Simansky D A, Paley M, Refaely Y, Yellin A
Department of Thoracic Surgery, Sheba Medical Center, Tel Hashomer affiliated with Sackler Faculty of Medicine of Tel Aviv University, Israel.
Thorax. 2002 Jul;57(7):613-6. doi: 10.1136/thorax.57.7.613.
A study was undertaken to evaluate whether adults differ from children in the indications and outcome of diaphragmatic plication following phrenic nerve injury.
A retrospective study was performed of 21 patients, 10 below the age of 5 and 11 older than 37 years. The indication for surgery for all the children was failure to wean from ventilatory support. The indications for surgery in the adult group were ventilator dependency (n=4) and symptomatic dyspnoea (n=7). All patients had at least one imaging study confirming diaphragmatic paralysis. The American Thoracic Society (ATS) dyspnoea scale, pulmonary function tests, and quantitative pulmonary perfusion scans were used as evaluation parameters. At surgery the diaphragm was centrally plicated.
One child died immediately after surgery due to irreversible heart failure and two children died within 2 months of surgery from ongoing complications of their original condition. These three patients were considered as selection failures. Seven children were weaned from ventilatory support within a median of 4 days (range 2-140). Only one of four ventilated adults was successfully weaned. Seven adults who underwent surgery for chronic symptoms had a marked subjective improvement of 2-3 levels in the ATS dyspnoea scale. Pulmonary function studies in the seven symptomatic adults showed a 40% improvement above baseline. Severely asymmetrical perfusion scans reverted to a normal pattern after plication.
Diaphragmatic plication offers a significant benefit to children with diaphragmatic paralysis and should be performed early to facilitate weaning from mechanical ventilation. While plication is of limited benefit in weaning ventilated adults, it results in significant subjective and objective lifetime improvement in non-ventilated symptomatic adults.
开展了一项研究，以评估膈神经损伤后膈折叠术的适应症及结果在成人和儿童中是否存在差异。
对21例患者进行了回顾性研究，其中10例年龄在5岁以下，11例年龄在37岁以上。所有儿童的手术适应症均为撤机失败。成人组的手术适应症为呼吸机依赖（n = 4）和有症状的呼吸困难（n = 7）。所有患者均至少进行了一项影像学检查以确认膈麻痹。采用美国胸科学会（ATS）呼吸困难量表、肺功能测试和定量肺灌注扫描作为评估参数。手术时对膈肌进行中央折叠。
1例儿童术后因不可逆性心力衰竭立即死亡，2例儿童在术后2个月内因原发病的持续并发症死亡。这3例患者被视为选择失败。7例儿童在中位时间4天（范围2 - 140天）内成功撤机。4例使用呼吸机的成人中只有1例成功撤机。7例因慢性症状接受手术的成人在ATS呼吸困难量表上主观改善了2 - 3级。7例有症状成人的肺功能研究显示较基线水平改善了40%。严重不对称的灌注扫描在折叠术后恢复为正常模式。
膈折叠术对膈麻痹儿童有显著益处，应尽早进行以促进机械通气撤机。虽然折叠术在撤机的成人中益处有限，但它能使有症状的非通气成人在主观和客观上得到显著的终生改善。
