Ann Thorac Surg 1998;65:1776-1777
© 1998 The Society of Thoracic Surgeons
Case Reports
Large Eventration of Diaphragm in an Elderly Patient Treated With Emergency Plication
Shun-ichi Watanabe, MDa,
Shinji Shimokawa, MDa,
Mikio Fukueda, MDa,
Tamahiro Kinjyo, MDa,
Akira Taira, MDa
a Second Department of Surgery, Kagoshima University Faculty of Medicine, Kagoshima, Japan
Accepted for publication December 20, 1997.
Address reprint requests to Dr Watanabe, Second Department of Surgery, Kagoshima University Faculty of Medicine, 8-35-1 Sakuragaoka, Kagoshima, 890 Japan
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Abstract
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Total eventration of the hemidiaphragm is a rare condition in adults. We report a 75-year-old woman with large eventration of the right diaphragm who required an emergency plication because of acute progressive respiratory distress. The symptom disappeared immediately after operation. Even in asymptomatic elderly patients with eventration, close follow-up is recommended.
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Introduction
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Eventration of the diaphragm is a well-recognized disease. An operation, however, is infrequently required in adults. We encountered an elderly patient with eventration of the hemidiaphragm who required an emergency operation because of acute progressive respiratory distress.
A 75-year-old woman with an eventration of the right diaphragm, which had been first noticed with routine chest roentgenogram in 1986, presented with severe dyspnea on January 8, 1997. An arterial blood gas analysis under O2 mask inhalation (5 L/min) revealed the following values: pH, 7.105; carbon dioxide tension, 98.0 mm Hg; oxygen tension, 69.9 mm Hg; base excess, -2.6; and O2 saturation, 86.1%. She was transferred to our hospital under intratracheal intubation. On admission, a chest roentgenogram disclosed tremendous elevation of the right hemidiaphragm, marked dislocation of the heart to the left, and displacement of the liver and the small intestinal convolution into the right thoracic cavity (Fig 1). The diagnosis of large eventration of the diaphragm was confirmed with a computed tomographic scan.
She underwent a right posterolateral thoracotomy through the eighth intercostal space the next day. The thoracic cavity was considerably filled by a mass of abdominal organs covered with a thin diaphragm. The phrenic nerve showed a normal appearance. After the atelectatic middle and lower lobes of the lung adhering to the diaphragm and the mediastinal and parietal pleurae were easily freed, the thinned-out diaphragmatic leaf was repaired by plication. Seven rows of 2-0 nonabsorbable sutures were inserted into the diaphragm in an anterolateral to posterolateral direction. Each row consisted of six pleats avoiding the branches of the phrenic nerve. The sutures passing not to traumatize the abdominal viscera were left untied until all rows were in place, and then were tied at the end over a pledget. The atelectatic lobes could ultimately be inflated.
The postoperative course was uneventful except for preexisting mild bronchial asthma. The patient was extubated on the second postoperative day. The postoperative arterial blood gas findings showed remarkable improvement, and the chest roentgenogram revealed the plicated diaphragm returning to almost normal position (Fig 2). She was discharged from our hospital 1 month postoperatively.
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Fig 2. Postoperative chest roentgenogram showing the plicated diaphragm returning to almost normal position.
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Comment
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Diaphragmatic eventration causes severe respiratory insufficiency, especially in infants and children. There are, however, few reports regarding emergency operation in adults such as our patient. Piehler and colleagues [1] reviewed the records of 142 patients, most of whom were adults, with unexplained diaphragmatic paralysis. In the 64 patients with initial respiratory complaints, the most common were dyspnea, cough, and chest wall pain. There was, however, no description regarding the cases of rapid progression of respiratory failure requiring intratracheal intubation during a long follow-up period. In general, the routine surgical procedure is plication of the diaphragm without incision of the diaphragmatic membrane [2], although various substitutes sutured over the surface of the diaphragm have been used to reinforce the weak membrane [3]. We avoided use of a substitute or incision of the diaphragm in the present case.
Diaphragmatic plication is intended to decrease lung compression, to make the thoracic base and mediastinum more stable, and to strengthen the respiratory action of the intercostal, perithoracic, and abdominal muscles [4]. Wright and associates [5] reported a significant increase in arterial oxygen tension after plication for unilateral diaphragmatic paralysis. Graham and coworkers [6] described that all of their patients showed both subjective and objective improvement, and the effect of initial improvement continued for 5 or more years after plication. In the present case, the dyspnea disappeared and the arterial oxygen tension improved, although during a short follow-up period.
An emergency diaphragmatic plication is a safe and effective procedure for patients with acute respiratory disorder due to a large eventration of diaphragm. Considering the occurrence of such a disastrous complication, close follow-up is recommended even in asymptomatic elderly patients with eventration of the diaphragm.
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References
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- Piehler J.M., Pairolero P.C., Gracey D.R., Bernatz P.E. Unexplained diaphragmatic paralysis: a harbinger of malignant disease?. J Thorac Cardiovasc Surg 1982;84:861-864.[Abstract]
- Shields T.W. Diaphragmatic function, diaphragmatic paralysis, and eventration of the diaphragm. In: Shields T.W., ed. General thoracic surgery. Baltimore: Williams and Wilkins, 1994:607-612.
- Gatzinsky P., Lepore V. Surgical treatment of a large eventration of the left diaphragm. Eur J Cardiothorac Surg 1993;7:271-274.[Abstract]
- Ribet M., Linder J.L. Plication of the diaphragm for unilateral eventration or paralysis. Eur J Cardiothorac Surg 1992;6:357-360.[Abstract]
- 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]
- 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]
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Abstract
Introduction
