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Diaphragmatic plication is a safe procedure and should be performed for patients with symptomatic diaphragmatic paralysis or eventration.
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The diagnosis of symptomatic diaphragmatic paralysis or eventration is mostly clinical.
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Preoperatively, all patients should have a chest radiograph, pulmonary function tests, and a respiratory quality-of-life questionnaire.
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Although pulmonary function tests are often abnormal in symptomatic patients, these changes are inconsistent and do not correlate with the
Best Approach and Benefit of Plication for Paralyzed Diaphragm
Section snippets
Key points
Pathophysiology and clinical presentation
Normal diaphragm function exerts caudal movement of the diaphragm during inspiration, resulting in expansion of the rib cage, which generates negative intrathoracic pressure and results in lung expansion.15 In patients with eventration or paralysis, diaphragmatic movement can be diminished, absent, or even paradoxic. As a result, ventilation and perfusion to the basal portion of the lung ipsilateral to the paralyzed or eventrated diaphragm are impaired, the latter possibly caused by regional
Diagnosis and preoperative evaluation
Most adults with paralysis or eventration are asymptomatic. Most cases are discovered incidentally on a chest radiograph, showing hemidiaphragm elevation.4, 7
The diagnosis of symptomatic diaphragmatic eventration or paralysis is mostly clinical, and is based on a focused history and physical examination and a chest radiograph. Dyspnea secondary to eventration or paralysis is predominantly a diagnosis of exclusion. These patients must be evaluated for other primary causes of dyspnea, and if
Diaphragmatic Plication
Surgical repair of diaphragmatic eventration was first described in 1923.32 Since then, a variety of open and minimally invasive diaphragm transthoracic and transabdominal plication techniques have been described. Although alternative treatments have been described (eg, diaphragmatic pacing for quadriplegic patients with bilateral diaphragmatic paralysis33), they have not gained widespread acceptance.
Indications
The only goal of diaphragm plication is to treat dyspnea; hence, operative intervention is
Rehabilitation and recovery
To assess the response to plication, we reevaluate symptoms with the SGRQ, and repeat PFTs. All patients are systematically evaluated by inpatient physical and respiratory therapists and based on objective assessments we occasionally recommend for additional time in rehabilitation (Table 2).
Summary
Plication of the diaphragm should be performed on symptomatic patients (with no other explanation for symptoms) with evidence of an elevated diaphragm that is not caused by any other pathologic process besides paralysis or eventration. A variety of open and minimally invasive transthoracic and transabdominal techniques have been described in the international literature. The choice of plication approach is dependent on the expertise of the surgeon. Laparoscopic diaphragm plication for diaphragm
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Cited by (15)
Separate evaluation of unilateral lung function using upright/supine CT in a patient with diaphragmatic paralysis
2022, Radiology Case ReportsCitation Excerpt :To our knowledge, this is the first report of a patient with unilateral diaphragmatic paralysis who underwent both upright and supine CT. A PFT is widely used for assessing the severity of diaphragmatic paralysis [2], and can be performed both in the upright and supine positions [9]. However, PFTs cannot be used to separately evaluate the function of each lung.
Paradoxical Motion on Sniff Test Predicts Greater Improvement Following Diaphragm Plication
2021, Annals of Thoracic SurgeryCitation Excerpt :Furthermore, the sniff test’s specificity has been questioned: 1 study discovered that 6% of healthy subjects had paradoxical cephalad motion of a hemidiaphragm during the sniff maneuver.16 Some researchers were also discouraged by the difficulty of interpreting NPM results, as well as by radiation exposure associated with fluoroscopy.13,23 However, based on our analysis, the sniff test has a great deal of value.
Nerve-Sparing Surgery in Advanced Stage Thymomas
2019, Annals of Thoracic SurgeryCitation Excerpt :Surprisingly, there was no correlation between neoadjuvant therapy and postoperative PN palsy, despite possible fibrosis due to induction treatments. Nerve-sparing thymectomy was reported for the first time in 2010 by Yano and colleagues [8] when they published results in terms of postoperative pulmonary function, survival, and relapse of 9 patients affected by stage III thymoma who underwent phrenic nerve-sparing surgery compared with 9 patients in whom the nerve was resected. They described minimal visible residual tumor tissue surrounding the preserved PN (R2), whereas we have always reached a macroscopically complete resection of the tumor.
Diaphragm Dysfunction in Critical Illness
2018, ChestMinimally-Invasive Diaphragmatic Plication in Patients with Unilateral Diaphragmatic Paralysis
2023, Journal of Clinical Medicine