Ann Thorac Surg 2007;84:1029-1031
© 2007 The Society of Thoracic Surgeons
Case Reports
Satisfactory Results of Diaphragmatic Plication for Bilateral Phrenic Nerve Paralysis
Mitsunori Ohta, MD, PhDa,*,
Naoki Ikeda, MD, PhDa,
Hisaichi Tanaka, MD, PhDb,
Akihide Matsumura, MD, PhDb,
Hisatoshi Ohsumi, MD, PhDb,
Keiji Iuchi, MD, PhDb
a Osaka Prefectural Medical Center for Respiratory and Allergic Diseases, Habikino City, Osaka, Japan
b National Hospital Organization Kinki-chuo Chest Medical Center, Osaka, Japan
Accepted for publication April 18, 2007.
* Address correspondence to Dr Ohta, Department of General Thoracic Surgery, Osaka Prefectural Medical Center for Respiratory and Allergic Disease, 3-7-1, Habikino, Habikino City, Osaka, 853-8588, Japan (Email: ootami{at}opho.jp).
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Abstract
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Bilateral diaphragmatic plication was performed in a 44-year-old man who underwent complete resection of a thymoma infiltrating the right lung, bilateral brachiocephalic vein, pericardium, and bilateral phrenic nerves. The plication procedure allowed him to be weaned from the ventilator on postoperative day 4. He demonstrated no restrictive or obstructive pattern of lung function, and after respiratory rehabilitation he returned to work full time 5 weeks after the operation. The present results indicate that ventilatory movement of the thoracic cage can compensate for loss of bilateral diaphragmatic ventilation for at least 18 months.
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Introduction
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Unilateral phrenic nerve paralysis usually results in asymptomatic ventilatory insufficiency, whereas plication of the paralyzed diaphragm prevents paradoxical movement of the affected diaphragm and improves contralateral diaphragm function [1, 2]. In contrast, bilateral paralysis usually causes severe breathlessness and often requires mechanical ventilation [3]. Little is known about the effects of bilateral plication on ventilation in those cases. Herein we describe the favorable clinical course of a patient who underwent bilateral plication after bilateral phrenic nerve resection for a tumor.
A 44-year-old man with an upper mediastinal mass was referred to our hospital for a diagnostic workup. Chest computed tomography demonstrated a fist-sized tumor in the anterior mediastinum and the biopsy specimen showed it to be a thymoma (World Health Organization, type B1). Because the tumor had invaded to the brachiocephalic vein, superior vena cava, and right lung, chemotherapy was performed as the initial treatment. After three cycles of therapy, the tumor size was reduced and the massive tumor shadow had changed into a cyst-like structure (Fig 1).
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Fig 1. Chest computed tomographic image after chemotherapy showing the tumor reduced in size with cystic degeneration.
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Through a median sternotomy, an elastic hard tumor was identified with no pleural dissemination. The thymoma was completely removed along with the affected pericardium, bilateral brachiocephalic veins, superior vena cava, right upper lung, a 5-cm long portion of the left phrenic nerve, and a 3-cm long portion of the right phrenic nerve. The left brachiocephalic vein was reconstructed between the left brachiocephalic vein and right appendage, whereas the right brachiocephalic vein was reconstructed between the right brachiocephalic vein and superior vena cava stump using ringed polytetrafluoroethylene grafts. Through additional bilateral short incisions in the seventh intercostal space, plication with 2-0 nonabsorbable sutures was performed for the right diaphragm approximately 10 cm in width and 8 cm in depth, and for the left approximately 15 cm in width and 8 cm in depth. The paralytic diaphragms were then fixed in the maximal inspiratory position. Intermittent positive pressure ventilation was used to assist breathing after surgery. Spontaneous tidal volume was improved from 450 mL on postoperative day 2 to 600 mL on postoperative day 3, and the patient was weaned from ventilatory support on postoperative day 4. Chest roentgenograms showed that the rib cage expanded sufficiently at maximum inspiration, without active diaphragmatic displacement (Fig 2).
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Fig 2. Chest roentgenogram images of full inspiration (left) and full expiration (right) showing active displacement of the thoracic cage. The bilateral diaphragm demonstrated no displacement corresponding to ventilation.
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After 3 weeks of respiratory rehabilitation, the patient was able to walk 570 m with 95% minimum blood oxygen saturation during a 6-minute walk test without oxygen supplementation. He was discharged 5 weeks after the operation and resumed his full-time job. At a check-up examination performed 18 months after surgery, there was approximately a 20% decrease in vital capacity, whereas tidal volume, forced expiratory volume in 1 second at 1.0%, and peak flow rate were slightly increased (Table 1). Furthermore, total lung capacity had reached 97% of the predicted value, showing that the lung was sufficiently inflated.
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Comment
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The results of the present case suggest that ventilatory movement of the rib cage can compensate for loss of bilateral diaphragmatic function in a healthy adult patient with normal pulmonary function. When a patient showed restrictive or obstructive lung function before surgery, the compensatory mechanism might be ineffective. Weak peri-thoracic muscles or diaphragmatic breathing (as in small children) would also result in insufficient ventilation.
Except for a nerve resection, hypothermic injury, stretching, or blunt trauma of the phrenic nerve causes transient paralysis, which recovers in most patients within 1 year [4]. In a previous study of cases of bilateral diaphragmatic paralysis induced by neuralgic amyotrophy, most adult patients improved symptomatically, but not functionally, during follow-up periods of 2 to 4 years [5]. In addition, Stolk and Versteeg [3] reported that the mean vital capacity value of neuralgic amyotrophy patients was improved by 17% after bilateral diaphragmatic plication, and the effect was sustained for at least 12 months.
Because recovery of phrenic paralysis could not be expected in the present case, the aim of the bilateral plication was to fix both diaphragms for increasing efficiency of chest wall ventilation. Although the patient was dependent on chest wall motion exclusively for breathing, he showed no symptomatic or functional insufficiency for 18 months. However, when the plicated diaphragms become stretched with time and are gradually elevated, the ventilatory function likely decreases back to its original impaired level. Thus, phrenic nerve reconstruction with a nerve graft might be an effective intervention to maintain the recovery of phrenic function for a long period of time [6]. Based on the present results, we believe that bilateral diaphragmatic plication is an effective means of providing sufficient ventilatory function in selected patients with bilateral phrenic nerve paralysis.
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References
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- Watanabe T, Trusler GA, Williams WG, Edmond JF, Coles JG, Hosokawa Y. Phrenic nerve paralysis after pediatric cardiac surgeryRetrospective study of 125 cases. J Thorac Cardiovasc Surg 1987;94:383-388.[Abstract]
- Mulvey DA, Aquilina RJ, Elliot MW, Moxham J, Green M. Diaphragmatic dysfunction in neuralgic amyotrophy: an electrophysiologic examination of 16 patients presenting with dyspnea Am Rev Respir Dis 1993;147:66-71.[Medline]
- Schoeller T, Ohlbauer M, Wechselberger G, Piza-Katzer H, Margreiter R. Successful immediate phrenic nerve reconstruction during mediastinal tumor resection J Thorac Cardiovasc Surg 2001;122:1235-1237.[Free Full Text]
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Abstract
Introduction
