Utility of Rigorous Preoperative Testing for Unilateral Diaphragmatic Dysfunction

Kim RS and Khaitan PG

Department of General Surgery, Georgetown University School of Medicine, Medstar Washington Hospital Center, USA Department of Surgery, Division of Thoracic Surgery, Sheikh Shakhbout Medical City, Abu Dhabi, UAE

^*Correspondance to: Puja Gaur Khaitan 

 PDF  Full Text DOI: 10.25107/2474-1647.3693

Abstract

Is a CXR and/or a CT scan enough to plicate the diaphragm in a symptomatic patient? An elevated hemidiaphragm is indicative of either a paretic/paralyzed diaphragm or eventration of diaphragm. While central paralysis can affect the entire hemidiaphragm, an eventration is suggestive of thinning of only a small segment of the hemidiaphragm. Regardless of the underlying etiology, management remains the same. Signs and symptoms may include difficulty breathing (at rest or on exertion), chronic atelectasis, recurrent pneumonia, and/or fatigue limiting one’s quality of life. Once diagnosed on CXR or CT scan in a symptomatic patient, generally surgery is recommended with a few exceptions. For example, patients with certain neuromuscular disorders (e.g. amyotrophic lateral sclerosis or muscular dystrophy) may not benefit from plication and require pacing instead [1]. The etiology of unilateral diaphragm paralysis can be considered in three broad categories: Iatrogenic secondary to a surgical procedure or nerve block, inflammatory disease or infiltrative process, or idiopathic. Infiltrative causes resulting in phrenic nerve dysfunction include lymphoma or lymphadenopathy encasing the nerve, thymoma, or other hilar infiltrative pathologies or malignancies. Neuropathies, demyelinating disorders and cervical spinal cord injury can also result in diaphragmatic paralysis. Of these, the most common cause of unilateral diaphragm paralysis is either post-procedural (50-60%) or idiopathic (20%) [1]. Specifically, coronary artery bypass grafting is frequently associated with lesions of phrenic nerves resulting in postoperative diaphragmatic paralysis due to harvesting of internal mammary artery and/or cardiac cooling process [1]. Occasionally, a central line placement in the internal jugular vein can lead to an injury to the ipsilateral phrenic nerve. Typically, these patients are observed and placed under pulmonary rehabilitation for a period of at least 6 months to a year prior to considering any surgical intervention to allow recovery of the nerve [2,3]. However, if the patient’s clinical picture deteriorates compromising their quality of life, early surgical intervention is reasonable.

Keywords

Hemidiaphragm paralysis; Eventration; Diaphragmatic placation.

Cite the article

Kim RS, Khaitan PG. Utility of Rigorous Preoperative Testing for Unilateral Diaphragmatic Dysfunction. Clin Surg. 2024; 9: 3693..