.3% and was right-sided in 66.7% of the cases. Indication for treatment depended essentially on respiratory symptoms and level of the diaphragmatic dome. The initial treatment was a surgical, with a diaphragmatic plication, in 87 cases (62%) and conservative, consisting of clinical follow-up in 52 children (38%). Of the latter, 25 children underwent surgery secondarily. Intra- and early post-operative complications occurred in 32 children (29%) and eventration recurrence in 8 children (7%). With a median follow-up of 28 months, the median level of diaphragmatic dome improved from the 6th to the 9th back rib, and the rate of respiratory symptoms decreased from 64% to 14% in the overall cohort of patients. ConclusionsDiaphragmatic plication is effective in symptomatic patients with a dome level above the 6th posterior rib, but is associated with a 29% complication rate and 7% of recurrence. ClinicalTrialsNCT04862494, April 28, 2021. Level of evidencelevel III treatment study.

Uniportal thoracoscopic plication of diaphragmatic eventration: loop needle technique for better visualization.

Symptomatic unilateral diaphragmatic eventration require surgical intervention. A 56-year-old woman complained of dyspnoea on exertion and was noted to have left diaphragm elevation on chest radiographs. Dynamic magnetic resonance imaging showed paradoxical movement of the left diaphragm. We performed diaphragmatic plication by uniportal thoracoscopy with knifeless endostaplers and a loop needle device. Her symptoms significantly improved immediately after the operation, and this condition had been maintained for 6 months. We thus suggest this minimally invasive technique as an easy and safe method for diaphragmatic plication.

Adoption of the Robotic Platform across Thoracic Surgeries.

With the paradigm shift in minimally invasive surgery from the video-assisted thoracoscopic platform to the robotic platform, thoracic surgeons are applying the new technology through various commonly practiced thoracic surgeries, striving to improve patient outcomes and reduce morbidity and mortality. This review will discuss the updates in lung resections, lung transplantation, mediastinal surgeries with a focus on thymic resection, rib resection, tracheal resection, tracheobronchoplasty, diaphragm plication, esophagectomy, and paraesophageal hernia repair. The transition from open surgery to video-assisted thoracoscopic surgery (VATS) to now robotic video-assisted thoracic surgery (RVATS) allows complex surgeries to be completed through smaller and smaller incisions with better visualization through high-definition images and finer mobilization, accomplishing what might be unresectable before, permitting shorter hospital stay, minimizing healing time, and encompassing broader surgical candidacy. Moreover, better patient outcomes are not only achieved through what the lead surgeon could carry out during surgeries but also through the training of the next generation via accessible live video feedback and recordings. Though larger volume randomized controlled studies are pending to compare the outcomes of VATS to RVATS surgeries, published studies show non-inferiority data from RVATS performances. With progressive enhancement, such as overcoming the lack of haptic feedback, and future incorporation of artificial intelligence (AI), the robotic platform will likely be a cost-effective route once surgeons overcome the initial learning curve.

Liver and pancreas transplantation in adult donor and recipients with situs inversus totalis: a case series and review of the literature

BackgroundSitus inversus totalis is a rare congenital anomaly characterized by a mirror-image orientation of abdominal, and in some cases, thoracic organs. Here, we report our situs inversus totalis transplantation experience and further review liver transplantations in adult recipients and donors with situs inversus totalis.Case presentationWe describe three cases with situs inversus totalis. The first case was liver transplantation in a recipient (a 61-year-old Iranian man) with situs inversus totalis, the second was a liver transplantation from a donor (a 52-year-old Iranian woman) with situs inversus totalis, and finally, for the first time, a simultaneous pancreas and kidney transplantation in a recipient (a 26-year-old Iranian man) with situs inversus totalis. In patient one, hepatectomy could be performed according to the standard method and on the basis of preoperative studies. Hepatic vein and arterial anastomosis were performed as in every other patient without situs inversus totalis. To prevent biliary complications, a Roux-en-Y hepaticojejunostomy was performed. In patient two, implantation time, suprahepatic vein, portal vein, arterial, and biliary reconstruction could be done as in any other case without situs inversus totalis. Plication of the right-sided diaphragm and fixation of the falciform ligament was done for our patient. In patient three, systemic drainage was preferred to portal flow for establishing the outflow drainage of the pancreas compared with otherwise normal patients.ConclusionAlthough situs inversus totalis is a rare condition, our reported techniques are suitable, considering advantages such as easier accessibility, more acceptable placement of the implanted organs regarding vascular variations, and the appropriate location of the allograft in the proximity of other organs.

Unraveling the mysteries of parsonage turner syndrome: A journey towards optimal management. A systematic review

AimsParsonage Turner Syndrome (PTS) is a peripheral neuropathy manifesting as sudden onset pain, muscle weakness, and atrophy. This review aims to analyse long-term outcomes reported in adult patients with PTS, and establish an optimised management approach. MethodsA comprehensive literature search was performed using MEDLINE, PubMed, and the Cochrane Library. Articles that met the eligibility criteria were included. Analysis on time to presentation, presentation, interventions and long-term functional outcomes was conducted. All relevant information was collected by two independent reviewers. ResultsTwenty-five studies, comprising 950 PTS patients, were identified. Patients averaged 43.8 years in age, with a F:M ratio of 0.6:1, and presented symptoms spanning 1–24 months prior to seeking medical attention. Management details were elucidated for 402 patients (42 ​%), with 87 ​% managed conservatively. Among conservatively managed patients, over 50 ​% exhibited no improvement. 62/402 (15 ​%) necessitated surgical interventions, including neurolysis, decompression, nerve transfers, and diaphragmatic plication. 25/31 (80.6 ​%) neurolysis cases demonstrated full functional recovery, including pain resolution and full muscle strength, between 1 day and 13 months (average 2.9 months). 2 nerve transfer cases achieved full forward flexion at 2.5 months. Overall, long-term outcomes of PTS, reported at 5–25 months, revealed residual neuropathic pain in 60 ​% and incomplete motor function return in 70 ​% of patients. ConclusionsPTS recognition and referral challenges persist, impeding timely management. While surgical interventions are advocated after three months for incomplete recovery, long-term surgical outcomes are inadequately reported. An optimal surgical strategy for stagnant nerve recovery needs to be devised for this challenging cohort of patients.

Robot-assisted thoracoscopic versus conventional thoracoscopic plication for diaphragmatic eventration in children: Comparison of mid-term outcomes

ObjectiveMinimally invasive surgery has been widely used for diaphragmatic eventration (DE). We aimed to compare the mid-term outcomes of robot-assisted thoracoscopic (RTP) and conventional thoracoscopic plication (CTP) for DE and to discuss the technical advantages of RTP. MethodsFrom January 2015 to July 2022, the clinical outcomes of 30 RTP patients and 35 CTP patients were retrospectively analyzed. The baseline data, surgical outcomes and surgical technique will be compared in detail. ResultsThe baseline data of two groups were comparable. No intraoperative conversion or complications occurred. The total operation time and intraoperative blood loss were similar between two groups, but RTP group had a significantly shorter diaphragmatic plication time compared to CTP group (25.77±3.55 min vs 44.49±4.43 min, p < 0.001). The total surgical cost of RTP group was higher than that of CTP group (48,593.06±2752.33 RMB vs 25,181.23±5681.51 RMB, p < 0.001). No significant differences were found in postoperative hospital stay, diclofenac suppository dosage, unplanned readmission rate within 30 days postoperatively, recurrence rate, or postoperative complications within 1 year postoperatively between RTP and CTP groups. Sixty patients had preoperative symptoms resolved or significantly improved with normal diaphragmatic position. However, two patients in CTP group encountered recurrence, and one patient in CTP group and two patients in RTP group had a diaphragm descent in only one intercostal space. ConclusionRTP is a feasible and effective minimally invasive option for the treatment of DE, with mid-term outcomes comparable to CTP, which has a great advantage in terms of easier suturing and free knotting. DE can serve as an ideal disease type to train robots for thoracoscopic surgery by young doctors. Level of evidenceLevel III.

Early Physical Therapy Management of a Patient with Diaphragmatic Eventration Following Diaphragmatic Plication: A Case Report

AbstractDiaphragmatic plication is the recommended surgical procedure for the treatment of diaphragmatic eventration in those who have failed conservative care. The present case report describes a 63-year-old male patient who presented with breathlessness on exertional activities. Chest X-ray and Computed Tomography (CT) of the thorax revealed diaphragmatic eventration on the right side. After failed conservative management, the patient underwent diaphragmatic plication surgery and was followed up with postoperative physical therapy management. Physical therapy intervention was started from 3 days postsurgery and was continued for 1 week. The treatment goals focused on reducing breathlessness, reducing pain on the incision site, preventing postoperative complications, and improving functional capacity. The present study highlights the benefits of early physical therapy interventions including incentive spirometer, dyspnea relieving techniques, Transcutaneous Electrical Nerve Stimulation (TENS), and light- to moderate-intensity aerobic exercises in the patient after plication surgery.

A Contemporary Tertiary Centre Experience With Diaphragm Plication for Improving Breathlessness

A Contemporary Tertiary Centre Experience With Diaphragm Plication for Improving Breathlessness

Editorial to “Improvement in respiratory function and exercise tolerance following video‐assisted thoracoscopic diaphragm plication for symptomatic iatrogenic persistent diaphragm paralysis after radiofrequency catheter ablation”—An essential respiratory physiology every electrophysiologist should know‐

Editorial to “Improvement in respiratory function and exercise tolerance following video‐assisted thoracoscopic diaphragm plication for symptomatic iatrogenic persistent diaphragm paralysis after radiofrequency catheter ablation”—An essential <scp>respiratory physiology</scp> every <scp>electrophysiologist</scp> should know‐

Improvement in respiratory function and exercise tolerance following video‐assisted thoracoscopic diaphragm plication for symptomatic iatrogenic persistent diaphragm paralysis after radiofrequency catheter ablation

Improvement in respiratory function and exercise tolerance following video‐assisted thoracoscopic diaphragm plication for symptomatic iatrogenic persistent diaphragm paralysis after radiofrequency catheter ablation

Congenital cardiac surgery and diaphragmatic paralysis: efficacy of diaphragm plication

BackgroundDiaphragmatic paralysis due to phrenic nerve injury is a rare but potentially serious complication following congenital cardiac surgery, with reported incidences ranging from 0.28 to 5.6%. Early plication has been recommended for children diagnosed with diaphragmatic paralysis, especially those requiring prolonged respiratory support after cardiopulmonary bypass. It is important to note that late plication may jeopardize the results of successful surgical plication due to diaphragm atrophy.ResultsThis retrospective study was performed between May 2020 and June 2023. Patients who could not be weaned from the ventilator and underwent diaphragmatic plication in symptomatic patients after phrenic nerve injury were included in the study. During the study period, 22 (3.5%) of 624 pediatric patients operated for congenital heart disease required diaphragm plication. The mean age of the patients ranged from 1 month to 13 years with a mean of 23.88 ± 37.99 months. Fourteen (63.6%) of the patients were female, and 8 (36.4%) were male. Two of the patients (9%) were exited due to ventilator-associated pneumonia and sepsis.ConclusionsIn conclusion, diaphragmatic paralysis after congenital heart surgery is a rare but important complication that can lead to serious respiratory and cardiac problems. Diaphragmatic plication has been shown to be an effective intervention for pediatric patients with the potential to improve pulmonary function, reduce dyspnea, and minimize complications associated with diaphragmatic paralysis. Careful consideration of patient selection, timing, and potential complications is crucial in optimizing the outcomes of this surgical intervention.

Pulmonary blood flow in children with univentricular heart and unilateral diaphragmatic paralysis.

Spontaneous breathing has an important effect on pulmonary arterial blood flow in patients with Glenn/Fontan circulation. Unilateral diaphragmatic paralysis (DP) is a frequent complication after heart surgery in congenital heart disease. The aim of this study was to investigate the influence of unilateral DP on blood flow distribution in the pulmonary arteries with Glenn/Fontan circulation. Magnetic resonance phase-contrast imaging was used to evaluate stroke volume index (SVI) in the left and right pulmonary arteries in patients with Glenn/Fontan circulation with unilateral DP. Data for 18 patients with univentricular heart and unilateral DP were analysed, 8 in the Glenn stage and 10 in the Fontan stage. Ten patients had right-sided DP, and 8 had left-sided DP. A diaphragmatic plication was performed in 7 patients. The control group consisted of 36 patients with Glenn (n = 16)/Fontan (n = 20) circulation without DP. In both left- and right-sided DP, the SVI to the ipsilateral side was significantly lower than in controls [2.81 (1.45-4.50) ml/m2 left vs 11.97 (7.36-16.37) ml/m2 in controls, P < 0.0002; 8.2 (4.49-12.64) ml/m2 with right vs 12.64 (9.66-16.61) ml/m2 in controls; P = 0.0284]. The SVI to the contralateral side showed a slight but non-significant increase in the presence of unilateral DP. Unilateral DP in patients with Glenn/Fontan circulation has a negative impact on pulmonary arterial SVI on the side of the paralysis.

Quality-of-life impact of diaphragm plication in patients with diaphragmatic paralysis: A retrospective study.

While the overall incidence and prevalence of diaphragmatic paralysis are unknown due to a wide variety of underlying causes, symptomatic patients experience a marked decline in their quality of life. The goal of this study was to measure the impact of diaphragm plication surgery on the quality of life in patients who were diagnosed with diaphragmatic paralysis. A retrospective review of the medical records of 46 patients who underwent diaphragmatic plication surgery was performed. The review included patients who experienced unilateral and bilateral diaphragmatic paralysis. Patients who underwent repeat diaphragm plication surgery were also included in the study. Patients from the retrospective cohort were then contacted by telephone to answer the Dyspnea-12 (D-12) questionnaire. Patients were asked to recall the severity of their symptoms and quality of life preplication, 1-month postplication, and 6-month postplication. Severity of symptoms was ranked as either none, mild, moderate, or severe. Values were then assigned to each rank as follows: none = 0, mild = 1, moderate = 2, and severe = 3. Relative change and statistical significance were calculated with preplication measurements used as the baseline. Scores between preplication versus 1-month postplication and 6-month postplication were then compared by Student's paired t-test. All tests were two-sided and statistical significance was set at P < 0.05. Forty-six patients were included in the study, from which 21 answered the D-12 questionnaire. Average scores from each component of the D-12 questionnaire showed improvement in the severity of symptoms from preplication to 1-month postplication. The latter period was then followed by continued improvement in all areas when symptoms 6-month postplication were assessed. In patients with diaphragmatic paralysis, diaphragm plication was effective in reducing patients' symptoms while improving overall quality of life.

Mechanical support for bridge to transplant in an infant with post-cardiotomy end-stage heart failure and complete heart block: report of a case.

The patient was diagnosed with perimembranous ventricular septal defect (VSD). She underwent VSD closure and muscle bundle resection across right ventricular outflow tract at the age of 3 months. Since then, she had suffered from severe heart failure and complete heart block. Permanent pacemaker generator was implanted in the left hypochondrium. She was depended on continuous catecholamine administration, so transferred to our hospital for further management. On arrival, her body weight was 5686g (- 2.7 SD). She underwent Excor pediatric left ventricular assist device implantation at the age of 9 months. Because the position of the left ventricular assist device cannula interfered with the pacemaker, herein, the pacemaker pocket was newly created in the left thoracic cavity. An 1mm in thickness of expanded polytetrafluoroethylene sheet was trimmed and sutured under the anterolateral wall of left thoracic cavity as a pacemaker pocket. Bipolar ventricular lead was sutured on left ventricular apex and basal wall to face each other, mimicking cardiac regeneration therapy. Even though she unfortunately required right diaphragmatic plication for iatrogenic phrenic nerve palsy, her respiratory function was well maintained; therefore, secondary right heart failure was not observed. Her cardiopulmonary function was quite stable until post-operative day 275 when the patient was transferred to another hospital for heart transplantation.

Towards Zero Phrenic Nerve Injury in Reoperative Pediatric Cardiac Surgery: The Value of Intraoperative Phrenic Nerve Stimulation.

Phrenic nerve injury is a devastating complication that results in significant morbidity and mortality. We developed a novel technique to localize the phrenic nerve and evaluate its success. Two groups of children underwent repeat sternotomy for a variety of indications. Group I (69 patients, nerve stimulator) and Group II (78 patients, no nerve stimulator). There was no significant difference in the mean age and weight between the two groups: (6.4 ± 6.5 years vs. 5.6 ± 6.4 years; p = 0.65) and (25.2 ± 24.1 vs. 22.6 ± 22.1; p = 0.69), respectively. The two groups were comparable in the following procedures: pulmonary conduit replacement, bidirectional cavopulmonary anastomosis, aortic arch repair, and Fontan, while Group I had more pulmonary arterial branch reconstruction (p = 0.009) and Group II had more heart transplant patients (p = 0.001). There was no phrenic nerve injury in Group I, while there were 13 patients who suffered phrenic nerve injury in Group II (p < 0.001). No early mortality in Group I, while five patients died prior to discharge in Group II. Eleven patients underwent diaphragm plication in Group II (p = 0.001). The mean number of hours on the ventilator was significantly higher in Group II (137.3 ± 324.9) compared to Group I (17 ± 66.9), p < 0.001. Group II had a significantly longer length of ICU and hospital stays compared to Group I (p = 0.007 and p = 0.006 respectively). Phrenic nerve injury in children continues to be associated with significant morbidities and increased length of stay. The use of intraoperative phrenic nerve stimulator can be an effective way to localize the phrenic nerve and avoid its injury.

Robotic-Assisted Transthoracic Diaphragm Plication

Diaphragm dysfunction, either from congenital eventration or acquired paralysis, impairs the ability of the diaphragm to contract, thereby disrupting normal respiratory mechanics. While a proportion of patients will present with respiratory insufficiency or symptoms of dyspnea, the majority of patients are asymptomatic and most cases are identified incidentally on chest imaging by the presence of an elevated hemidiaphragm. In symptomatic patients, surgical plication of the diaphragm remains the gold standard treatment. Traditionally, diaphragm plication is performed through an open transthoracic approach via a posterolateral thoracotomy. However, more recently there has been increased utilization of minimally invasive techniques, including video-assisted thoracoscopic and laparoscopic approaches. Here, we present our technique for robotic-assisted transthoracic plication, with advantages including enhanced ergonomics, seamless motion, decreased surgeon fatigue, tremor filtering, and three-dimensional vision. This approach has been demonstrated to be a technically feasible and safe option for performing diaphragm plications with an associated decreased hospital length of stay and trend towards decreased 30-day post-operative complications compared to open plication.

Pneumothorax during laparoscopic plication of diaphragmatic eventration: A case report

Diaphragmatic eventration is the abnormal elevation of the hemidiaphragm or part of it caused due to the lack of muscle or nerve function with normal anatomical attachments. Pneumothorax is a common occurrence during thoracoscopic approaches of diaphragmatic plication but a very rare complication in laparoscopic approaches.A 56-year-old male presented with complaints of pain in the left upper abdomen, bloating, and difficulty in breathing. He was diagnosed with idiopathic diaphragmatic eventration and was taken up for laparoscopic plication under American society of anaesthesiologists – physical status 1. Intra-op, he developed sudden onset increase in peak pressures with poor tidal volumes and desaturation. Examination revealed reduced breath sounds and movement of left side of chest, possibly a left sided pneumothorax. The placement of a left-sided intercostal chest drain led to improvements in ventilatory parameters.The patient was successfully extubated following the completion of surgery.: Pneumothorax is an established complication of laparoscopic surgery, with a reported incidence of 0.01%-0.4%. But early detection and diagnosis of a pneumothorax intraoperatively is difficult and often missed because of controlled ventilation and pneumoperitoneum. A high index of suspicion should be maintained for early diagnosis and management of such conditions.Intraoperative tension pneumothorax and its progression can have devastating consequences. A high index of suspicion, prompt recognition of the condition despite many factors that may mask the condition and prompt remediation leads to an effective management of such cases.

Abstract 16019: Right Hemidiaphragm Paralysis Leading to Right Heart Failure

Background Diaphragmatic paralysis occurs due to direct or indirect damage to the phrenic nerve and can cause unilateral elevation. Diaphragmatic paralysis is usually asymptomatic; however, we present a case of syncope caused by right hemidiaphragm paralysis leading to extrinsic compression of the right heart causing hemodynamic compromise. Case A 78-year-old female with a history of advanced dementia, and hypertension presented following a syncopal episode and was found altered and hypotensive. A chest X ray showed an elevated right hemidiaphragm. A Transthoracic echocardiogram demonstrated hyperdynamic systolic function of the left ventricle with an ejection fraction of 70 to 75% and a left ventricular outflow tract (LVOT) gradient of 64 mmHg. It was suspected that extrinsic compression of the right atrium and ventricle lead to underfilling of the left ventricle causing LVOT obstruction resulting in hypotension and syncope. Discussion . Due to the patient’s underlying severe dementia her family wished for a conservative approach and additional cardiac investigation was deferred. She was treated conservatively with beta blockers to increase her diastolic filling time and intravenous fluids to promote LV filling in order to reduce her LVOT obstruction. Treatment of diaphragm paralysis depends on the severity of symptoms such as dyspnea on exertion, fatigue and syncope. An option that was discussed was diaphragmatic plication to decrease the intrathoracic pressure and the extrinsic compression on the right heart. More commonly, unilateral diaphragmatic paralysis is asymptomatic and is managed conservatively with observation. Conclusion: Cardiac complications of hemidiaphragm paralysis are rare but this case illustrates how extrinsic compression of the right heart can lead to dynamic LVOT obstruction and highlights the importance of integrating imaging findings when evaluating patients for syncope.

Laparoscopic approach in the management of diaphragmatic eventration in adults: gastrointestinal surgical perspective.

The current literature is poor with studies handling the role of laparoscopy in managing diaphragmatic eventration (DE). Herein, we describe our experience regarding the role of laparoscopy in managing DE patients presenting mainly with gastrointestinal symptoms. We retrospectively reviewed the data of 20 patients who underwent laparoscopic diaphragmatic plication between January 2010 and December 2018. Postoperative outcomes and quality of life were assessed. Most DEs were left sided (95%). Laparoscopic diaphragmatic plication was possible in all patients, along with correcting all associated gastrointestinal and diaphragmatic problems. The former included gastric volvulus (60%), reflux esophagitis (25%), cholelithiasis (5%), and pyloric obstruction (5%), while the latter included diaphragmatic and hiatus hernia (10% and 15%, respectively).The average operative time was 142min. All patients had a regular (reviewer #1) postoperative course except for one who developed hydro-pneumothorax. At a median follow-up of 48months, midterm outcomes were satisfactory, with an improvement (reviewer #1) in gastrointestinal symptoms. Three patients (reviewer #1) developed radiological recurrence without significant clinical symptoms. Patient's quality of life, including all parameters, significantly improved after the laparoscopic procedure compared to the preoperative values. Laparoscopic approach is safe and effective for managing adult diaphragmatic eventration (reviewer #1).