EVENTRATION OF DIAPHRAGM


 

Eventration of the diaphragm

Definition : Abnormal elevation of the diaphragm and paradoxical motion of the affected diaphragm during inspiration and expiration.

Etiology
: Congenital - Congenital muscular deficiency (CMD); congenital defect in the development of central tendon or diaphragmatic muscle. (non-paralytic type)
                     - Phrenic nerve paralysis - caused by injury of phrenic nerve during birth or - less common - during (cardiothoracic ) operation. Obstetric injury may be combined with lesion of brachial plexus leading to a paralysis of the Erb-Duchenne type.

Manifestations: Wide spectrum of signs and symptoms: - ranging from asymptomatic to
        Respiratory symptoms; dyspnea , tachypnea , recurrent pneumonia , chronic bronchitis, exercise intolerance, life - threatening respiratory distress Obstetric cause - low APGAR score Thoracotomy cause - failure weaning from respirator (hypercapnea)

        Gastrointestinal tract symptoms; functional disorder of stomach, failure to thrive, nausea and vomiting, post prandial pain, bloating
        Others; Cardiac arrhythmia

Evaluation:- Chest - x rays; the affected hemidiaphragm should be at least two intercostal spaces higher than the other side.
                Fluoroscopy; paradoxical movement during breathing (elevate ipsilateral diaphragm during inspir.)
                Ultrasonography;
                Pulmonary function test ;

Indications for surgery: - 

Congenital cases

  • Respiratory distress which requires continuing ventilatory support . Repeated pulmonary infections . Respiratory compromise associated with feeding difficulty and failure to thrive.

  • Large eventration: the displaced diaphragm can potentially interfere with lung functions and post natal development and on this grounds surgical intervention may be warranted.

Phrenic nerve injury: Conservative treatment should not last longer than one month

Approaches: Thoracotomy, Thoracoscopic assisted, or Laparotomy

Post operative evaluation: Respiratory function Motion of the plicated diaphragm, by fluoroscopy.

  • Grading system by Kizilcan et al.

Postoperative motion according to the contribution of various parts of the diaphragm to motion and amplitude and direction of movement.

Grade 1 : Satisfactory Motion of equal amplitude with synchronous contraction in the same direction of the entire plicated hemidiaphragm compared with the contralateral normal hemidiaphragm.
Grade 2 : Moderately satisfactory Varying amplitudes of motion of the entire plicated hemidiaphragm or part of it in the absence of paradoxical motion compared with the normal hemidiaphragm.
Grade 3 : Unsatisfactory Entire operated hemidiaphragm was immobile or showed paradoxic motion ever at any part of it.

  • Thickness of the plicated diaphragm , by ultrasonography.

  • Operative complications: Intraabdominal organs injury


 
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