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Combination of diaphragmatic plication with major abdominal surgery in patients with phrenic nerve palsy
Brief clinical report Combination of diaphragmatic plication with major abdominal surgery in patients with phrenic nerve palsy Vassilios Smyrniotis, MD, PhD,a Nikolaos Arkadopoulos, MD, PhD,a Georgia Kostopanagiotou, MD, PhD,b Evangelos Gamaletsos, MD,a Lida Pistioli, MD,a and Elias Kostopanagiotou, MD,c Athens, Greece
The role of simultaneous prophylactic diaphragmatic plication during major abdominal operations is evaluated. In five patients with a history of phrenic nerve injury, postoperative ventilation requirements and hospital stay were significantly reduced when synchronous diaphragmatic plication was performed, compared with corresponding values obtained during previous abdominal operation without diaphragmatic plication. In addition, diaphragmatic plication was associated with postoperative improvement of respiratory mechanics and blood gas exchange. (Surgery 2005;137:243-5.) From the Second Department of Surgerya and the Anesthesiology Unit,b University of Athens Medical School, and the Department of Surgery, ‘‘G. Gennimatas’’ General Hospital c
PHRENIC NERVE INJURY may occur at any point along its cervical and thoracic course and may be due to various causes.1-3 Unilateral phrenic nerve injuries are of varying severity and are rarely associated with respiratory failure.4 Diaphragmatic plication is the treatment of choice when prolongation of mechanical ventilation is anticipated or when respiratory impairment has developed.1,4 In this study, we evaluate whether, in patients with phrenic nerve palsy who undergo major intra-abdominal procedures, the addition of ‘‘prophylactic’’ diaphragmatic plication diminishes the respiratory impairment induced by surgery and improves the patients’ outcome. PATIENTS AND METHODS After approval by the Institutional Research Committee, all patient data was retrieved and studied retrospectively. Between 1995 and 2002, five patients with documented diaphragmatic palsy were Accepted for publication May 26, 2004. Reprint requests: V. Smyrniotis, MD, 22, Hanioti Str, 154 52 Athens, Greece. E-mail: [email protected]. 0039-6060/$ - see front matter Ó 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.surg.2004.05.052
referred to our center for a major abdominal operation. In the past, at various times after their nerve injury, all patients had undergone abdominal surgery without concurrent repair of the paralyzed hemidiaphragm (first abdominal operation in Table I). Awareness of the postoperative respiratory failure during their previous intra-abdominal surgery prompted us to proceed with the present strategy. The preoperative workup of all patients included evaluation of diaphragmatic function and respiratory mechanics as well as measurement of arterial blood gases. Chest radiograms were obtained before and after surgery in all cases (Figure). Comorbidities included hypertension in 2 patients and diabetes in another patient. All patients were operated on after they were administered combined epidural and general anesthesia. Anesthesia was maintained with isoflurane (minimum alveolar concentration of anesthetic 0.9 to 1.2). The lungs were ventilated with a mixture of oxygen (FIO2 0.4) in air, to keep the PaO2 greater than 100 mm Hg and the PaCO2 around 35 mm Hg. The abdominal cavity was accessed via a bilateral subcostal incision, and after termination of the scheduled operation (Table I), plication of the paralyzed hemidiaphragm was performed by means of a modification of a technique that has been SURGERY 243
244 Smyrniotis et al
Surgery February 2005
Table I. Clinical characteristics of patients Age/Sex 69/M
79/F
81/F 53/M
78/M
Cause of nerve injury
First abdominal operation (without diaphragmatic plication)
Current disease and second abdominal operation (with diaphragmatic plication)
Operation for neck tuberculosis Kidney stone removal 2 years ago. Intrabilliary hydatid cyst rupture– 52 years ago. Right phrenic right atypical hepatectomy. nerve injury. Excisional biopsy of neck lymph Partial gastrectomy 2 months ago. Lithiasis of common bile duct, node 3 months ago. Left phrenic ascending cholangitis–exploration nerve injury. of common bile duct and hepaticoduodenal anastomosis. Mediastinal surgery 4 years ago. Open cholecystectomy 3 years ago. Gastric carcinoma–total gastrectomy. Left phrenic nerve injury. Transthoracic approach of liver Open cholecystectomy 8 years ago. Pheochromocytoma, with hepatic hydatid cyst 15 years ago. Right involvement–right hepatectomy phrenic nerve injury. and adrenalectomy. Unknown. Right phrenic nerve Open cholecystectomy 6 years ago. Liver tumor–right extended injury. hepatectomy.
previously described in transplanted patients.3 Briefly, the paralyzed hemidiaphragm was fully exposed by mobilization of the surrounding structures. Plication was achieved with 3 successive layers of continuous polypropylene 2-0 sutures, beginning on the medial part of the tendinous portion of the diaphragm and passing laterally. Several interrupted sutures reinforced the last row until the hemidiaphragm was flattened and firm to palpation. Postoperative analgesia was achieved with epidural administration of morphine and bupivacaine. No complications related to the procedure were noted. Respiratory mechanics and arterial blood gas measurements were assessed before and one month after diaphragmatic plication in all patients. Statistical analysis was conducted by Mann--Whitney U test and chi-square test. RESULTS Values are expressed as medians with range. Postoperative mechanical ventilation requirements and hospital stay after the second abdominal operation and diaphragmatic plication were 0 (0-0,5) days and 8 (6-16) days, respectively, whereas the corresponding values during the first abdominal operation, when diaphragmatic plication was not performed, were 4 (2-21) days and 12 (4-26) days (P < .04). One month after the diaphragmatic plication, forced vital capacity (FVC), forced expiratory volume1 (FEV1), total lung capacity (TLC), functional residual capacity (FRC), and PaO2 increased by 13% (9%-16%), 16% (10%-26%), 17% (14%-24%), 21% (17%-28%), and 22% (18%-35%),
respectively (Table II). One year after plication, all patients were free of respiratory complications and had resumed their normal activity. COMMENT Unilateral phrenic nerve injury rarely leads to severe respiratory impairment because the adverse consequences caused by the paralyzed hemidiaphragm are compensated by the musculoskeletal elements involved in the biomechanics of respiratory function.1 Nevertheless, the activity of intercostal and other accessory respiratory muscles is inhibited during rapid eye movement sleep, which leads to nocturnal apnea.4 In addition, patients with phrenic nerve injury are at risk for pulmonary postoperative complications if they undergo major surgery. Postoperative pain, gastrointestinal ileus, and ascites all exacerbate respiratory impairment and increase the possibility of prolonged ventilatory support with all its inherent complications and cost.5-7 Diaphragmatic plication by either thoracic or abdominal approach is the treatment of choice when prolonged mechanical ventilatory support is anticipated or when respiratory insufficiency has already been established.1 Compared with adults, children are less able to compensate the phrenic palsy and require diaphragmatic plication as early as possible.2,3 Patients with unilateral phrenic nerve injury present with restrictive respiratory insufficiency, with diminished FVC, FEV1, TLC, and FRC. The movement of the diaphragm during the respiratory cycle is paradoxical and governs the degree of respiratory failure.1,3,4 Successful plication considerably improves those variables by expanding
Smyrniotis et al 245
Surgery Volume 137, Number 2
Table II. Preoperative and postoperative lung function parameters (median [range]) Preoperative
Figure. Chest radiogram of a patient with left phrenic nerve injury, before (left) and after (right) diaphragmatic plication (case number 2 in Table I).
lung volumes and abolishing the paradoxical diaphragmatic movements.2,4 Patients regain their capacity to expectorate effectively, minimizing their chances of developing lung atelectasis and chest infections, both of which are responsible for the majority of postoperative complications.5-7 In this study, we address the hypothesis that prophylactic diaphragmatic plication has a place in elective major abdominal surgery, even when respiratory impairment is moderate. The fact that all our patients had undergone a previous abdominal operation without concurrent repair of their paralyzed hemidiaphragm allowed us a comparison, with the patients serving as their own controls. Despite the larger incisions used, the addition of diaphragmatic plication to the second operation seems to be associated with improvement of respiratory mechanics and a consequent reduction of postoperative mechanical ventilation requirements and hospital stay compared with outcomes experienced by the same patients during their first abdominal surgery. In conclusion, our findings suggest that patients with respiratory impairment caused by unilateral phrenic nerve palsy who are scheduled for major abdominal surgery can safely undergo simultaneous
FVC (% of predicted) FEV1 (% of predicted) TLC (% of predicted) FRC (% of predicted) PaO2 (mm Hg)
Postoperative
68% (60%-75%) 78% (65%-85%) 78% (65%-82%) 88% (82%-95%) 75% (68%-80%) 88% (82%-91%) 75% (68%-85%) 91% (83%-102%) 70 (65-72)
86 (82-88)
FVC, Forced vital capacity; FEV1, forced expiratory volume1; TLC, total lung capacity; FRC, functional residual capacity.
diaphragmatic plication, a procedure that may improve their respiratory mechanics and decrease postoperative morbidity. Of course, larger prospective studies are needed in order to establish firm conclusions on the issue.
REFERENCES 1. Graham DR, Kaplan D, Evans CC, Hind CR, Donelly RJ. Diaphragmatic plication for unilateral diaphragmatic paralysis: a 10-years experience. Ann Thorac Surg 1990;49:248-51. 2. van Onna IE, Metz R, Jekel L, Woolley R, van de Wal H. Post cardiac surgery phrenic nerve palsy: value of plication and potential for recovery. Eur J Cardiothorac Surg 1998;14: 179-84. 3. Smyrniotis V, Andreani P, Muiesan P, Mieli-Vergani G, Rela M, Heaton ND. Diaphragmatic nerve palsy in young children following liver transplantation. Transpl Int 1998;11:281-3. 4. Higgs S, Hussain A, Jackson M, Donnelly R, Berrisford R. Long term results of diaphragmatic plication for unilateral diaphragm paralysis. Eur J Cardiothorac Surg 2002;21:294-7. 5. Trayner E, Celli B. Postoperative pulmonary complications. Med Clin North Am 2001;85:1129-39. 6. Warner DO. Preventing postoperative pulmonary complications: the role of the anesthesiologist. Anesthesiology 2000; 92:1467-72. 7. Brooks-Brunn JA. Predictors of postoperative pulmonary complications following abdominal surgery. Chest 1997;111: 564-71.
The role of simultaneous prophylactic diaphragmatic plication during major abdominal operations is evaluated. In five patients with a history of phrenic nerve injury, postoperative ventilation requirements and hospital stay were significantly reduced when synchronous diaphragmatic plication was performed, compared with corresponding values obtained during previous abdominal operation without diaphragmatic plication. In addition, diaphragmatic plication was associated with postoperative improvement of respiratory mechanics and blood gas exchange. (Surgery 2005;137:243-5.) From the Second Department of Surgerya and the Anesthesiology Unit,b University of Athens Medical School, and the Department of Surgery, ‘‘G. Gennimatas’’ General Hospital c
PHRENIC NERVE INJURY may occur at any point along its cervical and thoracic course and may be due to various causes.1-3 Unilateral phrenic nerve injuries are of varying severity and are rarely associated with respiratory failure.4 Diaphragmatic plication is the treatment of choice when prolongation of mechanical ventilation is anticipated or when respiratory impairment has developed.1,4 In this study, we evaluate whether, in patients with phrenic nerve palsy who undergo major intra-abdominal procedures, the addition of ‘‘prophylactic’’ diaphragmatic plication diminishes the respiratory impairment induced by surgery and improves the patients’ outcome. PATIENTS AND METHODS After approval by the Institutional Research Committee, all patient data was retrieved and studied retrospectively. Between 1995 and 2002, five patients with documented diaphragmatic palsy were Accepted for publication May 26, 2004. Reprint requests: V. Smyrniotis, MD, 22, Hanioti Str, 154 52 Athens, Greece. E-mail: [email protected]. 0039-6060/$ - see front matter Ó 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.surg.2004.05.052
referred to our center for a major abdominal operation. In the past, at various times after their nerve injury, all patients had undergone abdominal surgery without concurrent repair of the paralyzed hemidiaphragm (first abdominal operation in Table I). Awareness of the postoperative respiratory failure during their previous intra-abdominal surgery prompted us to proceed with the present strategy. The preoperative workup of all patients included evaluation of diaphragmatic function and respiratory mechanics as well as measurement of arterial blood gases. Chest radiograms were obtained before and after surgery in all cases (Figure). Comorbidities included hypertension in 2 patients and diabetes in another patient. All patients were operated on after they were administered combined epidural and general anesthesia. Anesthesia was maintained with isoflurane (minimum alveolar concentration of anesthetic 0.9 to 1.2). The lungs were ventilated with a mixture of oxygen (FIO2 0.4) in air, to keep the PaO2 greater than 100 mm Hg and the PaCO2 around 35 mm Hg. The abdominal cavity was accessed via a bilateral subcostal incision, and after termination of the scheduled operation (Table I), plication of the paralyzed hemidiaphragm was performed by means of a modification of a technique that has been SURGERY 243
244 Smyrniotis et al
Surgery February 2005
Table I. Clinical characteristics of patients Age/Sex 69/M
79/F
81/F 53/M
78/M
Cause of nerve injury
First abdominal operation (without diaphragmatic plication)
Current disease and second abdominal operation (with diaphragmatic plication)
Operation for neck tuberculosis Kidney stone removal 2 years ago. Intrabilliary hydatid cyst rupture– 52 years ago. Right phrenic right atypical hepatectomy. nerve injury. Excisional biopsy of neck lymph Partial gastrectomy 2 months ago. Lithiasis of common bile duct, node 3 months ago. Left phrenic ascending cholangitis–exploration nerve injury. of common bile duct and hepaticoduodenal anastomosis. Mediastinal surgery 4 years ago. Open cholecystectomy 3 years ago. Gastric carcinoma–total gastrectomy. Left phrenic nerve injury. Transthoracic approach of liver Open cholecystectomy 8 years ago. Pheochromocytoma, with hepatic hydatid cyst 15 years ago. Right involvement–right hepatectomy phrenic nerve injury. and adrenalectomy. Unknown. Right phrenic nerve Open cholecystectomy 6 years ago. Liver tumor–right extended injury. hepatectomy.
previously described in transplanted patients.3 Briefly, the paralyzed hemidiaphragm was fully exposed by mobilization of the surrounding structures. Plication was achieved with 3 successive layers of continuous polypropylene 2-0 sutures, beginning on the medial part of the tendinous portion of the diaphragm and passing laterally. Several interrupted sutures reinforced the last row until the hemidiaphragm was flattened and firm to palpation. Postoperative analgesia was achieved with epidural administration of morphine and bupivacaine. No complications related to the procedure were noted. Respiratory mechanics and arterial blood gas measurements were assessed before and one month after diaphragmatic plication in all patients. Statistical analysis was conducted by Mann--Whitney U test and chi-square test. RESULTS Values are expressed as medians with range. Postoperative mechanical ventilation requirements and hospital stay after the second abdominal operation and diaphragmatic plication were 0 (0-0,5) days and 8 (6-16) days, respectively, whereas the corresponding values during the first abdominal operation, when diaphragmatic plication was not performed, were 4 (2-21) days and 12 (4-26) days (P < .04). One month after the diaphragmatic plication, forced vital capacity (FVC), forced expiratory volume1 (FEV1), total lung capacity (TLC), functional residual capacity (FRC), and PaO2 increased by 13% (9%-16%), 16% (10%-26%), 17% (14%-24%), 21% (17%-28%), and 22% (18%-35%),
respectively (Table II). One year after plication, all patients were free of respiratory complications and had resumed their normal activity. COMMENT Unilateral phrenic nerve injury rarely leads to severe respiratory impairment because the adverse consequences caused by the paralyzed hemidiaphragm are compensated by the musculoskeletal elements involved in the biomechanics of respiratory function.1 Nevertheless, the activity of intercostal and other accessory respiratory muscles is inhibited during rapid eye movement sleep, which leads to nocturnal apnea.4 In addition, patients with phrenic nerve injury are at risk for pulmonary postoperative complications if they undergo major surgery. Postoperative pain, gastrointestinal ileus, and ascites all exacerbate respiratory impairment and increase the possibility of prolonged ventilatory support with all its inherent complications and cost.5-7 Diaphragmatic plication by either thoracic or abdominal approach is the treatment of choice when prolonged mechanical ventilatory support is anticipated or when respiratory insufficiency has already been established.1 Compared with adults, children are less able to compensate the phrenic palsy and require diaphragmatic plication as early as possible.2,3 Patients with unilateral phrenic nerve injury present with restrictive respiratory insufficiency, with diminished FVC, FEV1, TLC, and FRC. The movement of the diaphragm during the respiratory cycle is paradoxical and governs the degree of respiratory failure.1,3,4 Successful plication considerably improves those variables by expanding
Smyrniotis et al 245
Surgery Volume 137, Number 2
Table II. Preoperative and postoperative lung function parameters (median [range]) Preoperative
Figure. Chest radiogram of a patient with left phrenic nerve injury, before (left) and after (right) diaphragmatic plication (case number 2 in Table I).
lung volumes and abolishing the paradoxical diaphragmatic movements.2,4 Patients regain their capacity to expectorate effectively, minimizing their chances of developing lung atelectasis and chest infections, both of which are responsible for the majority of postoperative complications.5-7 In this study, we address the hypothesis that prophylactic diaphragmatic plication has a place in elective major abdominal surgery, even when respiratory impairment is moderate. The fact that all our patients had undergone a previous abdominal operation without concurrent repair of their paralyzed hemidiaphragm allowed us a comparison, with the patients serving as their own controls. Despite the larger incisions used, the addition of diaphragmatic plication to the second operation seems to be associated with improvement of respiratory mechanics and a consequent reduction of postoperative mechanical ventilation requirements and hospital stay compared with outcomes experienced by the same patients during their first abdominal surgery. In conclusion, our findings suggest that patients with respiratory impairment caused by unilateral phrenic nerve palsy who are scheduled for major abdominal surgery can safely undergo simultaneous
FVC (% of predicted) FEV1 (% of predicted) TLC (% of predicted) FRC (% of predicted) PaO2 (mm Hg)
Postoperative
68% (60%-75%) 78% (65%-85%) 78% (65%-82%) 88% (82%-95%) 75% (68%-80%) 88% (82%-91%) 75% (68%-85%) 91% (83%-102%) 70 (65-72)
86 (82-88)
FVC, Forced vital capacity; FEV1, forced expiratory volume1; TLC, total lung capacity; FRC, functional residual capacity.
diaphragmatic plication, a procedure that may improve their respiratory mechanics and decrease postoperative morbidity. Of course, larger prospective studies are needed in order to establish firm conclusions on the issue.
REFERENCES 1. Graham DR, Kaplan D, Evans CC, Hind CR, Donelly RJ. Diaphragmatic plication for unilateral diaphragmatic paralysis: a 10-years experience. Ann Thorac Surg 1990;49:248-51. 2. van Onna IE, Metz R, Jekel L, Woolley R, van de Wal H. Post cardiac surgery phrenic nerve palsy: value of plication and potential for recovery. Eur J Cardiothorac Surg 1998;14: 179-84. 3. Smyrniotis V, Andreani P, Muiesan P, Mieli-Vergani G, Rela M, Heaton ND. Diaphragmatic nerve palsy in young children following liver transplantation. Transpl Int 1998;11:281-3. 4. Higgs S, Hussain A, Jackson M, Donnelly R, Berrisford R. Long term results of diaphragmatic plication for unilateral diaphragm paralysis. Eur J Cardiothorac Surg 2002;21:294-7. 5. Trayner E, Celli B. Postoperative pulmonary complications. Med Clin North Am 2001;85:1129-39. 6. Warner DO. Preventing postoperative pulmonary complications: the role of the anesthesiologist. Anesthesiology 2000; 92:1467-72. 7. Brooks-Brunn JA. Predictors of postoperative pulmonary complications following abdominal surgery. Chest 1997;111: 564-71.