Chest
Volume 117, Issue 3, March 2000, Pages 786-789
Journal home page for Chest

Clinical Investigations
THE PLEURA
Long-term Effect of Bilateral Plication of the Diaphragm

https://doi.org/10.1378/chest.117.3.786Get rights and content

Study objectives

To assess the feasibility and clinical outcome of bilateral plication of the diaphragm in patients with bilateral diaphragmatic paralysis (BDP) caused by neuralgic amyotrophy (NA), a mononeuritis of the phrenic nerves.

Design

Prospective, case-control study over a 1-year period.

Setting

A university hospital in The Netherlands.

Patients

Six patients who presented with BDP caused by NA.

Methods

The diagnosis of BDP was based on the absence of muscle response after cervical magnetic stimulation of both phrenic nerves. Three patients did not undergo surgery but were observed for a period of 2 years, and the other three patients underwent a limited lateral thoracotomy at the eighth intercostal space. Plication was performed by U-stitches until the diaphragm was as tight as possible. Vital capacity (VC) and arterial blood gas was measured during follow-up.

Results

One month postoperatively, mean VC measured in the supine position was significantly improved by 17%, and this effect was sustained for 12 months. Arterial Po2 increased by 45%. VC and blood gas levels did not improve in the three patients that were only observed during the 2-year period. All three surgical patients could sleep in the supine position after the operation.

Conclusion

Bilateral plication of the diaphragm for NA-induced paralysis results in improvement of ventilation and blood gas exchange, allowing patients to sleep in the supine position without dyspnea.

Section snippets

Study Subjects

Six patients who had isolated BDP caused by NA were assessed. The patient characteristics are presented in Table 1. All six patients had signs of right-sided heart failure. They were unable to lie flat and could sleep only while sitting in a chair. A neurologist found no signs of limb, neck, or thoracic muscle paralysis. Cervical magnetic stimulation and bilateral electrical stimulation of the phrenic nerves showed no activity in any of the patients. CT scans of the cervical and thoracic part

Results

The results of pulmonary function tests administered to patients at presentation in our clinic are shown in Table 1. The pulmonary artery pressures (mean ± SEM) were elevated in all six patients (systolic, 62 ± 15 mm Hg; diastolic, 46 ± 8 mm Hg). Patients 1 and 2 were the first patients in whom disease was diagnosed, and at that time we recommended only oxygen supplementation for relief of symptoms. Patient 3 (Table 1) refused the proposed operation. The three patients on whom surgery was

Discussion

Diaphragmatic paralysis producing symptoms in adults is an uncommon clinical problem, with sparse literature available about its treatment and long-term outcome. After observing the first two patients, who remained in poor clinical condition, we were particularly struck by the third patient (patient 4 in Table 1). This patient was a 47-year-old police officer who worked in active service on the street and who presented with signs of severe pulmonary hypertension that had developed in 2 weeks

ACKNOWLEDGMENT

The authors thank Dr. D. Koolbergen for the drawing of Figure 1.

References (12)

There are more references available in the full text version of this article.

Cited by (35)

  • Phrenic Nerve Reconstruction and Bilateral Diaphragm Plication After Lobectomy

    2017, Annals of Thoracic Surgery
    Citation Excerpt :

    There is no known curative treatment for bilateral PNP and dysfunction of the diaphragm. Positive pressure ventilation, permanent ventilatory support, diaphragmatic pacing, and plication of the diaphragm have been used to treat respiratory failure caused by bilateral PNP [1]. Reconstruction of the injured nerve may be the only curative treatment option for PNP.

  • Sleep hypoventilation in neuromuscular and chest wall disorders

    2014, Sleep Medicine Clinics
    Citation Excerpt :

    The benefit of this surgery has been demonstrated to continue for more than 5 years. Many investigators suggest that in the setting of NA, plication should be delayed for 2 to 3 years to assess the possibility of spontaneous return of phrenic function.69 Overall, NA is an excellent model for understanding the physiology of primary disorders of the phrenic nerve, because hypoventilation has a unique presentation and therapeutic approach (Fig. 7).

  • Diaphragm Disorders: Paralysis, Hernia, Eventration

    2010, Medical Management of the Thoracic Surgery Patient
  • Diaphragmatic Eventration

    2009, Thoracic Surgery Clinics
    Citation Excerpt :

    Another technique includes resecting the redundant portion of diaphragm and repairing the tissue in overlapping layers.7,15 Open transthoracic plication has also been described as an approach to treating bilateral diaphragm paralysis.50 Multiple single-institution studies have demonstrated significant improvement in symptoms and respiratory function after open transthoracic plication.42–46,51,52

View all citing articles on Scopus
View full text