Bilateral diaphragm plication prior to transplantation

1. Ann Thorac Surg CASE REPORT SHIHATA AND MULLEN 1201
2007;83:1201–3 BILATERAL DIAPHRAGMATIC PLICATION
with significant resolution of the stricture of the left
common carotid artery by steroid therapy alone.
Although there have been several reports of surgical
treatment for fibrosing mediastinitis where it caused
strictures of the great vessels, esophagus, and airway [9],
we believe that idiopathic fibrosing mediastinitis should
first be treated by steroids or tamoxifen rather than by
surgical treatment if the symptoms do not need immedi-ate
relief.
References
1. Meredith SD, Madison J, Fechner RE, Levine PA. Cervical
manifestations of fibrosing mediastinitis: a diagnostic and
therapeutic dilemma. Head Neck 1993;15:561–5.
2. Comings DE, Skubi KB, Van Eyes J, Motulsky AG. Familial
multifocal fibrosclerosis. Findings suggesting that retroperi-toneal
fibrosis, mediastinal fibrosis, sclerosing cholangitis,
Riedel’s thyroiditis, and pseudotumor of the orbit may be
different manifestations of a single disease. Ann Intern Med
1967;66:884 –92.
3. Clark CP, Vanderpool D, Preskitt JT. The response of retro-peritoneal
fibrosis to tamoxifen. Surgery 1991;109:502– 6.
4. Ahsan N, Choudhury AA, Berger A. Retroperitoneal fibrosis.
Am Fam Physician 1990;41:1775– 80.
5. Rice DH, Batsakis JG, Coulthard SW. Sclerosing cervicitis:
homologue of sclerosing retroperitonitis and mediastinitis.
Arch Surg 1975;110:120 –2.
6. Dehner LP, Coffin CM. Idiopathic fibrosclerotic disorders and
other inflammatory pseudotumors. Semin Diagn Pathol 1998;
15:161–73.
7. Savelli BA, Parshley M, Morganroth ML. Successful treat-ment
of sclerosing cervicitis and fibrosing mediastinitis with
tamoxifen. Chest 1997;111:1137– 40.
8. Bays S, Rajakaruna C, Sheffield E, Morgan A. Fibrosing
mediastinitis as a cause of superior vena cava syndrome. Eur
J Cardiothorac Surg 2004;26:453–5.
9. Parish JM, Rosenow EC. Mediastinal granuloma and medias-tinal
fibrosis. Semin Respir Crit Care Med 2002;23:135– 43.
Bilateral Diaphragmatic Plication
in the Setting of Bilateral
Sequential Lung Transplantation
Mohammad Shihata, MD, and John C. Mullen, MD
Division of Cardiac Surgery, The University of Alberta,
Edmonton, Alberta, Canada
Diaphragmatic paralysis can lead to significant ventila-tory
impairment, especially if associated with underlying
lung disease. Adequate ventilatory mechanics are essen-tial
for good outcomes after lung transplantation. We
report a case of bilateral diaphragmatic plication at the
time of double lung transplantation as an attempt to
improve posttransplant ventilation, with good outcome.
(Ann Thorac Surg 2007;83:1201–3)
© 2007 by The Society of Thoracic Surgeons
Patients listed for lung transplantation for end-stage
lung disease can present with a number of associ-ated
abnormalities involving the chest wall, mediastinal
structures, and the diaphragm. If possible, correcting any
of these problems at the time of transplantation may
provide adjuncts for a better recovery in the immediate
postoperative course as well as for the long-term
outcome.
The patient is a 58-year-old man who had progressive
respiratory failure after idiopathic pulmonary lung fibro-sis
developed 11 years ago. Despite maximal medical
therapy, he experienced progressive worsening of symp-toms
in the form of incapacitating dyspnea and was
dependent on home oxygen therapy (3 to 5 L/min) for the
last 3 years. That had to be increased to 10 L/min during
any form of increased activity, such as walking, and even
then, his oxygen saturation would drop to 75%.
During the pretransplantation work-up, spirometry
showed a forced vital capacity of 34%, a forced expiratory
volume in 1 second of 30%, and a diffusion lung capacity
of carbon monoxide of 37%. Compared with a previous
study, a chest computed tomography scan showed pro-gression
of the underlying parenchymal pathology, with
further volume loss bilaterally (but more on the right
side), worsening fibrosis, and resultant traction bronchi-ectasis.
Ventilation-perfusion studies showed bilateral
reduction that was markedly worse on the right side.
These findings were all in keeping with an advanced
progressive interstitial lung process.
He was persistently noted to have markedly elevated
hemidiaphragms on chest roentgenograms (Fig 1). Fluo-
Accepted for publication Sept 5, 2006.
Address correspondence to Dr Mullen, Department of Surgery, The
University of Alberta Hospital, 2D2.18 W.C. Mackenzie Health Sciences
Centre, 8440-112 St, Edmonton, Alberta T6G 2B7 Canada; e-mail:
jmullen@ualberta.ca.
Fig 1. End-stage pulmonary fibrosis with severely elevated
hemidiaphragms.
© 2007 by The Society of Thoracic Surgeons 0003-4975/07/$32.00
Published by Elsevier Inc doi:10.1016/j.athoracsur.2006.09.033
FEATURE ARTICLES

2. 1202 CASE REPORT SHIHATA AND MULLEN Ann Thorac Surg
BILATERAL DIAPHRAGMATIC PLICATION 2007;83:1201–3
roscopy confirmed the diagnosis of a left-sided diaphrag-matic
paralysis. The right hemidiaphragm showed a
relatively small degree of excursion, but moved appro-priately.
Inspiratory mouth and transdiaphragmatic
pressures were not available.
The operation was performed through a standard
clamshell incision (bilateral anterolateral thoracotomy).
The domes of both hemidiaphragms were elevated to the
level of the superior pulmonary veins. Because of this
severe elevation, and the documented left-sided dia-phragmatic
paralysis, we decided to perform bilateral
diaphragmatic plication. We thought it would be very
unlikely for the right hemidiaphragm to return to a
normal position and not impose a mechanical restraint
on the new right lung without intervention.
The plication was accomplished with approximately 8
sets of radially placed size 0 Ethibond sutures (Ethicon,
Somerville, NJ) per side. Care was taken to avoid damage
to the phrenic nerve or any of its visible branches during
plication. At the end, both hemidiaphragms were low-ered
by about 5 inches. The resultant increase in in-trathoracic
dimensions facilitated the implantation of the
donor lungs in an unrestricted fashion.
The patient was extubated on the first postoperative
day, had a short intensive care (ICU) stay of only 3 days,
and was discharged home in excellent condition on
postoperative day 18. The predischarge chest x-ray film
(Fig 2) shows the end result, with both hemidiaphragms
in a normal position.
Comment
The diaphragm is the most important muscle of ventilation.
The development of intrathoracic pressure is mostly the
result of diaphragmatic contraction [1]. Unilateral diaphrag-matic
paralysis is usually well tolerated in adults with a
normal chest wall and no underlying lung disease. Regard-less
of the cause, bilateral diaphragmatic paralysis or weak-ness
is almost always symptomatic in the form of variable
degrees of dyspnea and hypoxia. As demonstrated in pre-vious
reports, the abnormally reduced total lung capacity
and forced vital capacity as well as the limited exercise
capacity are direct results of ventilatory failure [2].
Bilateral (double) lung transplantation is becoming an
increasingly available therapeutic option for patients
with end-stage lung disease owing to the improvement
in surgical technique and immunosuppressive therapy.
We have more knowledge now that lung transplanta-tion
produces physiologic improvements in the endur-ance
of respiratory muscles and the neural drive of the
diaphragm [3].
A number of groups have reported a variable incidence
of phrenic nerve dysfunction after single-lung and dou-ble-
lung transplantation owing to extensive mediastinal
dissection and retraction [4, 5], which lead to undesired
outcomes that include prolonged ICU and hospital stay,
severe respiratory failure, and death. Diaphragmatic pli-cation
has been proven to improve ventilatory mechanics
in the case of an existent diaphragmatic paralysis [6],
leading to a shorter need for mechanical ventilatory
support and improved symptoms on the long term.
We report here the use of bilateral diaphragmatic
plication in the setting of bilateral lung transplantation.
In this particular case, although the patient had a unilat-eral
(left-sided) diaphragmatic paralysis, as shown by
fluoroscopy, both hemidiaphragms were markedly ele-vated
to the level of the lung hila, with redundant
diaphragmatic tissue. In view of this preexistent dia-phragmatic
disease, we decided that the bilateral dia-phragmatic
plication would be necessary to restore in-trathoracic
dimensions for an unrestricted size match
with the transplanted lungs, and also for improved ven-tilatory
mechanics in the postoperative period. As antic-ipated,
the outcome was extremely favorable in terms of
easy weaning from the ventilator, a short ICU, and total
hospital stay.
We believe that plication at the time of transplantation
would be helpful for all cases of complete diaphragmatic
paralysis and for patients with severely elevated he-midiaphragms
(level of lung hila). Plication might also be
useful in patients with significant abdominal obesity
where the hemidiaphragms are also severely elevated
owing to pressure from the abdominal viscera.
We conclude that concomitant diaphragmatic plication
can be a very useful surgical adjunct in patients present-ing
with diaphragmatic paralysis or weakness at the time
of lung transplantation.
References
1. Celli BR. Respiratory management of diaphragm paralysis.
Semin Respir Crit Care Med 2002;23:275– 81.
Fig 2. Predischarge chest x-ray film shows normal position of both
hemidiaphragms after plication.
FEATURE ARTICLES

3. Ann Thorac Surg CASE REPORT SHIHATA AND MULLEN 1203
2007;83:1201–3 BILATERAL DIAPHRAGMATIC PLICATION
2. Hart N, Nickol AH, Cramer D, et al. Effect of severe isolated
unilateral and bilateral diaphragm weakness on exercise
performance. Am J Respir Crit Care Med 2002;165:1265–70.
3. Brath H, Lahrmann H, Wanke T. The effect of lung transplan-tation
on the neural drive to the diaphragm in patients with
severe COPD. Eur Respir J 1997;10:424–9
4. Ferdinande P, Bruyninckx F, Van Raemdonck D, Daenen W,
Verleden G. Leuven Lung Transplant Group. Phrenic nerve
dysfunction after heart–lung and lung transplantation.
J Heart Lung Transplant 2004;23:105–9.
5. Maziak DE, Maurer JR, Kesten S. Diaphragmatic paralysis: a
complication of lung transplantation. Ann Thorac Surg 1996;
61:170 –3.
6. Stolk J, Versteegh MI. Long-term effect of bilateral plication of
the diaphragm. Chest 2000;117:786 –9.
FEATURE ARTICLES