What is the best course of treatment for a patient, particularly a child or young adult, with diaphragm eventration?

Management of Diaphragm Eventration

Primary Recommendation

Surgery via diaphragmatic plication is indicated only when patients are symptomatic with respiratory or gastrointestinal complaints; asymptomatic eventration should be managed conservatively with observation. 1, 2, 3

Clinical Decision Algorithm

Step 1: Confirm Diagnosis and Assess Symptoms

• Obtain chest radiograph showing abnormal diaphragmatic elevation as initial diagnostic study 2
• Perform fluoroscopy to confirm paradoxical diaphragmatic motion and distinguish eventration from other causes of diaphragmatic elevation 2
• Document specific symptoms: dyspnea, tachypnea, orthopnea, recurrent pneumonia, failure to thrive in children, or nonspecific gastrointestinal complaints 1, 2

Step 2: Determine Need for Intervention

Indications for surgery:

• Presence of respiratory symptoms (dyspnea, tachypnea, recurrent pneumonia) that fail conservative management 2, 3
• Failure to thrive in pediatric patients 2
• Documented compression of ipsilateral lung with mediastinal shift 2

Conservative management:

• Asymptomatic patients should be observed without surgical intervention, as most adults with eventration remain asymptomatic throughout life 1, 3
• Medical therapy should be attempted first in symptomatic patients; surgery is reserved for those unresponsive to conservative measures 3

Step 3: Select Surgical Approach

For pediatric patients and young adults:

• Laparoscopic transperitoneal plication is the preferred approach, offering clear visualization of intraabdominal organs, avoiding single-lung ventilation, and eliminating need for chest tube 4
• Video-assisted thoracoscopic surgery (VATS) is an acceptable alternative using a 3-port technique for left-sided eventration 1

For adult patients:

• VATS plication is recommended for symptomatic left hemidiaphragm eventration, as it is less invasive with good outcomes 1
• Open thoracotomy or laparotomy may be necessary for extensive eventration requiring reinforcement with mesh or foreign material 5

Step 4: Surgical Technique

• Perform diaphragmatic plication without incision or excision of the pathologically thinned diaphragm 5
• Use interrupted non-absorbable sutures to create multiple rows of plication, restoring the diaphragm to its normal anatomical position 2, 5
• In pediatric laparoscopic approach, place inverting sutures at the apex creating tension toward the pelvis, then use endostapler to remove redundant diaphragm 4
• Reserve mesh reinforcement only for cases with extremely thin diaphragmatic membrane that cannot support plication sutures alone 5

Expected Outcomes and Follow-Up

• Immediate symptom remission occurs in most patients, with gradual improvement continuing for up to one year postoperatively 2
• The plicated diaphragm typically becomes immobile without paradoxical motion on postoperative fluoroscopy 2
• Perform fluoroscopic studies 1-5 years post-plication to assess diaphragmatic function and position 2
• Monitor for potential late complications: approximately 5 of 7 adult patients in one series experienced gradual diaphragmatic rise or symptom relapse after repair 3

Critical Pitfalls to Avoid

• Do not operate on asymptomatic patients – surgical intervention should be reserved exclusively for symptomatic cases, as asymptomatic eventration rarely progresses to require treatment 1, 3
• Do not routinely excise the thinned diaphragm – standard plication without excision is the accepted technique, with excision reserved only for specific circumstances 5
• Do not assume permanent symptom resolution – be aware that some adult patients experience gradual recurrence of diaphragmatic elevation or symptoms despite technically successful plication 3
• Avoid misdiagnosis as pneumonia or bronchiolitis – eventration with respiratory symptoms can mimic infectious processes, particularly in children with antecedent viral illness 6

Special Considerations for Pediatric Patients

• Children have higher success rates with plication compared to adults, with 14 of 15 pediatric patients maintaining normal diaphragm position long-term 2
• Laparoscopic transperitoneal approach in children offers median operative time of 70 minutes with no mortality, complications, or recurrence at 17-month median follow-up 4
• Pediatric patients more commonly present with failure to thrive and recurrent pneumonia rather than isolated dyspnea 2