Taberham Rhona J, Raza Adnan, Alzetani Aiman, Woo Edwin B, Chamberlain Martin H, Koulaxouzidis George, Amer Khalid M
From the Cardiovascular & Thoracic Centre, Southampton General Hospital, Southampton, UK.
Innovations (Phila). 2017 Nov/Dec;12(6):398-405. doi: 10.1097/IMI.0000000000000441.
The aim of the study was to report the safety and efficacy of video-assisted thoracoscopic (VATS) plication of the diaphragm at our institution between 2006 and 2016.
Adult patients selected on etiology and combination of investigations including plain chest x-ray, computed tomography of chest and abdomen, lung functions in supine and sitting positions, radiological/ultrasonic screening for diaphragmatic movement, and phrenic nerve conduction studies. We incorporated a triportal VATS and Endostitch device for plication, using CO2 insufflation to maximum 12 mm Hg. Bilateral simultaneous plication and high-risk patients were electively admitted to intensive therapy unit postoperatively.
Thirty-five patients (24 males) had their diaphragm plicated. The mean age was 56.6 years (range = 23-76 years). The mean body mass index was 32.1 (range = 22.2-45.4). Twenty one were right, 13 left, 2 patients had VATS simultaneous bilateral plication, and 1 had sequential VATS bilateral plication. Paralysis was idiopathic in 17, posttraumatic in 5, postremoval of mediastinal tumor in 4, and postcardiac surgery in 3. All patients presented with lifestyle-limiting dyspnea and orthopnea, three were on nocturnal noninvasive ventilation. Five were diabetic and 16 were smokers. The mean supine forced expiratory volume in the first second was 62.5% of predicted. Twenty two were performed by VATS (63%), three converted to thoracotomy, and 13 were open limited thoracotomy (historic). The mean hospital stay was 4.5 days (range = 1-18, mode 2 days). Intensive therapy unit admission was required in six patients for mechanical ventilation 0 to 3 days. Five patients (14%) had no improvement in symptoms. There were no deaths, no 30-day readmissions, and no long-term neuralgia in this series.
We found minimal access VATS plication of the diaphragm to be feasible and safe, but no firm conclusions should be drawn from our limited resources. We report the feasibility of concomitant bilateral VATS plication of the diaphragm in two adults, and this was not previously reported in the adult population. There is a need for further good quality, prospective studies, and randomized controlled studies evaluating efficacy of VATS diaphragmatic plication.
本研究旨在报告2006年至2016年间我院采用电视辅助胸腔镜（VATS）折叠膈肌的安全性和有效性。
根据病因及多种检查结果选择成年患者，这些检查包括胸部X线平片、胸部和腹部计算机断层扫描、仰卧位和坐位肺功能、膈肌运动的放射学/超声检查以及膈神经传导研究。我们采用三孔VATS和Endostitch装置进行折叠，二氧化碳气腹压力最高达12 mmHg。双侧同时折叠以及高危患者术后选择性入住重症监护病房。
35例患者（24例男性）接受了膈肌折叠术。平均年龄为56.6岁（范围=23 - 76岁）。平均体重指数为32.1（范围=22.2 - 45.4）。21例为右侧，13例为左侧，2例患者接受了VATS双侧同时折叠，1例接受了VATS双侧序贯折叠。膈肌麻痹病因不明者17例，创伤后5例，纵隔肿瘤切除术后4例，心脏手术后3例。所有患者均出现限制生活方式的呼吸困难和端坐呼吸，3例接受夜间无创通气。5例患有糖尿病，16例吸烟。第一秒用力呼气量仰卧位时平均为预测值的62.5%。22例通过VATS进行手术（63%），3例中转开胸，13例为开放性有限开胸手术（历史对照）。平均住院时间为4.5天（范围=1 - 18天，众数为2天）。6例患者术后需要入住重症监护病房进行0至3天的机械通气。5例患者（14%）症状无改善。本系列中无死亡病例，无30天再入院病例，也无长期神经痛病例。
我们发现采用微创VATS折叠膈肌是可行且安全的，但鉴于我们有限的资源，不应得出确凿结论。我们报告了两名成年人同时进行双侧VATS折叠膈肌的可行性，此前在成年人群中未见此类报道。需要进一步开展高质量的前瞻性研究以及随机对照研究来评估VATS膈肌折叠术的疗效。
