What is the management approach for a patient with diaphragm eventration?

Management of Diaphragm Eventration

Symptomatic patients with diaphragm eventration should undergo surgical plication via minimally invasive thoracoscopic approach, while asymptomatic patients can be managed conservatively with observation. 1, 2

Initial Assessment and Diagnosis

Clinical Presentation

• Diaphragm eventration often presents asymptomatically and is discovered incidentally on chest imaging 2
• When symptomatic, patients typically report effort dyspnea, positional dyspnea, or less commonly cardiac or digestive symptoms 1
• Left-sided eventration is more common than right-sided, with male predominance 3

Diagnostic Workup

• Chest X-ray (anteroposterior and lateral views) is the initial diagnostic study to identify hemidiaphragm elevation 4, 5
• Fluoroscopic testing (sniff test) differentiates eventration from paralysis: eventration shows no paradoxic motion, while paralysis demonstrates paradoxic upward movement during inspiration 2
• CT scan with contrast may be obtained if diagnosis is uncertain or to evaluate for other pathology 4, 5
• Thorough functional investigation of neuromuscular and respiratory components is mandatory before considering surgical intervention 1

Management Algorithm

Conservative Management

• Asymptomatic patients should be observed without surgical intervention, as eventration alone without symptoms does not warrant operative repair 1, 3
• Optimal medical management should be attempted first in symptomatic patients before considering surgery 1, 3
• Conservative treatment is justified in adults who remain asymptomatic or have mild symptoms responsive to medical therapy 3

Surgical Indications

Surgery is indicated only when:

• Major functional symptoms persist despite optimal conservative management 1
• Symptoms include significant effort or positional dyspnea, cardiac symptoms, digestive symptoms, or pain that impairs quality of life 1
• In infants and children, immediate surgical repair is justified even in asymptomatic cases to optimize future lung growth 6

Surgical Technique

Approach:

• Minimally invasive video-assisted thoracoscopic surgery (VATS) is the preferred approach for diaphragmatic plication 1, 2
• Lateral thoracotomy is an alternative if VATS is not feasible 1
• Most thoracic surgeons perform thoracoscopic plication from a thoracic approach rather than abdominal 2

Plication Method:

• Use reefing mattress sutures on pledgets to create the plication 6
• Non-absorbable interrupted 2-0 or 1-0 monofilament or braided sutures in two layers should be employed 5
• The plication must be tight enough to prevent recurrence; inadequate tension may require reoperation 6
• In rare cases with very thin diaphragmatic membrane, reinforcement with mesh material may be necessary 7

Expected Outcomes

Efficacy

• Diaphragmatic plication achieves approximately 100% long-lasting functional benefit in properly selected patients 1
• The procedure improves lung volumes and decreases paradoxic elevation of the hemidiaphragm 2
• Immediate postoperative return of diaphragm to normal position with clinical improvement occurs in most patients 3
• In pediatric patients with respiratory distress, ventilatory support can typically be discontinued within 0-6 days (mean 3 days) after operation 6

Safety Profile

• Diaphragmatic plication is a safe procedure with low morbidity and mortality, primarily associated with comorbid factors rather than the procedure itself 1, 2
• Mortality in surgical series is not attributable to the plication procedure itself 6

Common Pitfalls and Caveats

Patient Selection

• The most critical pitfall is operating on asymptomatic adults or those with mild symptoms responsive to medical therapy 3
• Rigorous preoperative selection based on thorough functional investigation is essential for surgical success 1
• Some patients experience gradual diaphragmatic rise or relapse of respiratory symptoms after repair, particularly in adults 3

Technical Considerations

• Inadequate plication tension is a technical failure requiring reoperation 6
• Bilateral dysfunction is rare but may occasionally require bilateral plication 1

Special Populations

• In infants and children with symptomatic eventration, immediate surgical intervention is warranted with expected dramatic resolution of respiratory problems 6
• Pediatric patients with phrenic nerve injury who require prolonged mechanical ventilation (13-78 days preoperatively) show dramatic improvement postoperatively 6