What is the role of diaphragmatic plication in the treatment of unilateral diaphragmatic paralysis?

Updated: Oct 10, 2018
  • Author: Justina Gamache, MD; Chief Editor: Guy W Soo Hoo, MD, MPH  more...
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Answer

Stabilization from surgical plication of the paralyzed diaphragm provides good results in selected patients. Following plication, the paralyzed diaphragm does not paradoxically move cephalad into the thorax during inspiration and, therefore, improves ventilation to the affected site. Furthermore, the procedure also favors the healthy diaphragm, which now performs less work.

In a select group of patients, diaphragmatic plication decreased breathlessness, improved vital capacity by 10-20%, and improved PaO2 by 10%. In one surgical series, the mean forced tidal volume improved dramatically from 216 mL to 415 mL after plication and it was possible to discontinue mechanical ventilation within 2-12 days of plication. [21] Functional and physiologic results of diaphragm plication have been shown to endure over long-term follow-up. In another study, 41 patients underwent plication of the hemidiaphragm. Patients were followed up for at least 48 months. Mean forced vital capacity, forced expiratory volume at 1 second, functional residual capacity, and total lung capacity all improved by 17%, 21%, 20%, and 20% (P< .005), respectively, at 48 months. These mean values had remained constant when compared with the 6-month follow-up. [22]

Plication of the diaphragm can be performed using a number of techniques through a thoracotomy, video-assisted thoracoscopic surgery (VATS), or laparoscopy. The VATS approach can have similar results as the thoracotomy series, with fewer complications. [23]

A common relative contraindication to plication is morbid obesity, as surgical plication is technically more difficult in these patients. This group of patients should be evaluated for bariatric surgery and may be able to avoid plication with improvement of pulmonary function after significant weight loss. [9] Patients with certain neuromuscular disorders (ie, amyotrophic lateral sclerosis and muscular dystrophy) should be approached with caution as plication provides only modest benefit with more complications. [9]


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