Stapled Full-Thickness Diaphragm Resection: A Novel Approach to Diaphragmatic Resection in Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy.

Full-thickness diaphragm resection (FT-DR) during cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is sometimes required to achieve a complete cytoreduction. It is conventionally performed with electrocautery with primary repair or mesh repair. FT-DR using a linear cutting stapler is a novel technique that avoids entry to the chest cavity and minimizes the use of electrocautery on the diaphragm. We performed an institutional retrospective review of a prospectively maintained database of 145 patients who underwent CRS-HIPEC between 2013 and 2019. Patients were divided into the Conventional or Stapled group based on the FT-DR approach indicated in the operative report. Of the 145 patients who underwent CRS-HIPEC, 27 underwent FT-DR, with 63% (n = 17) in the Stapled group. There were no significant demographic or oncologic differences between the 2 groups. Patients in the Stapled group underwent tube thoracostomy (13.3% vs 60%; p = 0.008), were diagnosed with pneumonia (12% vs 50%; p = 0.04), required reintubation (6% vs 40%; p = 0.03), and required mechanical ventilation more than 48 hours (6% vs 50%; p = 0.02) less frequently than the Conventional group. There was no difference in pleural recurrence between the 2 groups (Conventional 20% vs Stapled 12%, p = 0.56). Stapled full-thickness diaphragm resection is a novel approach to achieving a complete cytoreduction that excludes the pleural cavity, minimizes diaphragm manipulation, and is associated with improved postoperative pulmonary outcomes in patients undergoing CRS-HIPEC.

Diaphragmatic Peritoneal Stripping Versus Full-Thickness Resection in CRS/HIPEC: Is There a Difference?

BACKGROUND: Pleural recurrence after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is rare and poorly delineated. Specifically, data are limited on the effect that diaphragmatic peritoneal stripping versus full-thickness resection has on the nature of ipsilateral pleural recurrence and postoperative morbidity. METHODS: Patients with peritoneal carcinomatosis who underwent CRS/HIPEC were included from a prospectively maintained database. The patients were divided into three cohorts based on surgical management of the diaphragm as follows: diaphragm-stripping (DS) cohort, full-thickness resection (FTR) cohort, and no diaphragm manipulation (ND) cohort. Postoperative morbidity and incidence of ipsilateral pleural recurrence were evaluated. All diaphragmatic defects were closed before abdominal chemoperfusion. RESULTS: The inclusion criteria were met by 409 CRS/HIPEC procedures: 66 in DS, 122 in FTR, and 238 in ND. Ipsilateral pleural recurrence rates did not differ significantly between the three cohorts (DS 6%, FTR 3%, ND 3%; p = 0.470). Postoperative respiratory complications and overall morbidity were significantly greater for the patients who underwent diaphragmatic disruption (stripping and/or resection) than for the patients who did not (p ≤ 0.0001), but the two groups did not differ in terms of 30-day mortality. However, comparison of FTR with DS showed no impact on major morbidity or pleural recurrence. CONCLUSION: Although patients undergoing surgical manipulation of the diaphragm during CRS/HIPEC experienced significantly greater morbidity, diaphragmatic stripping did not differ from full-thickness resection in terms of grades 3 and 4 complications or incidence of ipsilateral pleural recurrences. When deemed necessary to achieve complete cytoreduction, full-thickness diaphragmatic resection should be undertaken. In addition, the data support the observation that definitive repair of the diaphragmatic defect before abdominal chemoperfusion does not adversely influence ipsilateral pleural recurrence.

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.

Long-term Survival and Propensity Score Matched Outcomes of Bilateral vs. Unilateral Diaphragm Interventions in Cytoreductive Surgery plus Intra-peritoneal Chemotherapy.

BACKGROUND/AIM: To assess the impact of short- and long-term outcomes of bilateral vs. unilateral diaphragm interventions in cyto-reductive surgery (CRS) and intra-peritoneal chemotherapy (IPC). PATIENTS AND METHODS: A total of 652 CRS/IPC procedures, between 1996 and 2018, required diaphragm interventions. Among these, 388 underwent bilateral intervention. Preoperative heterogeneity was assessed in 6 parameters and addressed with propensity score matching. The association of each respective analysis was assessed with 11 outcomes. Overall survival was assessed based on histology. RESULTS: CRS/IPC requiring bilateral diaphragmatic interventions illustrated significantly increased operative hours (9.6 vs. 8.6 hours, p<0.001). Postoperatively, there was significantly increased red blood cell (RBC) transfusion (6.37 units vs. 4.47 units, p=0.007) and grade III and IV complications (57.3% vs. 40.6%, p=0.004). No difference was noted in ICU stay, total length of stay, hospital death and return to OT. In terms of respiratory complications, an increased incidence of pneumothorax (16.5% vs. 6.2%, p<0.001) was noted whilst pleural effusions and pneumonia occurrences were non-significant. Overall survival, revealed bilateral interventions in low-grade appendiceal mucinous neoplasm conferred an increased relative risk (p=0.037, RR=2.230, 95%CI=1.052-4.730). They did not have an effect on OS in colorectal cancer and mesothelioma. CONCLUSION: Despite the increase in short-term morbidity, bilateral diaphragm interventions resulted in similar long-term survival to unilateral interventions.

Perioperative anesthetic management of children with congenital central hypoventilation syndrome and rapid-onset obesity with hypothalamic dysfunction, hypoventilation, and autonomic dysregulation undergoing thoracoscopic phrenic nerve-diaphragm pacemaker implantation.

BACKGROUND: Congenital Central Hypoventilation Syndrome and Rapid-Onset Obesity with Hypothalamic dysfunction, Hypoventilation, and Autonomic Dysregulation are rare neurocristopathies characterized by autonomic dysregulation including bradyarrhythmias, abnormal temperature control, and most significantly, abnormal control of breathing leading to tracheostomy and ventilator dependence as life support. Surgical advancements have made phrenic nerve-diaphragm pacemakers available, to eliminate the tether to a mechanical ventilator for 12-15 hours each day. The thoracoscopic approach to implantation has allowed for a less invasive approach which may have implications for pain control and recovery time. However, thoracoscopic implantation of these devices presents several challenges to the anesthesiologist in these complex ventilator-dependent patients, including, but not limited to, sequential lung isolation, prevention of hypothermia, and management of arrhythmias. Postoperative challenges may also include strategies to treat hemodynamic instability, managing the ventilator following lung derecruitment, and providing adequate pain control. AIMS: We aimed to describe the anesthetic management of Congenital Central Hypoventilation Syndrome and Rapid-Onset Obesity with Hypothalamic dysfunction, Hypoventilation, and Autonomic Dysregulation patients undergoing thoracoscopic phrenic nerve-diaphragm pacemaker implantation and the nature and incidence of perioperative complications. METHODS: A retrospective chart review was performed of 14 children with Congenital Central Hypoventilation Syndrome and Rapid-Onset Obesity with Hypothalamic dysfunction, Hypoventilation, and Autonomic Dysregulation undergoing phrenic nerve-diaphragm pacemaker implantation at a single academic pediatric hospital between 2009 and 2017. Demographic information, intraoperative management, and perioperative complications were analyzed from patient records. RESULTS: Twelve of 14 patients (86%) underwent an inhalational induction via tracheostomy. Lung isolation was achieved via fiberoptic guidance of a single lumen endotracheal tube sequentially into the right or left mainstem bronchi for 12 patients (86%). Double lumen endotracheal tubes were utilized in two patients (7%) and bronchial blockers in two patients (7%) for lung isolation. Anesthesia was maintained using a balanced technique of volatile agents (sevoflurane/isoflurane) and opioids (fentanyl). Bradyarrhythmias developed in six patients (43%) during surgery, 5 (36%) responded to anticholinergics and one patient (7%) required backup cardiac pacing using a previously implanted bipolar cardiac pacemaker. Intraoperative hypothermia (<35.5°C) was present in five patients (36%) despite the use of warming devices. Hypercarbia (>50 mm Hg) during lung isolation was present in eight patients (57%) and hemoglobin desaturation (<90%) in four patients (29%). Postoperatively, oxygen desaturation was a common complication with nine patients (64%) requiring supplemental oxygen administration via mechanical ventilator or manual bag ventilation. Opioids via patient-controlled analgesia devices (12 patients, 86%) or intermittent injection (two patients, 14%) were administered to all patients for postoperative pain control. Phrenic nerve-diaphragm pacemaker placement was successful thoracoscopically in all patients with no perioperative mortality. CONCLUSION: The main anesthetic challenges in patients with Congenital Central Hypoventilation Syndrome and Rapid-Onset Obesity with Hypothalamic dysfunction, Hypoventilation, and Autonomic Dysregulation include hemodynamic instability, the propensity to develop hypothermia, hypercarbia/hypoxemia, and the need to perform bilateral sequential lung isolation requisite to the thoracoscopic implantation technique. Most anesthetic agents can be used safely in these patients; however, adequate knowledge of the susceptibility to complications, coupled with adequate preparation and understanding of the innate disease characteristics, are necessary to treat anticipated complications.

Surgical treatment of spondylitis and diaphragm relaxation in patient less than 1 year old.

DESIGN: Case report. INTRODUCTION: The combination of severe post-infectious kyphosis and diaphragm relaxation is extremely rare in patient early than 1 year old. Its no publications concerning their simultaneous surgical treatment. CASE DESCRIPTION: 7-Month-old girl had simultaneous spinal reconstruction with anterior and posterior instrumentation and plastic of diaphragm because of sequelae of non-granulenatous spondylitis complicated by severe kyphosis (54°) and diaphragm relaxation. Between 1.5 and 3 months of live she had several infections incl. pneumonia, enterocolitis, ENT infection. Anterior fusion was done by titanium mesh with auto-rib, posterior - by compressive rods based on low-profile hooks. The deformity was reduced till 20°. 2.5 years after initial surgery and 1 year after removal of posterior instrumentation the adequate level of diaphragm and minimal (4°) loss of kyphosis correction were identified. CONCLUSIONS: The combination of spondylitis and diaphragm relaxation in early aged patient could be explained but it could not be confirmed as a sequelae of late-onset neonatal sepsis with a multi-focal lesions. The simultaneous surgery provided on the combined approaches (trans-thoracic and posterior) looks as optimal options in such combination of pathologies. In remains controversial how will the spine develop after so early reconstructive surgery, including in situ stable anterior fusion carried out by titanium mesh with auto-rib.

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.

[OPERATIVE TREATMENT OF DIAPHRAGMATIC RELAXATION, USING WELDING OF BIOLOGICAL TISSUES].

The results of examination and treatment of 17 patients for relaxation of the diaphragm were analyzed. There was proved the efficacy of application of the biological tissues welding while operative treatment of patients, using a duplicature method. While the biological welding application a reduction of the intervention total duration time was noted, and of intraoperative blood loss - by 17%, and a need for analgetic preparations - in 1.3 times. Minimal irritation impact of biological welding on parietal pleura and the pain intensity reduction was established.

Cytoreductive surgery plus bicavitary chemohyperthermia as treatment of pseudomixoma peritonei with pleural extension. A case report and review of the literature.

AIM: Intrathoracic extension in patients with pseudomixoma peritonei is a rare event, but spread of the tumour beyond the abdomen in to pleuropulmonary cavity has been reported. MATERIALS AND METHODS: We report a case of a 50-years-old woman with synchronous pleural manifestation of pseudomixoma peritonei by a mucinous ovarian cancer. During the abdominal cytoreductive surgery an extensive disease under the right hemidiaphragm was noted, requiring partial diaphragmatic resection. Once the pleural space was entered,mucinous neoplastic implants on the pleural surface was observed. The diaphragmatic defect was left open during the hyperthermic chemoperfusion to treat both the pleural and peritoneal surfaces. After a postoperative course uneventful she died after 6 months for a myocardial infarction, in presence of a left side pleural effusion with a positive cytology for high-grade malignant cells with a smear background contained wispy mucin. DISCUSSION: Despite the aggressive spread of the pseudomixoma peritonei within the peritoneal cavity, lymphatic and hematogenous metastasis are rare. However, extension of disease into pleuropolmonary cavity has been well described as pleural effusion or pleuropulmonary metastases. This is the first report in literature, to our knowledge, in which the thoracic extension is due to a mucinous ovarian cancer, and is the second case in which a simultaneous bicavitary hyperthermic chemoperfusion was done as a management option for thoracic extension of pseudomixoma peritonei. CONCLUSION: Due to the rarity of the thoracic involvement by pseudomixoma peritonei, its correct treatment is still unclear. Simultaneous cytoreductive surgery associated to intraoperative intraperitoneal and intrathoracic chemohyperthermia can be a potential therapeutic option for these patients.

Extended use of diaphragm pacing in patients with unilateral or bilateral diaphragm dysfunction: a new therapeutic option.

BACKGROUND: Diaphragm dysfunction (DD) can cause sleep abnormalities, dyspnea, atelectasis, and respiratory failure. Historical treatments, including positive pressure ventilation or diaphragm plication, may alleviate symptoms but do not restore physiologic diaphragm function. Diaphragm pacing (DP) is approved for spinal cord-injured patients and in amyotrophic lateral sclerosis. We report a series of DD patients undergoing use of DP outside of these initial indications. METHODS: This report involves a prospective, nonrandomized, interventional trial under institutional review board approval at a single institution. DP involves laparoscopic motor point mapping with implantation of intramuscular electrodes in each hemidiaphragm. Postoperatively, diaphragm conditioning ensues. RESULTS: Twenty-seven patients were evaluated; all patients had symptomatic and objective hypoventilation for an average of 36 months of symptoms. Causes included idiopathic (n = 13), chest surgery (n = 5), shoulder surgery or trauma (n = 6), and others (n = 3); 17 had bilateral involvement, 6 had nonstimulable diaphragms and were not implanted, and 21 were implanted. Thirteen (62%) had substantial clinically relevant respiratory improvements. Four ventilator patients were weaned completely. Four had partial improvement, 3 had no improvement, and 1 patient was lost to follow-up for objective analysis. CONCLUSION: This is the first report of DP being used to treat diverse causes of DD. Eighty-one percent of implanted patients experienced improvements. This success suggests a potential for a wider use of DP and areas for future research.

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy for gallbladder cancer: a retrospective review.

Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) often prolongs survival in patients with peritoneal surface disease, yet is generally avoided in patients with peritoneal spread from gallbladder cancer as a result of its aggressive biologic behavior. Therefore, we reviewed our experience with CRS/HIPEC for patients with gallbladder cancer. We retrospectively evaluated the outcomes of CRS/HIPEC procedures performed from 1991 to 2013 using a prospectively maintained database of 1069 procedures. Patient and tumor characteristics, morbidity, mortality, and survival were reviewed. CRS/HIPEC was performed six times in five patients with peritoneal spread from gallbladder cancer. Patients were young (age 28 to 54 years) without pre-existing comorbidities. Eighty per cent had an Eastern Cooperative Oncology Group score of 0 or 1. At CRS, organs resected included omentum (n = 4), liver (n = 3), colon (n = 2), ovaries (n = 1), and diaphragm (n = 1). A complete macroscopic cytoreduction of intraperitoneal disease was achieved in every case. Clavien graded major morbidity was 17 per cent. There was no observed mortality. Median and 3-year survival were 22.4 months and 30 per cent, respectively. CRS/HIPEC may be performed safely in patients with peritoneal dissemination from gallbladder cancer. Carefully selected patients with low-volume disease amenable to complete cytoreduction may experience a meaningful survival benefit.

Significance of diaphragmatic resections and thoracic chemoperfusion on outcomes of peritoneal surface disease treated with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC).

BACKGROUND: Diaphragmatic resection (DR) during CRS/HIPEC exposes the thoracic cavity to direct contamination from the peritoneal cavity. The effect of thoracic chemoperfusion in combination with HIPEC in these patients is unknown. METHODS: A prospective database of 1,077 procedures was analyzed. Type of malignancy, thoracic perfusion, resection status, comorbidities, morbidity, mortality, and overall survival were reviewed. RESULTS: DR was a component of 102 CRS/HIPEC procedures performed for 57 (55.9 %) appendiceal and 22 (21.6 %) colon primary lesions. DR was associated with higher volume of disease as evidenced by more organ resections (3.7 vs. 2.8, p < 0.001) and increased rates of incomplete cytoreduction (67 vs. 52 %, p = 0.004). Patients with and without DR had similar 30-day major morbidity (23.5 vs. 16.8 %, p = 0.1) and worse 90-day mortality (12.8 % vs. 6.12 %, p = 0.03), respectively. Multivariate analysis showed DR (p = 0.01) and diabetes (p = 0.005) to be associated with worse mortality. Nineteen (20 %) DR patients underwent synchronous abdominal and thoracic chemoperfusion. Intrathoracic recurrence following DR with thoracic perfusion was 17 % (3/18) vs. 2.3 % (2/85) without perfusion (p = 0.04). Median survival following complete cytoreduction was similar for patients with low-grade appendiceal (LGA) (not reached with DR and 175 months without DR, p = 0.17) and colorectal cancer (23 months with and 31 months without DR, p = 0.76). CONCLUSIONS: Diaphragmatic resection during CRS/HIPEC is an independent predictor of surgical mortality. Intrapleural perfusion was associated with more thoracic recurrence; however, complete cytoreduction with or without DR can achieve similar survival for patients with LGA and colorectal primary lesions. DR should be performed only if careful inspection deems all peritoneal disease resectable.

Final analysis of the pilot trial of diaphragm pacing in amyotrophic lateral sclerosis with long-term follow-up: diaphragm pacing positively affects diaphragm respiration.

BACKGROUND: Respiratory insufficiency is the major cause of mortality in patients with amyotrophic lateral sclerosis or Lou Gehrig's disease. This is the final report of the diaphragm pacing (DP) pilot trial. METHODS: Patients underwent laparoscopic diaphragm electrode implantations and subsequent conditioning of diaphragms. Serial respiratory function tests were performed in the initial year and followed until death. RESULTS: Sixteen patients were implanted with no perioperative or unanticipated device-related adverse events. There were 452 implant-months of follow-up. DP allowed greater movement of the diaphragm under fluoroscopy, increased muscle thickness, and decreased the decline in forced vital capacity. Median survival from implant was 19.7 months with the cause of death respiratory in only 31%. CONCLUSIONS: Long-term analysis of DP in amyotrophic lateral sclerosis showed no safety issues and can positively influence diaphragm physiology and survival. This formed the initial basis for subsequent US Food and Drug Administration approval.

Electrophrenic pacing and decannulation for high-level spinal cord injury: a case series.

BACKGROUND: In 1997, guidelines were developed for the management of high-level ventilator-dependent patients with spinal cord injury who had little or no ventilator-free breathing ability (VFBA). This article describes the three categories of patients, the decannulation criteria, and the successful decannulation of four patients with no VFBA and electrophrenic/diaphragm pacing, using these criteria. METHOD: Case series. CONCLUSION: Lack of VFBA in patients with high-level spinal cord injury does not mandate tracheostomy or electrophrenic/diaphragm pacing.

Biological materials for diaphragmatic repair: initial experiences with the PeriGuard Repair Patch®.

BACKGROUND: We sought to analyze the efficacy of a bovine pericardial patch (PeriGuard®) for diaphragmatic repair. METHODS: Seven consecutive patients (6 males, median age 56 years) scheduled for diaphragmatic resection and/or repair were enrolled in this study. In all cases diaphragmatic repair was performed with a PeriGuard Repair Patch® (Synovis, St. Paul, MN, USA). At follow-up (median: 12 months; range: 6-18 months), quality of life, signs of reherniation and incorporation of mesh were assessed through clinical examination, blood samples and CT or MRT scan. RESULTS: Diagnosis on admission included sarcoma (n = 2), mesothelioma (n = 1), squamous cell carcinoma (n = 1), parachordoma (n = 1) and large congenital or posttraumatic herniation (n = 2). At follow-up successful diaphragmatic repair with no signs of reherniation, graft dehiscence or seroma formation was confirmed for all patients. Recorded inflammatory markers [C-reactive protein (CRP), white blood cell count (WBC) and procalcitonin (PCT)] reached their peak values between postoperative day (POD) 4 and POD 7. Values ranged from 122-282 mg/L for CRP, 0.4-4.6 µg/L for PCT and 6.2-15.6 Tsd/µL for WBC. Overall oncological results were good and 5 out of 6 survivors reported a fully reestablished quality of life. CONCLUSION: We consider the PeriGuard Repair Patch® a viable alternative to synthetic materials for diaphragm replacement. Moreover, we advise carrying out cautious follow-up in patients undergoing extensive oncological resection to learn more about the biological behavior of the bovine PeriGuard Repair Patch® after diaphragmatic repair.

Laparoscopic diaphragm pacing for tetraplegia.

(1) The NeuRx DPS is a laparoscopically implanted device that provides ventilatory support. (2) This device stimulates the diaphragm muscle, rather than the phrenic nerve, and is intended to lead to less risk of nerve damage than other therapies.(3) This technology provides an alternative to mechanical ventilation, and allows patients to increase day-to-day freedom and minimize the risk of respiratory infection. (4) The NeuRx DPS safety profile is based on clinical testing, which began with clinical trials starting in 2000. It has the potential to reduce costs, but this has not been well established.

Diaphragm pacing with natural orifice transluminal endoscopic surgery: potential for difficult-to-wean intensive care unit patients.

BACKGROUND: Up to 50% of the patients in the intensive care unit (ICU) require mechanical ventilation, with 20% requiring the use of a ventilator for more than 7 days. More than 40% of this time is spent weaning the patient from mechanical ventilation. Failure to wean from mechanical ventilation can in part be attributable to rapid onset of diaphragm atrophy, barotrauma, posterior lobe atelectasis, and impaired hemodynamics, which are normally improved by maintaining a more natural negative chest pressure. The authors have previously shown that laparoscopic implantation of a diaphragm pacing system benefits selected patients. They now propose that an acute ventilator assist with interventional neurostimulation of the diaphragm in the ICU is feasible and could facilitate the weaning of ICU patients from mechanical ventilation. Natural orifice transluminal endoscopic surgery (NOTES) has the potential to expand the benefits of the diaphragm pacing system to this acute patient population by allowing it to be performed at the bedside similarly to insertion of the common gastrostomy tube. This study evaluates the feasibility of this approach in a porcine model. METHODS: Pigs were anesthetized, and peritoneal access with the flexible endoscope was obtained using a guidewire, needle knife cautery, and balloon dilation. The diaphragm was mapped using a novel endoscopic electrostimulation catheter to locate the motor point (where stimulation provides complete contraction of the diaphragm). An intramuscular electrode then was placed at the motor point with a percutaneous needle. The gastrotomy was managed with a gastrostomy tube. RESULTS: Four pigs were studied, and the endoscopic mapping instrument was able to map the diaphragm to identify the motor point. In one animal, a percutaneous electrode was placed into the motor point under transgastric endoscopic visualization, and the diaphragm could be paced in conjunction with mechanical ventilation. CONCLUSIONS: These animal studies demonstrate the feasibility of transgastric mapping of the diaphragm and implantation of a percutaneous electrode for therapeutic diaphragmatic stimulation.

[Morpho-functional study of electrostimulated latissimus dorsi muscle flap for diaphragm substitution]. / Estudio morfofuncional de una plastia electroestimulada del músculo latissimus dorsi para sustitución diafragmática.

Based on practical applications of the muscle latissimus dorsi (MLD) as much in reconstruction thoracic-abdominal defects as functionally in cardiomyoplasty, and in our experience in the electrostimulation with diaphragm pacing, we elaborated the primary objective of this work consisting of the creation of functional muscle plasty of MLD for substitution of the diaphragm. In two groups of cats formed by 6 animals each one, with section of the corresponding phrenic nerve, MLD plasty has been done to replace hemidiaphragm, conserving the thoracodorsal pedicle, by thoracic route in a group (intrathoracic plasty), and in the other by abdominal route (intraabdominal plasty). In a second intervention the stimulador electrode is implanted on thoracodorsal pedicle and the rest of components of the diaphragmatic pacing in a subcutaneous pocket. During a month progressive electroestimulation of MLD plasty is made, carrying out radiological and spirometric evaluation, that compares with evaluation control made before making plasty. After the sacrifice of the animals planimetric and histologic evaluation of the extirpated diaphragm were performed. Morphologic and functional results obtained allow us to affirm that functional plasty of MLD is an effective diaphragmatic substitute, although with a smaller degree of function than the original diaphragm, and functionally intraabdominal plasty has been superior to intratorácica plasty.