Onders Raymond P, Elmo Maryjo, Khansarinia Saeid, Bowman Brock, Yee John, Road Jeremy, Bass Barbara, Dunkin Brian, Ingvarsson Páll E, Oddsdóttir Margrét
Department of Surgery, University Hospitals Case Medical Center, Cleveland, OH, USA.
Surg Endosc. 2009 Jul;23(7):1433-40. doi: 10.1007/s00464-008-0223-3. Epub 2008 Dec 6.
Diaphragm movement is essential for adequate ventilation, and when the diaphragm is adversely affected patients face lifelong positive-pressure mechanical ventilation or death. This report summarizes the complete worldwide multicenter experience with diaphragm pacing stimulation (DPS) to maintain and provide diaphragm function in ventilator-dependent spinal cord injury (SCI) patients and respiratory-compromised patients with amyotrophic lateral sclerosis (ALS). It will highlight the surgical experiences and the differences in diaphragm function in these two groups of patients.
In prospective Food and Drug Administration (FDA) trials, patients underwent laparoscopic diaphragm motor point mapping with intramuscular electrode implantation. Stimulation of the electrodes ensued to condition and strengthen the diaphragm.
From March of 2000 to September of 2007, a total of 88 patients (50 SCI and 38 ALS) were implanted with DPS at five sites. Patient age ranged from 18 to 74 years. Time from SCI to implantation ranged from 3 months to 27 years. In 87 patients the diaphragm motor point was mapped with successful implantation of electrodes with the only failure the second SCI patient who had a false-positive phrenic nerve study. Patients with ALS had much weaker diaphragms identified surgically, requiring trains of stimulation during mapping to identify the motor point at times. There was no perioperative mortality even in ALS patients with forced vital capacity (FVC) below 50% predicted. There was no cardiac involvement from diaphragm pacing even when analyzed in ten patients who had pre-existing cardiac pacemakers. No infections occurred even with simultaneous gastrostomy tube placements for ALS patients. In the SCI patients 96% were able to use DPS to provide ventilation replacing their mechanical ventilators and in the ALS studies patients have been able to delay the need for mechanical ventilation up to 24 months.
This multicenter experience has shown that laparoscopic diaphragm motor point mapping, electrode implantation, and pacing can be safely performed both in SCI and in ALS. In SCI patients it allows freedom from ventilator and in ALS patients it delays the need for ventilators, increasing survival.
膈肌运动对于充分通气至关重要，当膈肌受到不利影响时，患者将面临终身正压机械通气或死亡。本报告总结了全球范围内使用膈肌起搏刺激（DPS）来维持和提供依赖呼吸机的脊髓损伤（SCI）患者及呼吸功能受损的肌萎缩侧索硬化症（ALS）患者膈肌功能的完整多中心经验。它将突出这两组患者的手术经验以及膈肌功能的差异。
在前瞻性美国食品药品监督管理局（FDA）试验中，患者接受了腹腔镜下膈肌运动点定位及肌内电极植入。随后对电极进行刺激以调节和增强膈肌功能。
从2000年3月至2007年9月，共有88例患者（50例SCI和38例ALS）在5个地点接受了DPS植入。患者年龄在18至74岁之间。从SCI到植入的时间跨度为3个月至27年。87例患者成功进行了膈肌运动点定位并植入电极，唯一失败的是第二例SCI患者，其膈神经检查出现假阳性。ALS患者手术中发现膈肌功能明显较弱，有时在定位过程中需要进行成串刺激以确定运动点。即使是预测用力肺活量（FVC）低于50%的ALS患者，围手术期也无死亡病例。即使对10例已有心脏起搏器的患者进行分析，也未发现膈肌起搏对心脏有影响。即使同时为ALS患者放置胃造瘘管，也未发生感染。在SCI患者中，96%能够使用DPS提供通气，取代机械通气；在ALS研究中，患者能够将机械通气需求推迟长达24个月。
这一多中心经验表明，腹腔镜下膈肌运动点定位、电极植入和起搏在SCI和ALS患者中均可安全进行。对于SCI患者，它使患者摆脱了呼吸机；对于ALS患者，它延迟了对呼吸机的需求，提高了生存率。
