- Email: [email protected]
Bilateral Diaphragmatic Plication in the Setting of Bilateral Sequential Lung Transplantation
Ann Thorac Surg 2007;83:1201–3
References 1. Meredith SD, Madison J, Fechner RE, Levine PA. Cervical manifestations of fibrosing mediastinitis: a diagnostic and therapeutic dilemma. Head Neck 1993;15:561–5. 2. Comings DE, Skubi KB, Van Eyes J, Motulsky AG. Familial multifocal fibrosclerosis. Findings suggesting that retroperitoneal fibrosis, mediastinal fibrosis, sclerosing cholangitis, Riedel’s thyroiditis, and pseudotumor of the orbit may be different manifestations of a single disease. Ann Intern Med 1967;66:884 –92. 3. Clark CP, Vanderpool D, Preskitt JT. The response of retroperitoneal fibrosis to tamoxifen. Surgery 1991;109:502– 6. 4. Ahsan N, Choudhury AA, Berger A. Retroperitoneal fibrosis. Am Fam Physician 1990;41:1775– 80. 5. Rice DH, Batsakis JG, Coulthard SW. Sclerosing cervicitis: homologue of sclerosing retroperitonitis and mediastinitis. Arch Surg 1975;110:120 –2. 6. Dehner LP, Coffin CM. Idiopathic fibrosclerotic disorders and other inflammatory pseudotumors. Semin Diagn Pathol 1998; 15:161–73. 7. Savelli BA, Parshley M, Morganroth ML. Successful treatment of sclerosing cervicitis and fibrosing mediastinitis with tamoxifen. Chest 1997;111:1137– 40. 8. Bays S, Rajakaruna C, Sheffield E, Morgan A. Fibrosing mediastinitis as a cause of superior vena cava syndrome. Eur J Cardiothorac Surg 2004;26:453–5. 9. Parish JM, Rosenow EC. Mediastinal granuloma and mediastinal fibrosis. Semin Respir Crit Care Med 2002;23:135– 43.
1201
P
atients listed for lung transplantation for end-stage lung disease can present with a number of associated abnormalities involving the chest wall, mediastinal structures, and the diaphragm. If possible, correcting any of these problems at the time of transplantation may provide adjuncts for a better recovery in the immediate postoperative course as well as for the long-term outcome. The patient is a 58-year-old man who had progressive respiratory failure after idiopathic pulmonary lung fibrosis developed 11 years ago. Despite maximal medical therapy, he experienced progressive worsening of symptoms in the form of incapacitating dyspnea and was dependent on home oxygen therapy (3 to 5 L/min) for the last 3 years. That had to be increased to 10 L/min during any form of increased activity, such as walking, and even then, his oxygen saturation would drop to 75%. During the pretransplantation work-up, spirometry showed a forced vital capacity of 34%, a forced expiratory volume in 1 second of 30%, and a diffusion lung capacity of carbon monoxide of 37%. Compared with a previous study, a chest computed tomography scan showed progression of the underlying parenchymal pathology, with further volume loss bilaterally (but more on the right side), worsening fibrosis, and resultant traction bronchiectasis. Ventilation-perfusion studies showed bilateral reduction that was markedly worse on the right side. These findings were all in keeping with an advanced progressive interstitial lung process. He was persistently noted to have markedly elevated hemidiaphragms on chest roentgenograms (Fig 1). Fluo-
Bilateral Diaphragmatic Plication in the Setting of Bilateral Sequential Lung Transplantation Mohammad Shihata, MD, and John C. Mullen, MD Division of Cardiac Surgery, The University of Alberta, Edmonton, Alberta, Canada
Diaphragmatic paralysis can lead to significant ventilatory impairment, especially if associated with underlying lung disease. Adequate ventilatory mechanics are essential for good outcomes after lung transplantation. We report a case of bilateral diaphragmatic plication at the time of double lung transplantation as an attempt to improve posttransplant ventilation, with good outcome. (Ann Thorac Surg 2007;83:1201–3) © 2007 by The Society of Thoracic Surgeons Accepted for publication Sept 5, 2006. Address correspondence to Dr Mullen, Department of Surgery, The University of Alberta Hospital, 2D2.18 W.C. Mackenzie Health Sciences Centre, 8440-112 St, Edmonton, Alberta T6G 2B7 Canada; e-mail: [email protected].
© 2007 by The Society of Thoracic Surgeons Published by Elsevier Inc
Fig 1. End-stage pulmonary fibrosis with severely elevated hemidiaphragms. 0003-4975/07/$32.00 doi:10.1016/j.athoracsur.2006.09.033
FEATURE ARTICLES
with significant resolution of the stricture of the left common carotid artery by steroid therapy alone. Although there have been several reports of surgical treatment for fibrosing mediastinitis where it caused strictures of the great vessels, esophagus, and airway [9], we believe that idiopathic fibrosing mediastinitis should first be treated by steroids or tamoxifen rather than by surgical treatment if the symptoms do not need immediate relief.
CASE REPORT SHIHATA AND MULLEN BILATERAL DIAPHRAGMATIC PLICATION
1202
CASE REPORT SHIHATA AND MULLEN BILATERAL DIAPHRAGMATIC PLICATION
Ann Thorac Surg 2007;83:1201–3
FEATURE ARTICLES
roscopy confirmed the diagnosis of a left-sided diaphragmatic paralysis. The right hemidiaphragm showed a relatively small degree of excursion, but moved appropriately. Inspiratory mouth and transdiaphragmatic pressures were not available. The operation was performed through a standard clamshell incision (bilateral anterolateral thoracotomy). The domes of both hemidiaphragms were elevated to the level of the superior pulmonary veins. Because of this severe elevation, and the documented left-sided diaphragmatic paralysis, we decided to perform bilateral diaphragmatic plication. We thought it would be very unlikely for the right hemidiaphragm to return to a normal position and not impose a mechanical restraint on the new right lung without intervention. The plication was accomplished with approximately 8 sets of radially placed size 0 Ethibond sutures (Ethicon, Somerville, NJ) per side. Care was taken to avoid damage to the phrenic nerve or any of its visible branches during plication. At the end, both hemidiaphragms were lowered by about 5 inches. The resultant increase in intrathoracic dimensions facilitated the implantation of the donor lungs in an unrestricted fashion. The patient was extubated on the first postoperative day, had a short intensive care (ICU) stay of only 3 days, and was discharged home in excellent condition on postoperative day 18. The predischarge chest x-ray film (Fig 2) shows the end result, with both hemidiaphragms in a normal position.
result of diaphragmatic contraction [1]. Unilateral diaphragmatic paralysis is usually well tolerated in adults with a normal chest wall and no underlying lung disease. Regardless of the cause, bilateral diaphragmatic paralysis or weakness is almost always symptomatic in the form of variable degrees of dyspnea and hypoxia. As demonstrated in previous reports, the abnormally reduced total lung capacity and forced vital capacity as well as the limited exercise capacity are direct results of ventilatory failure [2]. Bilateral (double) lung transplantation is becoming an increasingly available therapeutic option for patients with end-stage lung disease owing to the improvement in surgical technique and immunosuppressive therapy. We have more knowledge now that lung transplantation produces physiologic improvements in the endurance of respiratory muscles and the neural drive of the diaphragm [3]. A number of groups have reported a variable incidence of phrenic nerve dysfunction after single-lung and double-lung transplantation owing to extensive mediastinal dissection and retraction [4, 5], which lead to undesired outcomes that include prolonged ICU and hospital stay, severe respiratory failure, and death. Diaphragmatic plication has been proven to improve ventilatory mechanics in the case of an existent diaphragmatic paralysis [6], leading to a shorter need for mechanical ventilatory support and improved symptoms on the long term. We report here the use of bilateral diaphragmatic plication in the setting of bilateral lung transplantation. In this particular case, although the patient had a unilateral (left-sided) diaphragmatic paralysis, as shown by fluoroscopy, both hemidiaphragms were markedly elevated to the level of the lung hila, with redundant diaphragmatic tissue. In view of this preexistent diaphragmatic disease, we decided that the bilateral diaphragmatic plication would be necessary to restore intrathoracic dimensions for an unrestricted size match with the transplanted lungs, and also for improved ventilatory mechanics in the postoperative period. As anticipated, the outcome was extremely favorable in terms of easy weaning from the ventilator, a short ICU, and total hospital stay. We believe that plication at the time of transplantation would be helpful for all cases of complete diaphragmatic paralysis and for patients with severely elevated hemidiaphragms (level of lung hila). Plication might also be useful in patients with significant abdominal obesity where the hemidiaphragms are also severely elevated owing to pressure from the abdominal viscera. We conclude that concomitant diaphragmatic plication can be a very useful surgical adjunct in patients presenting with diaphragmatic paralysis or weakness at the time of lung transplantation.
Comment
References
The diaphragm is the most important muscle of ventilation. The development of intrathoracic pressure is mostly the
1. Celli BR. Respiratory management of diaphragm paralysis. Semin Respir Crit Care Med 2002;23:275– 81.
Fig 2. Predischarge chest x-ray film shows normal position of both hemidiaphragms after plication.
2. Hart N, Nickol AH, Cramer D, et al. Effect of severe isolated unilateral and bilateral diaphragm weakness on exercise performance. Am J Respir Crit Care Med 2002;165:1265–70. 3. Brath H, Lahrmann H, Wanke T. The effect of lung transplantation on the neural drive to the diaphragm in patients with severe COPD. Eur Respir J 1997;10:424 –9 4. Ferdinande P, Bruyninckx F, Van Raemdonck D, Daenen W, Verleden G. Leuven Lung Transplant Group. Phrenic nerve
CASE REPORT SHIHATA AND MULLEN BILATERAL DIAPHRAGMATIC PLICATION
1203
dysfunction after heart–lung and lung transplantation. J Heart Lung Transplant 2004;23:105–9. 5. Maziak DE, Maurer JR, Kesten S. Diaphragmatic paralysis: a complication of lung transplantation. Ann Thorac Surg 1996; 61:170 –3. 6. Stolk J, Versteegh MI. Long-term effect of bilateral plication of the diaphragm. Chest 2000;117:786 –9.
FEATURE ARTICLES
Ann Thorac Surg 2007;83:1201–3
References 1. Meredith SD, Madison J, Fechner RE, Levine PA. Cervical manifestations of fibrosing mediastinitis: a diagnostic and therapeutic dilemma. Head Neck 1993;15:561–5. 2. Comings DE, Skubi KB, Van Eyes J, Motulsky AG. Familial multifocal fibrosclerosis. Findings suggesting that retroperitoneal fibrosis, mediastinal fibrosis, sclerosing cholangitis, Riedel’s thyroiditis, and pseudotumor of the orbit may be different manifestations of a single disease. Ann Intern Med 1967;66:884 –92. 3. Clark CP, Vanderpool D, Preskitt JT. The response of retroperitoneal fibrosis to tamoxifen. Surgery 1991;109:502– 6. 4. Ahsan N, Choudhury AA, Berger A. Retroperitoneal fibrosis. Am Fam Physician 1990;41:1775– 80. 5. Rice DH, Batsakis JG, Coulthard SW. Sclerosing cervicitis: homologue of sclerosing retroperitonitis and mediastinitis. Arch Surg 1975;110:120 –2. 6. Dehner LP, Coffin CM. Idiopathic fibrosclerotic disorders and other inflammatory pseudotumors. Semin Diagn Pathol 1998; 15:161–73. 7. Savelli BA, Parshley M, Morganroth ML. Successful treatment of sclerosing cervicitis and fibrosing mediastinitis with tamoxifen. Chest 1997;111:1137– 40. 8. Bays S, Rajakaruna C, Sheffield E, Morgan A. Fibrosing mediastinitis as a cause of superior vena cava syndrome. Eur J Cardiothorac Surg 2004;26:453–5. 9. Parish JM, Rosenow EC. Mediastinal granuloma and mediastinal fibrosis. Semin Respir Crit Care Med 2002;23:135– 43.
1201
P
atients listed for lung transplantation for end-stage lung disease can present with a number of associated abnormalities involving the chest wall, mediastinal structures, and the diaphragm. If possible, correcting any of these problems at the time of transplantation may provide adjuncts for a better recovery in the immediate postoperative course as well as for the long-term outcome. The patient is a 58-year-old man who had progressive respiratory failure after idiopathic pulmonary lung fibrosis developed 11 years ago. Despite maximal medical therapy, he experienced progressive worsening of symptoms in the form of incapacitating dyspnea and was dependent on home oxygen therapy (3 to 5 L/min) for the last 3 years. That had to be increased to 10 L/min during any form of increased activity, such as walking, and even then, his oxygen saturation would drop to 75%. During the pretransplantation work-up, spirometry showed a forced vital capacity of 34%, a forced expiratory volume in 1 second of 30%, and a diffusion lung capacity of carbon monoxide of 37%. Compared with a previous study, a chest computed tomography scan showed progression of the underlying parenchymal pathology, with further volume loss bilaterally (but more on the right side), worsening fibrosis, and resultant traction bronchiectasis. Ventilation-perfusion studies showed bilateral reduction that was markedly worse on the right side. These findings were all in keeping with an advanced progressive interstitial lung process. He was persistently noted to have markedly elevated hemidiaphragms on chest roentgenograms (Fig 1). Fluo-
Bilateral Diaphragmatic Plication in the Setting of Bilateral Sequential Lung Transplantation Mohammad Shihata, MD, and John C. Mullen, MD Division of Cardiac Surgery, The University of Alberta, Edmonton, Alberta, Canada
Diaphragmatic paralysis can lead to significant ventilatory impairment, especially if associated with underlying lung disease. Adequate ventilatory mechanics are essential for good outcomes after lung transplantation. We report a case of bilateral diaphragmatic plication at the time of double lung transplantation as an attempt to improve posttransplant ventilation, with good outcome. (Ann Thorac Surg 2007;83:1201–3) © 2007 by The Society of Thoracic Surgeons Accepted for publication Sept 5, 2006. Address correspondence to Dr Mullen, Department of Surgery, The University of Alberta Hospital, 2D2.18 W.C. Mackenzie Health Sciences Centre, 8440-112 St, Edmonton, Alberta T6G 2B7 Canada; e-mail: [email protected].
© 2007 by The Society of Thoracic Surgeons Published by Elsevier Inc
Fig 1. End-stage pulmonary fibrosis with severely elevated hemidiaphragms. 0003-4975/07/$32.00 doi:10.1016/j.athoracsur.2006.09.033
FEATURE ARTICLES
with significant resolution of the stricture of the left common carotid artery by steroid therapy alone. Although there have been several reports of surgical treatment for fibrosing mediastinitis where it caused strictures of the great vessels, esophagus, and airway [9], we believe that idiopathic fibrosing mediastinitis should first be treated by steroids or tamoxifen rather than by surgical treatment if the symptoms do not need immediate relief.
CASE REPORT SHIHATA AND MULLEN BILATERAL DIAPHRAGMATIC PLICATION
1202
CASE REPORT SHIHATA AND MULLEN BILATERAL DIAPHRAGMATIC PLICATION
Ann Thorac Surg 2007;83:1201–3
FEATURE ARTICLES
roscopy confirmed the diagnosis of a left-sided diaphragmatic paralysis. The right hemidiaphragm showed a relatively small degree of excursion, but moved appropriately. Inspiratory mouth and transdiaphragmatic pressures were not available. The operation was performed through a standard clamshell incision (bilateral anterolateral thoracotomy). The domes of both hemidiaphragms were elevated to the level of the superior pulmonary veins. Because of this severe elevation, and the documented left-sided diaphragmatic paralysis, we decided to perform bilateral diaphragmatic plication. We thought it would be very unlikely for the right hemidiaphragm to return to a normal position and not impose a mechanical restraint on the new right lung without intervention. The plication was accomplished with approximately 8 sets of radially placed size 0 Ethibond sutures (Ethicon, Somerville, NJ) per side. Care was taken to avoid damage to the phrenic nerve or any of its visible branches during plication. At the end, both hemidiaphragms were lowered by about 5 inches. The resultant increase in intrathoracic dimensions facilitated the implantation of the donor lungs in an unrestricted fashion. The patient was extubated on the first postoperative day, had a short intensive care (ICU) stay of only 3 days, and was discharged home in excellent condition on postoperative day 18. The predischarge chest x-ray film (Fig 2) shows the end result, with both hemidiaphragms in a normal position.
result of diaphragmatic contraction [1]. Unilateral diaphragmatic paralysis is usually well tolerated in adults with a normal chest wall and no underlying lung disease. Regardless of the cause, bilateral diaphragmatic paralysis or weakness is almost always symptomatic in the form of variable degrees of dyspnea and hypoxia. As demonstrated in previous reports, the abnormally reduced total lung capacity and forced vital capacity as well as the limited exercise capacity are direct results of ventilatory failure [2]. Bilateral (double) lung transplantation is becoming an increasingly available therapeutic option for patients with end-stage lung disease owing to the improvement in surgical technique and immunosuppressive therapy. We have more knowledge now that lung transplantation produces physiologic improvements in the endurance of respiratory muscles and the neural drive of the diaphragm [3]. A number of groups have reported a variable incidence of phrenic nerve dysfunction after single-lung and double-lung transplantation owing to extensive mediastinal dissection and retraction [4, 5], which lead to undesired outcomes that include prolonged ICU and hospital stay, severe respiratory failure, and death. Diaphragmatic plication has been proven to improve ventilatory mechanics in the case of an existent diaphragmatic paralysis [6], leading to a shorter need for mechanical ventilatory support and improved symptoms on the long term. We report here the use of bilateral diaphragmatic plication in the setting of bilateral lung transplantation. In this particular case, although the patient had a unilateral (left-sided) diaphragmatic paralysis, as shown by fluoroscopy, both hemidiaphragms were markedly elevated to the level of the lung hila, with redundant diaphragmatic tissue. In view of this preexistent diaphragmatic disease, we decided that the bilateral diaphragmatic plication would be necessary to restore intrathoracic dimensions for an unrestricted size match with the transplanted lungs, and also for improved ventilatory mechanics in the postoperative period. As anticipated, the outcome was extremely favorable in terms of easy weaning from the ventilator, a short ICU, and total hospital stay. We believe that plication at the time of transplantation would be helpful for all cases of complete diaphragmatic paralysis and for patients with severely elevated hemidiaphragms (level of lung hila). Plication might also be useful in patients with significant abdominal obesity where the hemidiaphragms are also severely elevated owing to pressure from the abdominal viscera. We conclude that concomitant diaphragmatic plication can be a very useful surgical adjunct in patients presenting with diaphragmatic paralysis or weakness at the time of lung transplantation.
Comment
References
The diaphragm is the most important muscle of ventilation. The development of intrathoracic pressure is mostly the
1. Celli BR. Respiratory management of diaphragm paralysis. Semin Respir Crit Care Med 2002;23:275– 81.
Fig 2. Predischarge chest x-ray film shows normal position of both hemidiaphragms after plication.
2. Hart N, Nickol AH, Cramer D, et al. Effect of severe isolated unilateral and bilateral diaphragm weakness on exercise performance. Am J Respir Crit Care Med 2002;165:1265–70. 3. Brath H, Lahrmann H, Wanke T. The effect of lung transplantation on the neural drive to the diaphragm in patients with severe COPD. Eur Respir J 1997;10:424 –9 4. Ferdinande P, Bruyninckx F, Van Raemdonck D, Daenen W, Verleden G. Leuven Lung Transplant Group. Phrenic nerve
CASE REPORT SHIHATA AND MULLEN BILATERAL DIAPHRAGMATIC PLICATION
1203
dysfunction after heart–lung and lung transplantation. J Heart Lung Transplant 2004;23:105–9. 5. Maziak DE, Maurer JR, Kesten S. Diaphragmatic paralysis: a complication of lung transplantation. Ann Thorac Surg 1996; 61:170 –3. 6. Stolk J, Versteegh MI. Long-term effect of bilateral plication of the diaphragm. Chest 2000;117:786 –9.
FEATURE ARTICLES
Ann Thorac Surg 2007;83:1201–3