What is the diagnosis and treatment for diaphragmatic eventration?

Diaphragmatic Eventration: Diagnosis and Treatment

Diagnosis

Diaphragmatic eventration is diagnosed by chest radiograph showing abnormal elevation of the hemidiaphragm, confirmed by fluoroscopy demonstrating paradoxical or absent diaphragmatic motion, with CT scan providing definitive anatomic detail when needed. 1

Key Diagnostic Features:

• Chest X-ray reveals abnormal elevation of the affected hemidiaphragm, more commonly left-sided and in males 1, 2
• Fluoroscopy is essential to document diaphragmatic dysfunction, showing either paradoxical motion or complete immobility during respiration 1
• CT scan (chest and abdomen) serves as the gold standard when anatomic detail is required, demonstrating diaphragmatic discontinuity and potential herniation of abdominal contents 3, 4

Clinical Presentation:

• Respiratory symptoms: dyspnea, orthopnea, tachypnea, recurrent pneumonia 1, 5
• Gastrointestinal symptoms: compression effects from displaced abdominal organs 6, 7
• Cardiovascular symptoms: mediastinal shift and cardiac compression 6
• Many cases remain asymptomatic and require only observation 6, 1

Treatment Algorithm

Asymptomatic or Mild Cases:

Conservative management with observation is appropriate for asymptomatic eventration, as many cases—particularly traumatic ones—show spontaneous recovery within 6-12 months. 7

• Monitor patients with serial imaging for 6-12 months before considering surgery 7
• Optimize medical management for any respiratory or gastrointestinal symptoms 6, 2

Symptomatic Cases Requiring Surgery:

Surgical plication is indicated only when patients have major functional impairment (effort dyspnea, positional dyspnea, cardiac or digestive symptoms) that persists despite optimal conservative management. 6

Surgical Approach Selection:

• Minimally invasive video-assisted thoracoscopic surgery (VATS) is the preferred approach for stable patients, offering low morbidity and effective long-term results 6, 5
• Lateral thoracotomy remains an alternative when VATS is not feasible 6
• Uniportal VATS with stapled resection represents a technically simple alternative to traditional plication 5

Surgical Technique:

• Diaphragmatic plication restores normal pulmonary parenchymal volume by replacing the diaphragm in its anatomic position 1
• The procedure involves folding and suturing the redundant diaphragmatic tissue to create a taut, functional surface 6, 1
• Primary repair should use interrupted non-absorbable sutures when performing plication 8, 4

Expected Outcomes:

• Immediate symptom remission occurs in most patients, with functional benefit approaching 100% in properly selected candidates 6
• The operated hemidiaphragm typically becomes immobile but maintains normal position without paradoxical motion 1
• Morbidity and mortality are low and primarily associated with comorbid conditions rather than the procedure itself 6

Critical Pitfalls and Caveats:

The most important caveat is that surgical success depends entirely on rigorous preoperative patient selection through thorough morphological and functional investigation. 6

• Do not operate on asymptomatic patients—surgery is symptomatic treatment only and does not restore diaphragmatic function 6, 2
• Beware of late relapse: 5 of 7 patients in one series experienced gradual diaphragmatic rise or symptom relapse after initially successful repair 2
• The diaphragm remains immobile after plication—the benefit comes from anatomic repositioning, not functional restoration 1
• Reserve surgery strictly for patients with distress unresponsive to medical therapy, as the procedure provides symptomatic relief but not cure 2

Special Populations:

• Children with symptomatic eventration (congenital or acquired) typically require surgical treatment and have excellent outcomes 1
• Adults require more selective surgical indication due to higher rates of late relapse and the non-curative nature of the procedure 2
• Bilateral eventration is rare; occasional bilateral plication cases have been reported but experience is limited 6

Alternative for Central Causes:

• Phrenic nerve pacing may be considered for diaphragmatic paralysis of central origin (e.g., high spinal cord injury above C3) in highly selected patients after complete functional investigation 6
• This achieves ventilator weaning in >90% of appropriate candidates but requires intact peripheral neuromuscular systems 6