Diaphragmatic plication offers functional improvement in dyspnoea and better pulmonary function with low morbidity

Abstract

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was as follows: In adults with unilateral diaphragmatic paralysis, does diaphragmatic plication offer functional improvement in dyspnoea, better pulmonary function tests (PFTs) and return to activity? A total of 126 papers were found using the reported search, of which 13 represented the best evidence to answer the clinical question. The authors, date and country of publication, patient group studied, surgical approach, study type, relevant outcomes and results of these articles are tabulated. Those articles reporting improvement in PFTs following plication, documented this benefit in the following parameters: mean forced vital capacity (range 17-40%), forced expiratory volume at 1 sec (range 21-27%), functional residual capacity (range 20-21%) and total lung capacity (range 16-19%). The percentage of postoperative improvement in shortness of breath as measured by a dyspnoea score was reported to be between 90 and 96% in the thoracotomy group and 100% in the Video Assisted Thoracoscopic Surgery (VATS) group, the dyspnoea score that was used in all the studies was a visual analogue scale between 0 and 10 where 0 is no dyspnoea and 10 is the worst dyspnoea a patient can have. One of the studies reported postoperative normalization in ventilation perfusion scan (VQ) scan parameters when compared with the preoperative mismatch. Complication rate was similar between the two groups, while the mortality rate was 4% in the thoracotomy group and 0% in the VATS group. The total number of patients included in all the studies combined was 161. All reports included in this review are observational studies (one cohort study and the remainder being case series); therefore, the risk of selection, information and publication biases are high and conclusions should be implemented with caution. We conclude that diaphragmatic plication can improve the functional status, shortness of breath and PFTs of patients with unilateral diaphragm paralysis. Patients undergoing a VATS approach appear to have more advantages in objective and subjective measures (including PFTs, dyspnoea score, length of hospital stay and postoperative complications). Further research with high-quality study designs is advised, focussing mainly on the long-term benefits and assessment of health-related quality of life.

Comparison of Mid-Term Clinical Outcomes of Different Surgical Approaches in Symptomatic Diaphragmatic Eventration

“…2,6) Pros and cons of both open and closed-repairs have widely been described in literature, but separately. [5][6][7][12][13][14][15]18) We have observed significantly decreased amount of postoperative drainage in group A, with no mortality or surgery-related morbidity in both groups. This result proves the feasibility and safeness of closed-repair technique, and no need for diaphragm incision.…”

“…[3][4][5][6] Same correction mechanism is found to be vital and life-saving in ventilatory dependent patients with uni/bilateral phrenic nerve paralysis. 2,[11][12][13][14] There are several surgical plication techniques described in literature, mainly differing by incising the diaphragm or not. The accordion and the double-breasted plication techniques are the most common transthoracic approaches used by thoracic surgeons aiming to achieve a tense and tight diaphragm.…”

“…[5][6][7][8]13,[15][16][17] We achieved a postoperative increase over 20% both in FVC and FEV 1 measurements of our patients, which still were permanent on the second year. This improvement in pulmonary functions ensures symptomatic relief and reflects directly to the patients' clinic.…”

“…The use of video assisted thoracoscopic surgery for diaphragm plication had lately been reported and shown to achieve similar outcome to plication via thoracotomy, which is thought to gain popularity in near future. 13,18) …”

Paralysis and Eventration of the Diaphragm

“…Fonksiyonel rezidüel kapasitede %35 oranında düşme görülür. VATS plikasyonda, kısa ve uzun dönem takiplerde solunum fonksiyon parametrelerinde de ciddi düzelmeler bildirilmiştir (15)(16)(17). Son yapılan dokuz vakadan oluşan ve değişik yaklaşımların uygulandığı bir çalışmada, plikasyon sonrası tidal volümlerin arttığı, solunum sıklığının azaldığı ve maksimal eksersiz kapasitenin ise değiş-meden kaldığı gösterilmiştir (18).…”