Right hemidiaphragm paralysis after ea & tef repair.

1. Things happen
Uncommon event of a common procedure
Dr. Abdur Rakib Talukder, MRCS

2. • 36 weeks, male, weighing 2 kg; NSVD.
• Diagnosed as a case of EA & TEF, accepted from other
Hospital.
• No other association was diagnosed.

3. X-Ray at Birth

4. Isolating TEF
• Operated at 4th day of life.
• Ligation of TEF & primary
anastomosis.
• Extra pleural approach.
• Minimal dissection.

5. • Extubated on 4th POD .
• Dye study on 7th POD.

6. Post Repair Upper GI Dye Study
No anastomotic leak. Right hemi diaphragm was up.

7. Fluroscopy

8. • Paralysis of right hemi diaphragm diagnosed.
• Initial trial of conservative management was
planned.

9. Summary
• Extrapleural approach (postero-lateral incision).
• Chest tube not placed.
• Easy extubation (4th POD).
• Established feeds on 7th POD & feeding was well tolerated.
• Maintaining Oxygen Saturation >95% in room air.
• He was discharged home after 2 weeks.

10. • At the age of 2 months he was presented to local hospital ER
and was admitted due to H/O shortness of breath, cough &
poor feeding for previous 2 weeks.
• Transferred to our hospital for further management.

11. Chest X-Ray on admission

12. • Child was admitted in PICU with a diagnosis of Aspiration
Pneumonia.
• IV antibiotics with supportive measures were started.
• He was on Oxygen 1L/min through Nasal canula.

13. After resolving Pneumonia

14. • Conservative management continued.
• End of the 6 week:
 He was oxygen dependent (>2L/min),
 Persistent tachypnoea,
 Not gaining weight,
 Requiring regular nebulization & CPT to maintain a clear air way.

15. Decision was taken for surgical intervention.

16. Plication of Diaphragm
• Right sided posterolateral
thoracotomy at 8th intercostal
space.
• Dome of diaphragm high up.

17. Plication of Diaphragm
Grasping diaphragm. Plicating using Pledgeted suture.

18. Plication of Diaphragm
Plication in 6 rows each 4 folds.

19. Lung Expansion

20. Post Op X-Ray

21. Eventration of right hemi
Diaphragm following
EA & TEF repair

22. 1st case Report
• Paralysis of the right hemidiaphragm following primary
anastomosis for oesophageal atresia and tracheo-oesophageal
fistula.
Man D, Wheildon MH, Eckstein HB
Z Kinderchiv 1982;37: 32-3

23. Anatomy Right Phrenic Nerve
• Phrenic nerve root C3–C5,
• At the thoracic inlet: the right phrenic
nerve is behind the innominate vein and
crosses in front of pulmonary hilum
beside internal mammary artery,
descends to the right of the superior
vena cava, anterior to the lung.
• Finally: descends along the inferior
vena cava toward the diaphragm, branch
just proximal to the diaphragm into small
terminal branches.

24. Incidence
• The 10% of infants and children those undergoing cardiac
surgery develop Phrenic nerve injury .
Phrenic nerve injury in infants and children undergoing cardiac surgery.
Q Mok, R Ross-Russell, D Mulvey, M Green, and E A Shinebourne
Department of Paediatric Cardiology, Royal Brompton National Heart and Lung Hospital, London.

25. Pathogenesis
• Two types:
• Congenital eventration: results from inadequate development
of the muscle or absence of the phrenic nerves.
• Acquired eventration: injury to the phrenic nerve, resulting
from either a traumatic birth or thoracic surgery for congenital
heart disease.
• The loss of contractility leads to muscle atrophy with elevation
of the hemidiaphragm

26. • Cause of Per Operative Phrenic Nerve Injury: stretching,
crushing, transection, and hypothermia.
• Cardiac surgery, chiropractic manipulation, trauma or
anesthetic blocks at neck, right subclavian vein catheterization,
ICT insertion.
• Metastasis.
Elevated hemidiaphragm after cardiac operations: incidence, prognosis and
relationship to the use of topical ice slush.
Curtis JJ, Weerachai N, Walls J, Ann Thorac Surg 48:764, 1989 [PMID 2596912]

27. Investigation
• Electrophysiologic examination.
• Fluroscopy.

28. Fluroscopy
• Sniff test:
• Paradoxical upward motion on affected side.
• Normal excursion of 1-2 ribs:
• Breathe in, diaphragm down.
• Breathe out, diaphragm up.
• Paralyzed – paradoxical motion:
• Breathe in, diaphragm up.
• Breath out, diaphragm down.

29. Management
• Management of eventration of diaphragm secondary to phrenic
nerve injury must be individualized and depends on the
incapacity of the individual.
 Medical
 Surgical

30. Medical Management
• When paralysis is thought to be potentially reversible and the
patient is asymptomatic, it may be managed conservatively.
Malek & Abdulrahman Al-Bassam,
http://faculty.ksu.edu.sa/5564/Publications/Forms/AllItems.aspx

31. • Diaphragmatic plication reserved for those patients who fail to
regain diaphragmatic function after 4 to 6 wks trial of
conservative management.
Right phrenic nerve injury as a complication of tracheoesophageal fistula repair.
Henderson PW, Spigland NA.
Division of Pediatric Surgery, Weill Cornell Medical College, New York, USA.
Pediatr Crit Care Med. 2010 Sep;11(5):e52-4.

32. Indication for surgery
• Failure of conservative treatment measures.
 Recurrent chest infection.
 Oxygen dependency.
 Failure to thrive.

33. Lap/Open
• Open thoracotomy is the preferred approach.
• Minimally invasive diaphragm plication techniques have
emerged as equally effective and less morbid alternatives to
open plication.
Diaphragm plication for eventration or paralysis: a review of the literature.
Groth SS, Andrade RS.
Department of Surgery, University of Minnesota, USA.
Ann Thorac Surg. 2010 Jun;89(6):S2146-50.

34. Phrenic Nerve Reconstruction
• Tried in adult but no published report in neonate/pediatric.

35. Pacing of Diaphragm
• Pacing of the diaphragm requires an intact phrenic nerve.
• Indications: Bilateral Paralysis, central alveolar
hypoventilation and high cervical spinal cord injury (Ondine's
curse); intractable hiccups and end-stage chronic obstructive
pulmonary disease.
• Phrenic nerve pacing was partially successful in 36%.
Phrenic nerve stimulation: the Australian experience.
Khong P, Lazzaro A, Mobbs R.
Department of Neurosurgery, Prince of Wales Hospital, Australia.

36. Conclusion
• 1st case of Right Diaphragmatic Paralysis after repair of EA &
TEF was published in 1982.
• Related complication was published in 2007.
• Possible mechanism for our case could be stretching/
?Aberrant course of Right Phrenic Nerve.

37. Things do
happen