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Eur J Cardiothorac Surg 2002;21:294-297
© 2002 Elsevier Science NL

Long term results of diaphragmatic plication for unilateral diaphragm paralysis

^a Royal Devon and Exeter NHS Trust, Barrack Road, Exeter, Devon EX2 5DW, UK
^b The Cardiothoracic Centre, Thomas Drive, Liverpool L14 3PE, UK

Received 21 November 2000; received in revised form 7 September 2001; accepted 20 November 2001.

* Corresponding author. Tel.:+44-1392-402-177; fax: +44-1392-402-067
e-mail: richard.berrisford{at}rdehc-tr.swest.nhs.uk

	Abstract

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 
Objectives: To examine whether diaphragmatic plication is an effective and lasting treatment option for non-malignant diaphragmatic paralysis. Methods: Nineteen patients who had undergone diaphragm plication (1983–1990) were recalled for interview, pulmonary function testing and chest X-ray. Results: There were 13 men and six women aged 24–73 (mean 55). Diaphragm paralysis was idiopathic (n=9), postsurgical (n=3), related to cervical spondylosis (n=4) and neck injury (n=2). Patients presented with breathlessness (18/19) or orthopnoea (1/19). Symptoms had lasted 3–60 months (mean 24 months). All patients had a raised hemidiaphragm on chest X-ray with paradoxical movement on ultrasound. Mean preoperative FVC was 71% predicted (range 38–93, SD 12.9) and mean FEV₁ was 67% predicted (range 33–90, SD 10.8). Supine lung volumes were 81% (mean) of sitting values. There were six right plications and 13 left. There were no postoperative deaths. One patient required re-plication. Follow-up (18/19 of original operated patients) ranged from 7–14 years (mean 10 years). Three patients had died of unrelated causes and one patient failed to attend long term follow-up, leaving 15 patients of the original 19 operated on. Positional change in lung volumes was not affected by surgery at early (6 week) or late (>5 year) follow-up. FVC, FEV₁, FRC and TLC improved by 10.1*, 11.8*, 16.9* and 9.2*%, respectively, at early follow-up and 11.8*, 15.4*, 26 and 13.3*% at late follow-up (*P<0.005 signed rank). Dyspnoea scores at long term follow-up improved 1 point (n=5), 2 points (n=5) and 3 points (n=2), remained unchanged (n=1) or dropped 1 point (n=2). Of the 15 patients followed up all but one who had been employed returned to work. 14/15 patients expressed satisfaction with their surgery. Conclusion: Diaphragm plication is an effective procedure with lasting results.

Key Words: Diaphragmatic paralysis • Diaphragmatic plication • Thoracic surgery • Long term follow-up

	1. Introduction

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 
Non-malignant diaphragmatic paralysis is an uncommon condition in the adult usually presenting with dyspnoea. Common causes include trauma, neuromuscular disorders, iatrogenic (especially cardiac or mediastinal surgery), cervical spondylosis and infection.

Unilateral diaphragmatic plication at thoracotomy in the adult is well described. Short and medium term results have been good. Graham et al. reported on six of 17 patients at 5–7 years showing a maintained improvement in visual analogue dyspnoea score. Improved lung volumes were shown although spirometry was presented as a mean value for the population, which could mask individual patient changes either way [1,2].

The aim of this study was to assess the longevity of subjective and objective improvement (changes in individual patient spirometry) following plication for unilateral diaphragmatic non-malignant paralysis.

	2. Materials and methods

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 
Nineteen consecutive patients who had undergone diaphragmatic plication between 1983 and 1990 for non-malignant unilateral diaphragmatic paralysis were recalled for interview (to gain a general impression of well being), pulmonary function testing, in the sitting and lying position, and chest X-ray. All patients had preoperatively complained of dyspnoea on exertion (18/19) or orthopnoea (1/19) with a mean duration of symptoms of 24 months (range 3–60 months). In nine patients the cause was unknown, four were postsurgical, four were related to cervical spondylosis and one each due to neck injury and radiotherapy. They were initially diagnosed on a chest X-ray finding of raised hemidiaphragm and paradoxical movement on ultrasound scanning. A CT had been performed to exclude other pathology. Objective preoperative assessment consisted of pulmonary function testing (forced vital capacity and forced expiratory volume in 1 s) and measurement of lung volumes (total lung capacity and functional residual capacity) in the sitting and supine positions. Assessment of dyspnoea was made using the MRC/ATS grading system [3] (Table 1). Dyspnoea score was correlated with (preoperative) percent predicted pulmonary function tests using Wilcoxon signed rank test.

The decision to operate was made jointly between the patient's general practitioner, physician, surgeon and the patient. Diaphragmatic plication was performed through a posterolateral thoracotomy in the seventh intercostal space. The lung, mediastinum and phrenic nerve were examined to rule out any unsuspected pathology. The diaphragm was then plicated in four to five layers until it became taut. The first and second suture layers were continuous and the third, fourth (and fifth) layers were interrupted and buttressed with Teflon pledgets to prevent cutting out. The thoracotomy was closed in layers with a single intercostal drain left in place for 24–48 h. Pain control was achieved with a thoracic epidural or paravertebral catheter using 0.25% bupivacaine for 24–48 h.

Individual patients' dyspnoea score and pulmonary function tests were measured at early and late follow-up. Statistical significance between the preop, immediate postop and long term follow-up pulmonary function tests calculated using the signed rank test.

Positional lung function tests were expressed as ‘percent change from lying to sitting’ and statistical significance between the pre and postop values calculated using a paired t-test. The change in dyspnoea score was correlated with the percent change from preoperative to long term postoperative values using the signed rank test

	3. Results

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 
Fifteen patients (13 men and six women) aged 34–73 (mean 55) were followed for an average of 10 years (range 7–14 years) after unilateral diaphragmatic plication (six right and 13 left).

3.1. Dyspnoea score
All presented with significant dyspnoea (13/15 having a MRC/ATS3). Dyspnoea grade at long term follow-up improved 1 point (n=5), 2 points (n=5), 3 points (n=2), stayed level (n=1) or dropped 1 point (n=2). (P=0.001). Dyspnoea score correlated with (preoperative) percent predicted pulmonary function tests are shown in Table 2. Change in dyspnoea score correlated with the percent change from preoperative to long term postoperative values are shown in Table 3

3.3. Spirometry
There were significant improvements in all spirometric values and lung volumes in the sitting position compared to the preoperative values and all but the FEV₁ at long term follow-up was significant in the supine position. The results are shown in Table 4.

Positional changes in pulmonary function tests were not significant (except borderline significance of follow-up FEV₁) when the percent changes from sitting to lying at the postop and long term follow-up stages were compared with the preoperative percent change. The P-values for each variable are shown in Table 5 (paired t-test).

View larger version (22K): [in this window] [in a new window]   Fig. 1. The percent predicted FEV1 for individual patients (n=15) (adjusted for age at follow-up).

	4. Discussion

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

The patients in this series all had significant dyspnoea preoperatively, in many cases sufficient to render the patient unable to work. Preoperative lung volumes were about 70% predicted (higher than might be expected, but similar to values reported by Clague and Hall [5]) and the fall from sitting to lying was not dramatic (Table 4). Neither did the operation significantly alter postural change in lung volumes (Table 5). Spirometry, therefore, although an important part of preoperative assessment, may not be as important as subjective dyspnoea in deciding on treatment. This is in keeping with the poor correlation of dyspnoea score with preoperative percent predicted pulmonary function tests (Table 2). However, plication has resulted in an improved dyspnoea score correlating with an improved long term postoperative pulmonary function value in FEV₁, FVC and TLC.

Diaphragm plication by minimally invasive methods has been reported [4]. Reports of follow-up after thoracoscopic plication have been small (the largest group being three patients [6]) and short term (maximum 2 year follow-up) [7], but all have shown improvement in symptoms and spirometric variables.

The mechanism by which unilateral plication improves dyspnoea is probably multifactorial. In mechanical terms a flaccid hemidiaphragm is effectively a flail segment in the ‘semi-rigid’ muscular component of the hemithorax. Plication in effect repairs this flail segment by stretching the paralysed diaphragm as a semi-taught sheet between the lower borders of the rigid chest wall.

It is difficult for the patient with a paralysed hemidiaphragm to generate a negative intrapleural pressure for ventilation when the pressure barrier (i.e. hemidiaphragm) between intrathoracic and intraabdominal pressure is dysfunctional. Plication probably makes the hemidiaphragm a more effective pressure barrier between abdominal and intrapleural compartments.

Experimental models using dogs [8] have shown that plication in the setting of unilateral diaphragmatic paralysis improves the kinetics of the intact hemidiaphragm. This may also be the case in humans.

Diaphragmatic pacemakers have been used in the management of patients with bilateral diaphragmatic paralysis secondary to high cervical cord injuries but there is no evidence in the literature that this technique can be used successfully in unilateral paralysis.

Plication is a valuable treatment of unilateral diaphragmatic paralysis, which improves patients' dyspnoea, work status and spirometry. The long term outcomes of minimally invasive techniques need to be evaluated further. Patients' own assessment of preoperative symptoms and postoperative improvement are an important factor in assessing the need for surgery and its outcome.

	Footnotes

 
Presented at the 8th European Conference on General Thoracic Surgery of the European Society of Thoracic Surgeons, London, UK, November 1–4, 2000.

	References

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 

1. Graham D.R., Kaplan D., Evans C.C., Hind C.R.K., Donnelly R.J. Diaphragmatic plication for unilateral diaphragmatic paralysis: a 10-year experience. Ann Thorac Surg 1990;49:248-252.[Abstract]
2. Wright C.D., Williams J.G., Ogilvie C.M., Donnelly R.J. Results of diaphragmatic plication for unilateral diaphragmatic paralysis. J Thorac Cardiovasc Surg 1985;90:195-198.[Abstract]
3. Mahler D.A., Weinberg D.H., Wells C.K., Feinstein A.R. The measurement of dyspnea. Chest 1984;85:751-758.[Abstract/Free Full Text]
4. Gharagozloo F., McReynolds S.D., Snyder L. Thoracoscopic plication of the diaphragm. Surg Endosc 1995;9:1204-1206.[Medline]
5. Clague H.W., Hall D.R. Effect of posture on lung volume, airway closure and gas exchange in hemidiaphragmatic paralysis. Thorax Aug 1979;34(4):523-526.
6. Knight S.R., Clarke C.P. VATS plication of diaphragmatic eventration. Surg Laparoscop Endosc 1998;8:319-321.
7. Suzumura Y., Tekida Y., Sonobe M., Nagasawa M., Shindo T., Kitano M. A case of diaphragmatic eventration treated by plication with thoracoscopic surgery. Chest 1997;112:530-532.[Abstract/Free Full Text]
8. Takeda S., Nakahara K., Fujii Y., Matsumara A., Minami M., Matsuda H. Effects of diaphragmatic plication on respiratory mechanics in dogs with unilateral and bilateral phrenic nerve paralyses. Chest 1995;107:798-804.[Abstract/Free Full Text]

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