From the Guidelines
Diaphragmatic eventration evaluation and treatment should prioritize surgical repair for symptomatic patients, with a primary approach of diaphragmatic plication via open thoracotomy or minimally invasive techniques, as supported by the most recent evidence from 2023 1.
Evaluation Approach
The evaluation of diaphragmatic eventration should include:
- Chest imaging (X-ray, CT scan) to assess diaphragm position and potential herniation of abdominal organs
- Pulmonary function tests to evaluate respiratory compromise
- Fluoroscopy (sniff test) to assess diaphragm movement
Treatment Approach
Asymptomatic patients generally require no intervention, while symptomatic individuals with dyspnea, recurrent respiratory infections, or chest pain may need surgical repair. The treatment approach should consider the following:
- Surgical repair is recommended for complicated non-traumatic diaphragmatic hernia, with a laparotomy approach suggested for unstable patients and a minimally invasive approach suggested for stable patients 1
- Primary repair with non-absorbable sutures should be attempted when possible, with biologic or biosynthetic meshes considered for clean-contaminated and contaminated diaphragmatic hernia repair 1
- Postoperative care should include pain management, incentive spirometry, and gradual return to normal activities over 4-6 weeks
Key Considerations
- Children with eventration may require more urgent intervention if they demonstrate failure to thrive or recurrent respiratory infections
- Surgical repair is justified by the mechanical principles of restoring normal thoracic volume and improving ventilation efficiency, with most patients experiencing significant symptom improvement following plication 1
From the Research
Evaluation of Diaphragmatic Eventration
- Diaphragmatic eventration is a condition where there is absence of muscle fibers in the diaphragm, which can be congenital or acquired 2.
- Evaluation of diaphragmatic eventration involves a thorough morphological and functional investigation of the neuromuscular and respiratory components 3.
- Imaging modalities such as chest x-ray, chest ultrasound, and computed tomography scan are used to diagnose diaphragmatic eventration 2.
- Fluoroscopic testing can be used to differentiate eventration from paralysis, with eventration showing no paradoxic motion and paralysis showing paradoxic motion 4.
Treatment Approach
- Surgical treatment of diaphragmatic eventration is symptomatic and non-curative, and depends on whether the dysfunction is of peripheral or central origin 3.
- Diaphragmatic plication is a recognized, safe, and effective procedure for treating diaphragmatic eventration, with low morbidity and mortality 3, 5, 4.
- Plication can be approached either from a thoracic or abdominal approach, though most thoracic surgeons perform minimally invasive thoracoscopic plication 4.
- The goal of plication is to improve lung volumes and decrease paradoxic elevation of the hemidiaphragm, with excellent outcomes and symptom improvement 4.
- Phrenic nerve pacing may be attempted in selected cases of diaphragmatic paralysis of central causation to achieve ventilator weaning 3.
Indications for Surgery
- Surgery is indicated in symptomatic patients with diaphragmatic eventration, with significant functional effects such as effort or positional dyspnea, cardiac or digestive symptoms, or pain 3, 5, 6.
- Selection of candidates for surgery depends on a thorough evaluation of the patient's condition, including morphological and functional investigations 3.
- Surgical intervention is only recommended for patients with distressing symptoms that are unresponsive to medical therapy 6.