Freeman Richard K, Wozniak Thomas C, Fitzgerald Edward B
Department of Thoracic and Cardiovascular Surgery, St. Vincent Hospital, Indianapolis, Indiana, USA.
Ann Thorac Surg. 2006 May;81(5):1853-7; discussion 1857. doi: 10.1016/j.athoracsur.2005.11.068.
Plication of the hemidiaphragm for unilateral diaphragm paralysis is infrequently performed in adults. Barriers to diaphragm plication have included the perceived need for thoracotomy and uncertainty of the potential benefits. The purpose of this investigation was to assess the effects of video-assisted thoracoscopic diaphragm plication in symptomatic adult patients with unilateral diaphragm paralysis.
Patients with unilateral diaphragm paralysis underwent an evaluation that included a chest radiograph, fluoroscopic sniff test, pulmonary spirometry, and the Medical Research Council (MRC) dyspnea score. Patients with symptomatic unilateral diaphragm paralysis present for at least 6 months were offered video-assisted thoracoscopic diaphragm plication. Patients who underwent diaphragm plication as well as those who declined surgery were reassessed at 6 months with a chest radiograph, spirometry, and the MRC dyspnea score.
Twenty-five patients underwent left (19) or right (6) diaphragm plication through video-assisted thoracoscopic diaphragm plication (22) or thoracotomy (3). There were no operative deaths. Mean hospital length of stay for diaphragm plication was 3.7 days for video-assisted thoracoscopic diaphragm plication and 5.4 days for thoracotomy. After diaphragm plication, mean forced vital capacity, forced expiratory volume at 1 second, functional residual capacity, and total lung capacity improved by 17%, 21.4%, 20.3%, and 16.1%, respectively (p < 005) at 6 months. Mean MRC dyspnea scores also significantly improved in the operative cohort (p < 0001). Seventeen patients in the surgical cohort had returned to work at 6 months. Seven patients treated without surgery displayed a trend toward more frequent hospitalizations and deteriorating pulmonary spirometry and MRC dyspnea scores during the follow-up period.
Plication of the hemidiaphragm using minimally invasive techniques produced significant improvements in patients' functional status, pulmonary spirometry, and MRC dyspnea scores. Video-assisted thoracoscopic diaphragm plication should be considered appropriate therapy in symptomatic adult patients with unilateral diaphragm paralysis.
在成人中，半膈肌折叠术治疗单侧膈肌麻痹并不常见。膈肌折叠术的障碍包括人们认为需要开胸手术以及潜在益处的不确定性。本研究的目的是评估电视辅助胸腔镜膈肌折叠术对有症状的单侧膈肌麻痹成年患者的效果。
单侧膈肌麻痹患者接受了包括胸部X线片、透视下吸气试验、肺功能测定以及医学研究委员会（MRC）呼吸困难评分在内的评估。有症状的单侧膈肌麻痹持续至少6个月的患者接受了电视辅助胸腔镜膈肌折叠术。接受膈肌折叠术的患者以及拒绝手术的患者在6个月时再次进行胸部X线片、肺功能测定和MRC呼吸困难评分评估。
25例患者通过电视辅助胸腔镜膈肌折叠术（22例）或开胸手术（3例）进行了左侧（19例）或右侧（6例）膈肌折叠术。无手术死亡病例。电视辅助胸腔镜膈肌折叠术的膈肌折叠术平均住院时间为3.7天，开胸手术为5.4天。膈肌折叠术后，6个月时平均用力肺活量、第1秒用力呼气量、功能残气量和肺总量分别提高了17%、21.4%、20.3%和16.1%（p<0.05）。手术组的平均MRC呼吸困难评分也显著改善（p<0.001）。手术组17例患者在6个月时已恢复工作。7例未手术治疗的患者在随访期间有住院更频繁、肺功能测定和MRC呼吸困难评分恶化的趋势。
采用微创技术进行半膈肌折叠术可显著改善患者的功能状态、肺功能测定和MRC呼吸困难评分。电视辅助胸腔镜膈肌折叠术应被视为有症状的单侧膈肌麻痹成年患者的合适治疗方法。
