Long-Term Follow-Up of the Functional and Physiologic Results of Diaphragm Plication in Adults With Unilateral Diaphragm Paralysis

doi:10.1016/j.athoracsur.2009.05.027

The Annals of Thoracic Surgery

Volume 88, Issue 4, October 2009, Pages 1112-1117

Presented at the Forty-fifth Annual Meeting of The Society of Thoracic Surgeons, San Francisco, CA, Jan 26–28, 2009.

https://doi.org/10.1016/j.athoracsur.2009.05.027 Get rights and content

Background

Patients with lifestyle-limiting dyspnea attributable to unilateral diaphragm paralysis have been shown to experience a decrease in their dyspnea and an improvement in their pulmonary spirometry and functional status with diaphragm plication acutely after surgery. This investigation summarizes these patients' outcomes with long-term follow-up.

Methods

Adult patients undergoing plication of the hemidiaphragm for lifestyle-limiting dyspnea secondary to unilateral diaphragm paralysis were assessed preoperatively, 6 month after surgery and then annually using the Medical Research Council dyspnea score, pulmonary spirometry, activities of daily living questionnaire, and a chest radiograph. Patients with at least 48 months of follow-up were included in this investigation.

Results

Forty-one patients underwent plication of the hemidiaphragm through video-assisted thoracoscopy (30) or thoracotomy (11). Mean follow-up was 57 ± 10 months. Mean forced vital capacity, forced expiratory volume at 1 second, functional residual capacity, and total lung capacity all improved by 19%, 23%, 21%, and 19% (p < 0.005), respectively, when measured 6 months after surgery, as were mean Medical Research Council dyspnea scores (p < 0.0001). These mean values remained constant over the follow-up period. Four patients did not show improvement in their Medical Research Council dyspnea scores nor functional status despite improvements in their pulmonary spirometry values. Two of these patients had a body mass index greater than 35 kg/m² and 3 had documented unilateral diaphragm paralysis for at least 4 years before plication.

Conclusions

Plication of the hemidiaphragm produces improvement for the vast majority of patients in pulmonary spirometry, dyspnea, and functional status that endures over long-term follow-up. Patients who are morbidly obese or who have longstanding unilateral diaphragm paralysis may not realize the same benefits of plication.

Section snippets

Patients and Methods

Between 2001 and 2007, patients at least 21 years of age who underwent plication of the hemidiaphragm through thoracotomy or video-assisted thoracoscopy for symptomatic unilateral paralysis were offered participation in this prospective investigation. This study was approved by our Institutional Review Board, with individual consent being waived. All patients received a standardized evaluation before consideration for surgery which included a history and physical examination, a chest

Results

During the study period, 52 patients underwent plication of the hemidiaphragm for symptomatic paralysis within our practice. Forty-one of these patients were eligible for inclusion in this investigation. The etiologies of diaphragmatic paralysis as well as patient demographics are listed in Table 2. The most common cause of diaphragmatic paralysis in this series was idiopathic. Patients underwent unilateral diaphragm plication at a mean of 8 ± 6 months (range, 6 to 60) after diagnosis through

Comment

Plication of the hemidiaphragm has become the accepted treatment for pediatric patients with significant respiratory impairment because of unilateral diaphragmatic paralysis [4, 5]. Modern series have found significant improvement in patients' respiratory status after diaphragmatic plication with little associated morbidity. Some have recommended and subsequently shown the benefit of including plication even earlier in the treatment algorithm of such patients [6].

The use of diaphragm plication

References (11)

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Functional and physiologic results of video-assisted thoracoscopic diaphragm plication in adult patients with unilateral diaphragm paralysis
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M.Z. Schwartz et al.
Plication of the diaphragm for symptomatic phrenic nerve paralysis
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There are more references available in the full text version of this article.

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Phrenic nerve injury results in paralysis of the diaphragm muscle, the primary generator of an inspiratory effort, as well as a stabilizing muscle involved in postural control and spinal alignment. Unilateral deficits often result in exertional dyspnea, orthopnea, and sleep-disordered breathing, whereas oxygen or ventilator dependency can occur with bilateral paralysis. Common etiologies of phrenic injuries include cervical trauma, iatrogenic injury in the neck or chest, and neuralgic amyotrophy. Many patients have no identifiable etiology and are considered to have idiopathic paralysis. Diagnostic evaluation requires radiographic and pulmonary function testing, as well as electrodiagnostic assessment to quantitate the nerve deficit and determine the extent of denervation atrophy. Treatment for symptomatic diaphragm paralysis has traditionally been limited. Medical therapies and nocturnal positive airway pressure may provide some benefit. Surgical repair of the nerve injury to restore functional diaphragmatic activity, termed phrenic nerve reconstruction, is a safe and effective alternative to static repositioning of the diaphragm (diaphragm plication), in properly selected patients. Phrenic nerve reconstruction has increasingly become a standard surgical treatment for diaphragm paralysis due to phrenic nerve injury. A multidisciplinary approach at specialty referral centers combining diagnostic evaluation, surgical treatment, and rehabilitation is required to achieve optimal long-term outcomes.
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Original articleGeneral thoracicLong-Term Follow-Up of the Functional and Physiologic Results of Diaphragm Plication in Adults With Unilateral Diaphragm Paralysis

Background

Methods

Results

Conclusions

Section snippets

Patients and Methods

Results

Comment

Ann Thorac Surg

J Pediatr Surg

J Pediatr Surg

J Am Soc Echocardiogr

J Pediatr Surg

Original article
General thoracic
Long-Term Follow-Up of the Functional and Physiologic Results of Diaphragm Plication in Adults With Unilateral Diaphragm Paralysis