Asian Cardiovasc Thorac Ann 2000;8:180-182
© 2000 Asia Publishing EXchange Pte Ltd
Surgical Management of Eventration of Diaphragm in an Elderly Patient
Lokeswara Rao Sajja, MCh,
Afroz Farooqi, MCh,
Ramesh Babu Yarlagadda, MD1,,
Mastan Saheb Shaik, MD1,
Division of Cardiothoracic Surgery
1 Division of Cardiac Anaesthesiology
Citi Cardiac Research Centre
Vijayawada, Andhra Pradesh, India
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For reprint information contact: Lokeswara Rao Sajja, MCh Tel: 91 866 47 0881 Fax: 91 866 47 3554 Division of Cardiothoracic Surgery, Citi Cardiac Research Centre, Ring Road, Near ITI College, Vijayawada, Andhra Pradesh 520008, India.
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Abstract
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A 70-year-old woman with eventration of the left dome of the diaphragm, presented with features of acute respiratory distress. She was successfully treated by emergency plication of the diaphragm. Computed tomography of the chest was useful for diagnosis.
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Introduction
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Eventration of the diaphragm is a well-known entity in infants and children, it is seen infrequently in adults, and it is very rare in the elderly. In this condition, the muscle is permanently elevated but retains its continuity and attachments to the costal margin. It is seldom symptomatic and often requires no treatment. For the symptomatic patient, plication of the diaphragm may offer relief.1
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Case Report
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A 70-year-old woman presented with sudden onset of breathlessness of 6-hours duration. There was no history of trauma and she was not a known asthmatic. The patient was short in stature with central obesity, her heart rate was 90 beats per minute and her respiratory rate was 40 breaths per minute. She was not cyanosed and there was no clubbing of the fingers or toes. Cardiovascular auscultation was unremarkable but there was decreased air entry in the left lower chest and intestinal gurgling sounds were heard in the left side of the chest. A posteroanterior chest radiograph showed haziness in the left lower half of the chest, an air fluid level, and displacement of the mediastinum to the right (Figure 1
). Arterial blood gas analysis while the patient was breathing room air showed pH 7.309, partial pressure of carbon dioxide 42.2 mm Hg, partial pressure of oxygen 62.9 mm Hg, oxygen saturation 90.1%, bicarbonate 20.7 mmol•L–1, and base excess –5.3 mmol•L–1. She was put on oxygen inhalation by mask. Computed tomography of the chest showed a thinned-out and raised left hemidiaphragm and an axial computed tomographic section through the level of the right pulmonary hilum showed upward displacement of the abdominal contents (stomach, spleen, and colon) and deviation of the mediastinum to the right (Figure 2).
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Figure 1. Preoperative posteroanterior chest radiograph showing the elevated left dome of the diaphragm.
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Figure 2. Axial computed tomographic section through the level of the right pulmonary hilum, showing upward displacement of abdominal contents into the lower left hemithorax and deviation of the heart to the right side.
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An emergency left thoracotomy was carried out. After opening the chest, it was observed that the lower thoracic cavity was filled with abdominal contents that were covered by the thinned-out left dome of the diaphragm. The phrenic nerve looked normal. The atelectatic lower and lingular lobes of the left lung were adherent to the diaphragmatic, parietal, and mediastinal pleura. The adhesions were flimsy and easily lysed. On inflation, the lower and lingular lobes of the left lung appeared normal. The thinned-out diaphragm was opened and the abdominal contents (stomach, splenic flexure of the colon, and the spleen) were pushed down after lysing adhesions. The incised diaphragm was double-breasted and then plicated by taking multiple interrupted sutures of no. 1 Vicryl (Ethicon, Johnson & Johnson Ltd, Aurangabad, Maharashtra, India) placed in an anteroposterior direction. The sutures were passed without traumatizing the abdominal viscera and were left untied until they were all in place. They were then tied serially, starting with the most medial suture. At the end of the procedure, the left lung was expanding fully. The patient was extubated after 6 hours of postoperative mechanical ventilation. Her arterial blood gas parameters were good and postoperative chest radiography showed the plicated left dome of the diaphragm in an almost normal position (Figure 3). She was discharged from hospital on the 7th postoperative day. She was doing well with no breathlessness at 9 months postoperatively and repeat chest radiography showed that the left dome of the diaphragm remained at the same level as seen in the immediate postoperative period.
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Figure 3. Postoperative posteroanterior chest radiograph showing the left dome of the diaphragm slightly lower than the right.
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Discussion
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Eventration of the diaphragm is known to cause severe respiratory distress in infants and children. When seen in adults, it is more common in males and the left dome of the diaphragm is most frequently affected.2 It is now generally accepted that surgery is indicated only in cases of distinct complaints involving the abdominal or thoracic organs, which may be related to the pathological condition.3 Piehler and colleagues4 reviewed the records of 142 cases of unexplained diaphragmatic paralysis: 64 patients had symptoms of dyspnea although cough and chest wall pain were the most common complaints; there was no description of progressive respiratory failure requiring endotracheal intubation in any of these patients. The accepted surgical procedure for eventration of the diaphragm is plication without either incision of the diaphragmatic membrane or excision of the pathologically altered segment; in rare cases, patch reinforcement of a very thin membrane may be necessary.3
In 7 patients with dyspnea resulting from nonmalignant unilateral diaphragmatic paralysis, Wright and colleagues5 reported a significant increase in arterial oxygen tension after plication. Graham and colleagues6 found both subjective and objective improvement sustained for 5 or more years after plication. On the other hand, Sung and colleagues2 noted relapse after initial improvement in the position of the dome of the diaphragm in 5 of 7 patients and recommend surgical intervention only in cases of distress unresponsive to medical therapy. Video-assisted thoracoscopic repair of eventration of the diaphragm in 3 adults was described by Mouroux and colleagues7 in 1996, using two superimposed transverse back-and-forth continuous sutures. The diaphragm was invaginated before suturing, the first suture line held the diaphragm down and retained the excess within the abdomen, the second suture line placed the desired tension on the diaphragmatic dome. Watanabe and colleagues8 described a large eventration of the diaphragm in an elderly patient who was treated by emergency plication without incising the diaphragm or using a patch.
In our patient, the thinned-out left hemidiaphragm was incised because of adherence of its lower surface to the abdominal viscera. We did not use any prosthetic material to strengthen the diaphragm, although the use of various materials to reinforce the weakened membrane has been described by others. Our experience indicates that emergency plication of a large eventration of the diaphragm with acute respiratory distress can be safe and effective even in an elderly patient.
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References
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Deslauriers J. Eventration of the diaphragm. Chest Surg Clin N Am 1998;8:315–30.[Medline]
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Sung DF, Huang BS, Huang MS, Wang LS, Huang MH, Chien KY. Surgical treatment of diaphragmatic eventration in adults. Chung Hua I, Hsuch Tsa Chih (Taipei) 1992; 50:297–301.
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Gatzinsky P, Lepore V. Surgical treatment of a large eventration of the left diaphragm. Eur J Cardio-thorac Surg 1993;7:271–4.[Abstract]
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Piehler JM, Pairolero PC, Gracey DR, Bernatz PE. Un-explained diaphragmatic paralysis: a harbinger of malignant disease? J Thorac Cardiovasc Surg 1982;84:861–4.[Abstract]
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Wright CD, Williams JG, Ogilvie CM, Donnelly RJ. Results of diaphragmatic plication for unilateral dia-phragmatic paralysis. J Thorac Cardiovasc Surg 1985; 90:195–8.[Abstract]
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Graham DR, Kaplan D, Evans CC, Hind CRK, Donnelly RJ. Diaphragmatic plication for unilateral diaphragmatic paralysis: a 10-year experience. Ann Thorac Surg 1990; 49:248–52.[Abstract]
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Mouroux J, Padovani B, Poirier NL, Benchimol D, Bourgeon A, Deslauriers J, et al. Technique for the repair of diaphragmatic eventration. Ann Thorac Surg 1996; 62:905–7.[Abstract/Free Full Text]
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Watanabe S, Shimokawa S, Fukueda M, Kinjyo T, Taira A. Large eventration of diaphragm in an elderly patient treated with emergency plication. Ann Thorac Surg 1998;65:1776–7.[Abstract/Free Full Text]
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Abstract
Introduction
