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PubMedDate not supplied

Diaphragmatic relaxation: pathophysiological alterations and current possibilities of surgical repair.

Diaphragmatic relaxation is a pathology not frequently observed because it is generally oligosymptomatic. The development of modern technology has induced an important contribution to the diagnosis and treatment of the disease which can find a possibility of restoration in surgery. A 63-year-old patient with a light syndrome of respiration deficiency and an altered relaxed profile of the right cupola was subjected to surgical treatment with the technique of diaphragmatic plicature without any adverse implication during and after the operation. After a brief recovery, the patient was discharged and after 9 years he affirmed still absence of dyspnoea from limited labor and absence of respiration problems. The selected surgical technique for the restoration of the altered muscle is the diaphragmatic plicature without incision or excision of the altered part of the muscle. The preferable access way today is that of laparotomy which is devoid of problems of thoracotomy and generally it permits quite easily the restoration of all diaphragmatic defects. Diaphragmatic plicature is a simple, effective and long-lasting intervention but we cannot determine the complete recovery of the normal contractile function of the muscle. There is no morbidity and mortality directly related to this technique, the latter incidentally associated with complications of general anesthesia.

Diaphragm↗
PubMed1991

Ultrasonography of the liver and biliary tract.

Evaluation of the liver and biliary tract is one of the principal applications of abdominal ultrasonography in small animals. Indications include hepatomegaly, mass in the area of the liver, suspected hepatic metastasis, jaundice, ascites, suspected diaphragmatic rupture, and weight loss. Ultrasonography is a valuable method for evaluating the internal structure of the liver and biliary tract. Certain functional assessments also may be made, for example, measurement of induced gallbladder emptying after cholecystokinin injection. Limitations of ultrasonography include lack of specificity for focal or multifocal hepatic lesions and insensitivity for certain infiltrative diseases, such as lymphosarcoma. These limitations contribute to diagnostic difficulties, which are adequately addressed only by biopsy. The technique of ultrasound-guided biopsy is described briefly.

Animals↗
PubMed1982

Prosthetic replacement of entire left hemidiaphragm in malignant fibrous histiocytoma of the diaphragm.

A case of primary malignant fibrous histiocytoma of the diaphragm which, to our knowledge, is the first record in the world literature, is presented. It occupied almost the entire left hemidiaphragm and was surgically removed with the left lower pulmonary lobe, stomach, colon, and spleen. The entire left hemidiaphragm then was replaced with Marlex mesh. Prosthetic replacement of the entire hemidiaphragm, which has not been previously reported, was successfully performed with preservation of pulmonary function on the affected side. The patient died of brain metastases of malignant fibrous histiocytoma more than 4 months postoperatively. Diagnosis of diaphragmatic tumors and a technique which involves the use of a prosthesis are discussed.

Brain Neoplasms↗
PubMed1990

[Classification for bullous emphysema based on analysis of chest wall motion and pulmonary function before and after bullectomy].

This study proposed a new classification for giant bullae based on analysis of chest wall motion during breathing efforts in the supine position using serial chest X-rays and examined the pulmonary function before and after bullectomy. Twenty-three patients with giant bullae were divided into two groups. Eight patients (group A) had a phase shift between the diaphragm motion and the rib cage motion or abnormal diaphragmatic motion. Almost all of them had dyspnea on exertion, and their FEV1.0 and MVV% had dyspnea on exertion, and their FEV1.0 and MVV%pred. were impaired but improved soon after bullectomy. Fifteen patients (group B) had good coordination of the diaphragm motion and rib cage motion. Most of them had no dyspnea and had normal pulmonary function. In addition, patients of group B were divided into three subgroups based on a phase shift between the diaphragm motion and inflation-deflation of giant bullae during a run. First, three patients whose bullae synchronized with the diaphragm motion showed significant decrease of %VC after bullectomy, and took a year for the decreased FEV1.0 and MVV%pred. to recover following the operation. Secondly, three patients whose bullae lay on the diaphragm and reached maximum size in the early phase of expiration showed little change in pulmonary function after bullectomy. Third, three patients whose bullae reached a maximum size at the end of expiration showed improvement of %VC and FEV1.0 soon after bullectomy. Chest wall distortion, defined as one side of caudal chest and upper abdomen not moving symmetrically compared with the other side, was found in three patients whose bullae were located in the middle and lower lung fields.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed2002

[Respiratory deadspace and compliance measurements in neonates with congenital diaphragmatic hernia].

The mortality rate of infants with congenital diaphragmatic hernia (CDH) remains high, despite clinical improvements. Many attempts have been made to find accurate and reliable predictors of outcome. Deadspace (Vd/Vt) and dynamic compliance (DC) measured by single breath CO2 analysis may be useful to evaluate pulmonary function and perfusion. In the present study we analyse both parameters in patients with CDH. Nine patients with CDH were included for Vd/Vt and DC study. Measurements of arterial blood gases (pH, PO2, pCO2) were obtained, oxygenation index and alveolo-arterial difference calculated at diagnosis, preoperatively and postoperatively. Vd/Vt and DC were measured at the same moments by analysis of the CO2 espirogram. Statistical analysis was performed using Fisher exact test, ANOVA and Mann Whitney and Chi-square. The Vd/Vt was significant lower for the group of patients who survived (0.39 +/- 0.07 vs 0.64 +/- 0.14, p = 0.038). DC was significantly higher in the survivors group (1.39 +/- 0.30 vs 0.5 +/- 0.07, p = 0.011). The analysis of the evolutive Vd/Vt and DC (initial and preoperative) showed significant differences within both groups. Respiratory deadspace can be easily quantified in neonates with congenital diaphragmatic hernia providing an important insight regarding the efficiency of the airway-alveolus and its relationship to pulmonary blood flow. Vd/Vt and DC measurement constitute a reliable method to predict outcome in patients with CDH.

Hernia, Diaphragmatic↗
PubMed1984

Effects and mechanism of action of terbutaline on diaphragmatic contractility and fatigue.

We studied the effects of intravenously administered terbutaline on diaphragmatic force and fatigue during electrical stimulation of the diaphragm in 17 anesthetized dogs. The diaphragm was stimulated indirectly through the phrenic nerves with electrodes placed around the fifth roots and directly with electrodes surgically implanted in the abdominal side of each hemidiaphragm. Transdiaphragmatic pressure (Pdi) during direct or indirect supramaximal 2-s stimulation applied over a frequency range of 10-100 Hz was measured with balloon catheters during tracheal occlusion at functional residual capacity. In seven dogs the administration of terbutaline (0.5 mg) had no effect on Pdi at any stimulation frequency applied directly or indirectly. The effect of terbutaline (0.5 mg) on diaphragmatic fatigue was then tested in 10 other dogs. Diaphragmatic fatigue was produced by continuous 20-Hz electrical supramaxial stimulation of the phrenic nerves during 30 min. At the end of the fatigue procedure Pdi decreased by 50 +/- 5 and 30 +/- 8% of control values at 10 and 100 Hz, respectively, for either direct or indirect stimulation. The decrease in Pdi for low frequencies of stimulation (10 and 20 Hz) lasted 100 +/- 18 min, whereas it lasted only 40 +/- 10 min for the high frequencies (50 and 100 Hz). When terbutaline (0.5 mg) was administered after the fatiguing procedure, Pdi increased within 15 min by 20 +/- 4% at 10 Hz and by 12 +/- 3% at 100 Hz for either direct or indirect stimulation.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed1995

Respiratory muscle function in infants.

In newborns and infants a variety of respiratory disorders lead to ventilatory failure. In early life the ventilatory response to loaded breathing is limited. The risk factors of ventilatory failure are related to the developing respiratory pump because of the immaturity of the chest wall, respiratory muscles and coupling between thoracic and abdominal movements. Assessment of respiratory muscle function in infants is limited, due to the objections to using invasive techniques. However, measurement of airway pressures during crying may provide an index of respiratory muscle strength in infants. Real-time ultrasonography allows investigation of diaphragmatic movements. Pattern of thoracoabdominal motion can be assessed using uncalibrated respiratory inductive plethysmography. Finally, electromyographic recording of respiratory muscles by surface electrodes is of clinical usefulness during sleep studies.

Humans↗
PubMed1998

Monitoring respiratory muscles.

The respiratory system consists of two main parts, the lung and the ventilatory pump. The latter consists of the bony structure of the thorax, the central respiratory controllers, the inspiratory and expiratory muscles, and the nerves innervating these muscles. Respiratory muscle fatigue occurs when respiratory muscle endurance is exceeded. Muscle fatigue is defined as a condition in which there is a reduction in the capacity for developing force and/or velocity of a muscle, resulting from muscle activity, and which is reversible by rest. The respiratory muscles are somewhat difficult to assess and the techniques employed are still relatively primitive. The most important methods of respiratory muscles function assessment are: 1) the vital capacity manoeuvre, which depends on maximum inspiratory and expiratory effort by the muscles and may be a useful indicator of respiratory muscle function; 2) radiological screening has been proposed for the detection of diaphragm paralysis. This may be helpful if the paralysis is unilateral, but bilateral paralysis is difficult to detect; and 3) respiratory muscles strength may be assessed with either voluntary or nonvoluntary manoeuvres. The function of the inspiratory muscles is assessed with 3 voluntary dependent manoeuvres. They are the so called Müller manoeuvre (or maximal inspiratory pressure), the sniff test and the combined test. All these three manoeuvres generate a pressure that is a reflection of complex interactions between several muscle groups since the efforts produce different mechanisms of activity of inspiratory and expiratory muscles. Two techniques are presently employed to assess diaphragm function, not being dependent on the patient's motivation: electrical phrenic nerve stimulation and cervical magnetic stimulation. Since it is less painful, magnetic cervical stimulation overcomes some of the difficulties encountered during electrical stimulation. With these two techniques recordings of diaphragmatic force are possible, and at the same time useful information about the conduction time of both phrenic nerves can be obtained.

Diaphragm↗
PubMed1998

Pulmonary and cardiac function in advanced fibrodysplasia ossificans progressiva.

Fibrodysplasia ossificans progressiva is a rare genetic disease characterized by heterotopic ossification in soft tissues. Severe disability results from progressive immobilization of the limbs, jaw, and chest wall. To determine whether cardiac function is altered in this disease, 25 patients ranging in age from 5 to 55 years (disease duration 1-51 years) were studied. History, physical examination, pulmonary functions, electrocardiography, and echocardiography were performed on each patient. Physical examination of the lungs and heart was unrevealing; no right sided ventricular gallops were heard, and no patient was found to have neck vein distention or peripheral edema. The patients had extremely limited chest expansion (1.9 +/- 0.8 inches), suggesting dependence on diaphragmatic breathing. Lung volumes were severely reduced (mean forced vital capacity 44% +/- 14% of predicted), but flow rates were relatively normal. All patients had normal capillary oxygen saturation. Echocardiography was technically difficult, but no abnormalities of left or right ventricular function were seen. Ten (40%) patients had electrocardiographic evidence of right ventricular dysfunction. Compared with patients without such evidence, these patients were older, had significantly longer disease duration, higher hemoglobin, and more impaired pulmonary function. The results of this study suggest that the presence of severely restrictive chest wall disease is associated with a high incidence of right ventricular abnormalities on electrocardiogram. Whether cor pulmonale will eventually occur remains to be determined.

Adolescent↗
PubMed2003

Thoracoscopic surgery for congenital diaphragmatic hernia: a report of nine cases.

PURPOSE: To describe the surgical technique and early results of thoracoscopic repair of congenital diaphragmatic hernia (CDH) in children. MATERIALS AND METHODS: A retrospective review was undertaken of patients with CDH who underwent thoracoscopic surgery in our institution over a period of 15 months. There were nine patients, five boys and four girls, ranging in age from 7 days to 8 years. All nine patients underwent surgery under general anaesthesia. Reduction of the hernia contents was carried out using one optical trocar and two operating trocars. Pleural insufflation with carbon dioxide was maintained at a pressure of 2 to 4 mmHg. The hernia defect was repaired using non-absorbable interrupted sutures. RESULTS: The hernia was located on the left side in seven patients and on the right side in two. The mean operative time was 80 minutes. In all patients, the chest tube was removed on the first postoperative day. All patients were discharged on the fifth postoperative day. Chest X-ray and clinical examination 3 months after surgery were normal in all patients. CONCLUSION: The thoracoscopic approach for the repair of CDH in children, including small infants and newborns, is feasible and safe. The technique causes minimal trauma, results in good respiratory function, and promotes early recovery.

Child↗
PubMed1994

Torsion of the spleen: an unusual presentation of congenital diaphragmatic hernia.

We describe an unusual case of congenital diaphragmatic hernia in a 6-week-old boy who presented with severe respiratory distress due to torsion of the spleen which had passed up into the chest through a Bochdalek hernia and caused a left hemothorax. Scintigraphy with heat-damaged red cells was diagnostic by showing a damaged but functioning spleen above the diaphragm. Surgical repair and return of the spleen to the abdomen resulted in complete recovery.

Hemothorax↗
PubMed2003

Laparoscopic esophagogastric devascularization in bleeding varices.

BACKGROUND: Bleeding from esophageal varices is the major cause of death in patients with portal hypertension. The ideal surgical procedure should effectively control bleeding and maintain liver function with low rates of encephalopathy. Based on this objective, laparoscopic devascularization of the lower esophagus and upper stomach was studied. METHODS: Eighteen patients were studied prospectively who underwent a laparoscopic esophagogastric devascularization procedure for variceal hemorrhage. The diaphragmatic hiatus and esophagus are dissected. The lower 7 or 8 cm of esophagus is devascularized. Devascularization of the gastric fundus is then accomplished by meticulous dissection and ligation of the short gastric vessels. The hepatogastric ligament is opened, permitting identification and isolation/ligation of the left gastric vessels. The dissection and ligation of the vessels at lesser curvature proceeded up to the diaphragmatic hiatus with devascularization of the external varices from the retroperitoneum or mediastinum at the esophagogastric junction. RESULTS: Mean operating room time was 111 min (range, 80-140 min) (6 emergent/12 elective). Mean blood loss 388 ml (range, 150-650 ml). Intensive care unit stay averaged 48 h, with a mean hospitalization of 11 days. Liver function and coagulation parameters remained stable postoperatively. Duplex sonography on the portal and splenic veins revealed patency in all patients. The flow velocity in the portal vein decreased from 15.5 +/- 4.1 to 13.4 +/- 3.5 cm/s postoperatively ( p = 0.021). Splenic vein velocity was unchanged. Bleeding recurred in 6 patients, and grade 1 encephalopathy developed in 1 patient. Follow-up endoscopy (8-24 months) demonstrated substantial reduction in variceal grade. CONCLUSION: Laparoscopic devascularization of the lower esophagus and the upper stomach is technically feasible and promising. Rapid recovery and control of variceal hemorrhage are accomplished in most patients without exposing them to the risk of open surgery.

Adult↗
PubMed2000

Thoracoscopic plication of diaphragmatic eventration using endostaplers.

Unilateral diaphragmatic eventration and paralysis require plication in cases of progressive dyspnea on exertion and recurrent respiratory infection. The patient, a 40-year-old woman, who had complained of worsening dyspnea on exertion and elevation of the left diaphragm on chest radiographs for 4 years, underwent plication by thoracoscopy with knifeless endostaplers. Improvements in pulmonary functions and dyspnea on exertion have been maintained for 14 months.

Adult↗
PubMed1978

[The effect of surgical incisions on ventilatory function].

Normal surveillance was extended to include respiratory function tests (Vital capacity, FEV1, Maximum Breathing Capacity) on 40 post-operative patients. The reduction relative to pre-operative values on the 1st day after operation was of the order of 60 p. 100 for high abdominal incisions, 35 p. 100 for low abdominal incisions and 15 p. 100 for non abdominal incisions. A return to preoperative values was obtained on the 15th, the 6th and the 4th post-operative days respectively. These changes are found to be well correlated to the limitation of diaphragmatic movement in high incisions. As a result, there is a hypoventilation of the lower lobes of the lungs and a shunt effect which lead to hypoxaemia. The reduction in respiratory function in those subjects without an abdominal incision demonstrated that other factors, particularly the influence of a general anaesthesia, need to be taken into account. Numerous clinical observations show that a reduction in respiratory volumes and capacities do not spare the young subjects and may be dramatic in certain cases. These indicate that a daily assessment of respiratory function at the bedside may provide a simple means for early recognition of intercurrent complications.

Abdomen↗
PubMed1986

Human diaphragmatic EMG: changes with lung volume and posture during supramaximal phrenic stimulation.

If esophageal and chest wall recordings of diaphragmatic electromyographic activity (EMG) accurately reflect neural drive to this muscle, then compound muscle action potentials (CMAPs) produced by supramaximal stimulation of the phrenic nerve should not alter with changes in diaphragmatic position. Maximal CMAPs were therefore recorded 1) during changes in lung volume from near residual volume to near total lung capacity, 2) during isovolume maneuvers at different lung volumes, and 3) while subjects were lying, sitting, and standing. The areas of maximal CMAPs recorded with the gastroesophageal catheter increased 5.1 +/- 3.6 times (mean +/- SD) between these volumes, increased 2.4 +/- 1.3 times as the diaphragm descended during an isovolume maneuver (at functional residual capacity), and increased 4.4 +/- 2.4 times between the lying and standing positions. Because the stimuli were supramaximal, these changes in EMG reflect changes in the relationship between the esophageal electrodes and the diaphragmatic muscle fibers. Artifactual changes were also documented for surface electrodes on the chest wall. Because of these positional changes in maximal CMAPs, previous studies, which used integrated diaphragmatic EMG to document "reflex" changes in neural drive, should be reevaluated.

Adult↗