Management of Diaphragm Paralysis and Eventration.

An elevated diaphragm may be due to eventration or paralysis. Diaphragm elevation is often asymptomatic and found incidentally on imaging. Fluoroscopic testing can be used to differentiate eventration (no paradoxic motion) from paralysis (paradoxic motion). Regardless of etiology, a diaphragm plication is indicated in all symptomatic patients with an elevated diaphragm. Plication can be approached either from a thoracic or abdominal approach, though most thoracic surgeons perform minimally invasive thoracoscopic plication. The goal of plication is to improve lung volumes and decrease paradoxic elevation of the hemidiaphragm. Diaphragm plication is safe, has excellent outcomes, and is associated with symptom improvement.

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 142 min. All patients had a regular (reviewer #1) postoperative course except for one who developed hydro-pneumothorax. At a median follow-up of 48 months, 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).

First case of bilateral diaphragm eventration successfully repaired through an abdominal approach following lung transplantation.

A 61-year-old male patient with bilateral lung transplantation was admitted to the outpatient clinic with increasing respiratory distress for a month. Bilateral diaphragm eventration was observed in his examinations. Bilateral diaphragm plication was successfully performed abdominally in the patient who had a complaint despite supportive treatment. The respiratory capacity of the patient returned to normal. The abdominal approach may be a good alternative option in cases where intrathoracic surgery cannot be performed due to adhesions in patients with eventration after lung transplantation. KEY WORDS: Acquired eventration, Diaphragm, Lung transplantation.

High insertion of the right diaphragm complicated with congenital diaphragmatic hernia: A case report of rare thoracoscopic findings.

We encountered a case of high insertion of the right diaphragm complicated with congenital diaphragmatic hernia that was diagnosed based on thoracoscopic findings. A full-term male baby was suspected of having right congenital diaphragmatic hernia or diaphragmatic eventration on postnatal imaging. He only had episodes of mild but prolonged symptoms following upper respiratory tract infection and his course was otherwise uneventful during outpatient monitoring. At 1 year old, the elevated liver volume remained large, which might eventually interfere with his lung growth, so thoracoscopic exploration was planned. Thoracoscopy revealed liver prolapse from a diaphragmatic defect. In addition, the anterior to lateral inserted part of the diaphragm was high, with the anterior part reaching the fourth rib. We repaired only the diaphragmatic defect without repositioning the diaphragm, and the postoperative course was uneventful. High insertion of the diaphragm should be considered as a differential diagnosis of congenital diaphragmatic eventration.

Laparoscopic management of gastric volvulus, diaphragmatic eventration and wandering spleen in a child.

Gastric volvulus (GV) and wandering spleen (WS) associated with eventration of diaphragm share a common pathological cause of absence or laxity of intraperitoneal ligaments. We herein report a rare case of a 13-year-old child presenting with an acute GV, WS, diaphragmatic eventration and an ectopic ascended kidney managed with a laparoscopic approach.

Diaphragmatic plication for diaphragmatic eventration caused by chronic constipation: a case report.

Diaphragmatic eventration in an adult patient is a rare condition. We describe a case of an elderly patient with hemidiaphragm dysfunction caused due to chronic constipation. A 67-year-old woman with a medical history of descending colon cancer that was treated 24 years before undergoing partial colectomy was admitted to our hospital with complaints of progressive shortness of breath and dyspnea on exertion for the past few months. She had no past history of any trauma. The patient had previously been suffering from chronic constipation after surgery. Physical examination revealed distension and incisional hernia of the abdomen. Chest X-ray demonstrated the high position of the left dome of the diaphragm with the megacolon gas. Chest and abdominal computed tomographic scans disclosed left diaphragmatic displacement containing the stomach and megacolon and abdominal incisional hernia. We performed open laparotomy, repair of abdominal incisional hernia using mesh, and diaphragmatic plication with nonabsorbable polyester suture and pledgets. Postoperative imaging confirmed the significant improvement of the patient's left lung space and clinical resolution of her respiratory symptoms. We describe the case of a patient with diaphragmatic eventration that was caused due to chronic constipation who underwent successful surgical repair.

Laparoscopic distal gastrectomy in a patient with gastric cancer complicated by eventration of the diaphragm: A case report.

Diaphragmatic eventration refers to an abnormal elevation of the diaphragm. Here, we report the case of a patient with gastric cancer who underwent successful laparoscopic distal gastrectomy despite the presence of diaphragmatic eventration. The patient was a 72-year-old man diagnosed with early gastric cancer in the antrum, as detected by upper gastrointestinal endoscopy. Preoperative imaging revealed an elevation of the left side of the diaphragm, which was diagnosed as diaphragmatic eventration. Laparoscopic surgery is beneficial for obtaining an optimal field of view. However, there are critical points that must be considered when laparoscopic distal gastrectomy is performed in patients with gastric cancer complicated by diaphragmatic eventration. There were difficulties that affected manipulation because the elevated diaphragm drew the intraperitoneal organs into the thoracic cavity, causing displacement of the normal anatomical position. We found it beneficial to secure the lesser curvature of the stomach given the possible effects of gastric deformation.

Diaphragmatic dysfunction.

The diaphragm is the main breathing muscle and contraction of the diaphragm is vital for ventilation so any disease that interferes with diaphragmatic innervation, contractile muscle function, or mechanical coupling to the chest wall can cause diaphragm dysfunction. Diaphragm dysfunction is associated with dyspnoea, intolerance to exercise, sleep disturbances, hypersomnia, with a potential impact on survival. Diagnosis of diaphragm dysfunction is based on static and dynamic imaging tests (especially ultrasound) and pulmonary function and phrenic nerve stimulation tests. Treatment will depend on the symptoms and causes of the disease. The management of diaphragm dysfunction may include observation in asymptomatic patients with unilateral dysfunction, surgery (i.e., plication of the diaphragm), placement of a diaphragmatic pacemaker or invasive and/or non-invasive mechanical ventilation in symptomatic patients with bilateral paralysis of the diaphragm. This type of patient should be treated in experienced centres. This review aims to provide an overview of the problem, with special emphasis on the diseases that cause diaphragmatic dysfunction and the diagnostic and therapeutic procedures most commonly employed in clinical practice. The ultimate goal is to establish a standard of care for diaphragmatic dysfunction.

VATS Diaphragm Plication.

Elevated diaphragm can be due to diaphragmatic eventration or diaphragm paralysis. Diaphragm paralysis is a rare condition that can be congenital or acquired. Acquired diaphragmatic paralysis can result from injury to the phrenic nerve. Subsequently, there is loss of contractility of the diaphragm muscle leading to progressive atrophy and, hence, distension of the dome of the diaphragm leading to elevated right, left, or both copula of the diaphragm. Diaphragm plication aims to return the abdominal contents back to their normal position and allow for greater lung expansion by reducing the abundant diaphragmatic surface. Traditionally, diaphragm plication was performed through thoracotomy, until 1996 when Moroux introduced the widely used thoracoscopic technique of diaphragm plication. With the advancement of minimally-invasive surgery over the years, the approach to diaphragm plication has evolved from four ports to an uniportal approach and robotics.

A breath of fresh air: A family ceremony.

Healing rituals and ceremonies are conducted with the hope of ushering a sick or impaired person back to wellness or preserving health against perceived threats (Burns, 1996). In medical settings, healing ceremonies can address biopsychosocial, existential, and spiritual aspects of difficult situations (Hammerschlag, 1989; Johnson, Feldman, Lubin, & Southwick, 1995; Mehl-Madrona, 1999). This article describes presents the case history of Lisa H. and her son, Anthony. Anthony experienced two medical crises within the first five days of his birth. The author suggested a healing ceremony might be valuable for Anthony's family. The ceremony opened the door to a candid conversation regarding everything that had transpired. It decreased the family's fear, anxiety, frustration, and guilt, and helped them cope better with the situation. Anthony sailed smoothly through his surgery and went home from the hospital a week later. The author notes that health care professionals generally set aside their spirituality while trying to help people, thus broaching the subject of ceremonies might make the care provider or the family feel uncomfortable. Care providers who are uncomfortable with participating could still provide a valuable service by presenting the notion of a ceremony as an option the patient or family may wish to consider, and directing them to useful resources.

To Sink the Lifted: Selection, Technique, and Result of Laparoscopic Diaphragmatic Plication for Paralysis or Eventration.

Introduction Diaphragmatic eventration is a congenital defect of the muscular portion of a hemidiaphragm that eventually leads to hemidiaphragmatic elevation and dysfunction. The clinical diagnosis of diaphragmatic eventration or diaphragmatic paralysis may be indistinguishable and diaphragmatic plication is the treatment of choice for both conditions. Discussion We review the indications, patient selection, and surgical techniques for diaphragmatic plication. We explain our preferred technique and guide the reader step by step on our approach. Conclusion Minimally invasive diaphragm plication techniques are effective alternatives to open transthoracic plication and result in significant improvement in dyspnea and quality of life in adequately selected patients.

[Laparoscopic gastric sleeve in gastric volvulus secondary to diaphragmatic eventration in an adult patient]. / Manga gástrica laparoscópica en vólvulo gástrico secundario a eventración diafragmática en paciente adulto.

BACKGROUND: Acute gastric volvulus is a rare, but potentially life-threatening, cause of upper gastrointestinal obstruction. CLINICAL CASE: Male of 60 years old with severe epigastric pain and abdominal distension with haematemesis on two occasions. The patient was haemodynamically stable, with abdominal distension and palpable epigastric fullness. Hematic cytology showed: haemoglobin 8.2g/dl and haematocrit 27%. Abdominal X-ray showed an elevation of left diaphragm with a hugely dilated stomach. A nasogastric tube was inserted. Endoscopy was performed. There was no active bleeding, but it was impossible to reach the duodenum due to the stomach distortion. The upper gastrointestinal X-ray study showed the appearance of an inverted stomach in the chest and an organoaxial gastric torsion. The CT scans of thorax and abdomen showed a gastric ascent into the thoracic cavity. Laparoscopic surgery was performed, finding the left hemi-diaphragm elevated, and the stomach, splenic angle of the colon, the spleen and tail of the pancreas were also raised. A linear gastrectomy (gastric sleeve) was performed. The postoperative progress was satisfactory. Oral feeding was started 72 hours after surgery, and the patient was discharged, and has remained asymptomatic during the following by 8 years. CONCLUSIONS: Emergency physicians must maintain a high level of suspicion in patients that present with signs and symptoms suggesting upper digestive tract occlusion. The gastric sleeve is an excellent alternative to avoid recurrence of gastric volvulus.

Is surgical plication necessary in diaphragm eventration?

BACKGROUND: Diaphragm plication surgery is conducted to remove dyspnea, which results from mediastinal shift, atelectasia, and ventilation/perfusion dyssynchrony in lungs that occur because of an eventrated diaphragm. This study aims to determine whether diaphragm plication has any effect on respiration by analyzing the patients' changing values in the respiratory function test (RFT) after plication surgery. METHODS: Sixteen patients who underwent diaphragm plication surgery in our clinic because of plication eventration or paralysis were examined prospectively. Diaphragm eventration values were assessed using a calculation method that uses posteroanterior pulmonary radiographies taken during patient admission and control; then, these data were recorded. The amount of changes in the eventration levels and in restrictive respiratory failure parameters-forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC) of RFTs-conducted in pre- and postoperative control periods were compared using statistical analysis methods. The compatibility between the amounts of RFT changes was examined through a satisfaction survey-using a questionnaire that consisted of multiple choice questions with answer options such as "better," "the same," and "worse"-to understand preoperative and postoperative symptom levels in the 12(th) month of postoperative control. RESULTS: According to postoperative levels, a decrease between 19% and 23% was observed in eventration amounts within the 1(st) postoperative month, 6(th) postoperative month, and 12(th) postoperative month. In addition, the highest average increase in FEV1 liter (lt) values was 0.2 lt and 0.25 in FVC (lt) values. CONCLUSION: Researchers of this study believe that more distinctive decisions need to be taken while identifying patients for surgery in unilateral diaphragm eventrations, especially in the adult patient group; surgical option should be used for cases in which the eventrated diaphragm results in mediastinal shift and respiratory failure.

Congenital diaphragmatic eventration in children: 12 years' experience with 177 cases in a single institution.

OBJECTIVE: This study sought to summarize the diagnostic and treatment aspects of congenital diaphragmatic eventration (CDE) in children by retrospectively analyzing their medical records to identify and understand the complications of CDE, its treatment, and to evaluate the long-term outcomes of diaphragmatic plication. METHODS: The medical records of children who received treatment for CDE from January 2000 to December 2011 at the Children's Hospital of Chongqing Medical University, China were analyzed. Data analyzed included the following: age, sex, symptom, location of eventration, associated anomalies, surgical procedures, complications, and survival and follow up details after diaphragmatic plication. RESULTS: The medical records of 177 children (boys: 128, girls: 49, mean age: 10.28±2.35 months) with CDE were included in this study. Specific symptoms of eventration of the diaphragm were reported for 86 cases; and the typical symptoms included rapid breathing, vomiting, and recurrent respiratory infections. Except for a bilateral case, all the other patients had unilateral CDE. Associated malformations were observed in 31 cases (17.5%), hypoplastic lung (10 cases) was the most common followed by congenital heart disease (9 cases), and cryptorchidism (3 cases). Interestingly, 91 patients were asymptomatic. Diaphragmatic plication was performed in all symptomatic patients (86 cases, 48.5%) and none had recurrence. CONCLUSIONS: Clinical symptoms of CDE varied in severity, ranging from asymptomatic conditions to life-threatening respiratory distress. Timely accurate diagnosis and treatment of symptomatic CDE could effectively resolve respiratory morbidity and reduce complications. The diaphragm plication surgery provided good results among the study population with no recurrence.

Eventration of diaphragm in adults: eleven years experience.

BACKGROUND: Eventration of diaphragm is a congenital condition in which there is absence of muscle fibers in the diaphragm while maintaining all the anatomical attachments normally. Surgical treatment is warranted in symptomatic patients so as to reduce the abnormal ascent of diaphragm. The present study was conducted to analyse the perioperative outcome of thoracotomy in adult patients with diaphragmatic eventration. METHODS: This descriptive case series was carried out in Cardiothoracic Surgery-Unit, Postgraduate Medical Institute, Lady Reading Hospital, Peshawar, Pakistan. Medical records of patients operated upon for eventration from June 2002 to June 2013 were reviewed. Patients of either gender, above 16 years who were operated for symptomatic eventrtaion were included in study. All the demographic data, presenting complaints, baseline and post-postoperative dyspnea grade, forced expiratory volume at 1 second (FEV1) and forced vital capacity (FVC) were recorded on predesigned pro forma and analysed using SPSS-16. RESULTS: A total of 38 adult patients underwent surgery for diaphragmatic eventration over the past 11 years in our unit out of which 29 (76%) were males and rest of 9 (24%) were females. Mean age of patients was 41.6±13.84 years. In 31 (81.5%) patients left side was involved. Majority of patients had a dyspnea grade-3 on presentation. Preoperative dyspnoea score (MRC), FEV1 and FVC values were 2.6±0.73, 63.5±13.3 and 67.2±14.6 respectively. Pre-operative and 6-months follow-up values of dyspnoea grade, FEV1 and FVC values showed statistically significant improvement. CONCLUSION: Our study showed that adult patients with symptomatic unilateral eventration of diaphragm significantly benefit from diaphragmmatic plication.

Multiple haemangiomas, diaphragmatic eventration and Beckwith-Wiedemann syndrome: an unusual association.

A 6-month-old girl with Beckwith-Wiedemann syndrome, multiple haemangiomas (axillary, laryngeal, pulmonary and hepatic) and diaphragmatic eventration was reported. All tumours responded to treatment with propranolol. The surgical correction of diaphragmatic eventration was crucial to a better outcome.

[Diaphragmatic eventration with shock and respiratory distress requiring emergency plication; report of a case].

A 80-year-old female with an eventration of the left diaphragm, which had been noticed with routine chest roentgenogram in 2006, presented with severe dyspnea and shock vital in 2012. The chest X-ray on admission disclosed elevation of the left hemidiaphragm, dislocation of the heart to the right. The diagnosis of eventration of the diaphragm was confirmed with a computed tomographic scan. She underwent diaphragmatic plication with endostaplers by thoracoscopic surgery. The postoperative course was uneventful except for transient reexpansion pulmonary edema. The patient was extubated on the 5th postoperative day. Dyspnea has disappeared after the operation. She was in a good condition without requiring any additional oxygen.