Management and Treatment of Diaphragmatic Eventration
Symptomatic diaphragmatic eventration requires surgical plication, while asymptomatic cases can be managed conservatively with observation. The decision hinges on whether the patient has respiratory or gastrointestinal symptoms that significantly impair quality of life 1, 2.
Defining Eventration vs. Other Diaphragmatic Pathology
Diaphragmatic eventration is the abnormal elevation of an intact diaphragm due to paralysis or aplasia of muscular fibers, maintaining all anatomical attachments 1. This differs from diaphragmatic hernias (traumatic, congenital, or hiatal) where there is an actual defect or tear in the diaphragm allowing organ herniation 3.
Diagnostic Approach
Start with chest X-ray (anteroposterior and lateral views) as the initial diagnostic study in patients presenting with respiratory symptoms 3, 4.
- Chest X-ray shows abnormal diaphragmatic elevation but has limited sensitivity (2-60% for left-sided, 17-33% for right-sided) 4
- Normal chest X-rays do NOT exclude the diagnosis—false negatives occur in 11-62% of cases 4, 5
- Diaphragmatic fluoroscopy is essential to confirm the diagnosis by demonstrating paradoxical motion or immobility of the affected hemidiaphragm 1
- CT scan with contrast is the gold standard if diagnosis remains uncertain, with sensitivity of 14-82% and specificity of 87% 5
Indications for Surgical Intervention
Surgery is indicated only when eventration causes significant symptoms that fail conservative management 1, 2, 6.
Specific Indications for Plication:
- Respiratory symptoms: Dyspnea (especially effort or positional), tachypnea, recurrent pneumonia 1, 2
- Gastrointestinal symptoms: Persistent pain, early satiety, gastric compression 6, 7
- Failure to thrive in pediatric patients 1
- Orthopnea or cardiac symptoms from mediastinal shift 7
When Conservative Management is Appropriate:
- Asymptomatic eventration discovered incidentally should be observed without surgery 1, 8
- Patients with minimal symptoms responsive to medical therapy 8
Surgical Technique
Diaphragmatic plication is the standard surgical procedure, which can be performed via multiple approaches 1, 2, 6.
Surgical Approach Options:
- Video-assisted thoracoscopic surgery (VATS) or uniportal VATS is preferred as a minimally invasive approach 6, 7
- Lateral thoracotomy remains a safe and effective alternative 6
- Stapled resection via uniportal VATS provides a technically simple alternative to traditional plication 7
Mechanism of Benefit:
The plication restores normal pulmonary parenchymal volume by replacing the diaphragm in its normal anatomical position, reducing compression of the ipsilateral lung and preventing paradoxical mediastinal shift 1.
Expected Outcomes
Surgical plication provides excellent immediate symptom relief with low morbidity and mortality 1, 2, 6.
Functional Improvement:
- Immediate remission of symptoms in most patients, with gradual improvement continuing for up to one year 1
- Significant improvement in dyspnea grade, FEV1, and FVC at 6-month follow-up (statistically significant) 2
- Long-lasting functional benefit approaching 100% in properly selected patients 6
- Post-operative fluoroscopy shows the operated hemidiaphragm becomes immobile without paradoxical motion 1
Important Caveats:
- Some patients (up to 5 out of 7 in one series) experienced gradual diaphragmatic rise or symptom relapse after repair 8
- The operated diaphragm remains immobile after plication—it does not regain normal contractile function 1
- Success depends on rigorous preoperative patient selection with thorough morphological and functional investigation 6
Critical Pitfalls to Avoid
- Do not operate on asymptomatic patients—surgery is symptomatic treatment only, not curative 6, 8
- Do not confuse eventration with diaphragmatic hernia—hernias may require emergency surgery for bowel strangulation, while eventration is typically elective 3, 5
- Do not rely solely on chest X-ray—proceed to fluoroscopy or CT if clinical suspicion persists despite normal radiographs 4, 5
- Ensure symptoms are truly attributable to eventration before proceeding with surgery, as some patients may not benefit despite anatomical correction 8