Diaphragmatic Plication?

[81709]

I’m a 50 year old male who was in an automobile accident in August 2009. My diaphragm was herniated on the right side and liver was pushed partially through the diaphragm. I had a bilateral pneumothorax and underwent emergency surgery. My injuries were numerous and I won't waste space here listing them. My liver and spleen were lacerated, but the surgeon was able to repair both, as well as the herniated diaphragm of course.

My pulmonologist has done lung function and volume tests on me, the last of which was almost a year ago. He said the right lung is normal, but due to the elevated diaphragm not making any progress over the two years since the accident, my lung capacity is not likely to get any better since the diaphragm is still in the same position year two as it was year one.

I have an appointment to see him in August, and since I saw him last I have heard of diaphragmatic plication.  Last time I saw him he did mention a surgery that might help and I suspect it was plication, but we didn’t discuss the specific procedure.

Otherwise I am in good health, and very lucky to even be here to ask these questions :)

Three questions:

1. My breathing is ok at rest or while walking or jogging at a VERY slow pace, but I get severe dyspnea when I exercise with any vigor. My heart rate also goes sky high very quickly during exercise. Will this worsen with age due to the elevated diaphragm?

2. Would I be a good candidate for plication, or would there be difficulties with adhesions or other issues caused by the trauma?

3. If I would be a candidate, what is a realistic expectation for improvement?

Thank you in advance, I just want to educate myself a bit before my appointment.

[kenscott]

A related discussion, sleep,sports and other observations was started.

[81709]

Sure- I should have been clearer. The biggest issue is getting to sleep. I am typically able to sleep through the night once I get to sleep, but I also get up earlier and am not able to get back to sleep. Before the accident this never happened.  Again I realize that insomnia can be a symptom of PSTD, but I have zero other symptoms.

I did take Paxil for 6 months, and it helped me sleep, but it made me feel exhausted all of the time; along with other nuisance side effects.

I just wonder if the difficulty in getting to sleep can be related to my altered breathing pattern based on my diaphragm injury. I have been able to improve my ability to fall asleep with relaxation techniques. I was just curious to understand if the diaphragm injury could be a factor.

[David Tinkelman, M.D.]

The answer to your question would depend upon what you mean by “sleep issues.”  Perhaps you could clarify the “issues”.

[81709]

Thank you! I will discuss this study with my pulmonologist and try to seek out a surgeon that was involved, or has experience with plication of diaphragms that have undergone trauma.

One more question if I may. I have had sleep issues starting about a month after I was released from the hospital. My GP says it's likely PSTD from the accident, but I have no other symptoms of PSTD, and the accident was almost three years ago. Could my diaphragm injury be contributing to my sleep difficulties?

[David Tinkelman, M.D.]

Your pulmonologist is right.  With no spontaneous improvement after two years, it is unlikely that improvement will occur in the future, but functional loss of your breathing will occur secondary to aging as it does for everyone.  

Diaphragmatic placation has proven to be quite effective in the circumstance of diaphragmatic paralysis and/or herniation.  Adhesions might make the surgery more difficulty but would not necessarily preclude the attempt.  Given the potential problems that adhesions might cause it would behoove you and your pulmonologist to request feedback from doctors who have had extensive experience with this operation.

The following is the abstract of a medical journal report of physicians' (in Indianapolis) experience with a relatively non-invasive technique for surgical plication.  You might want to share it with your pulmonologist.  It was a multicenter study and you might try to find out if a surgical team near your area was involved.

Good luck,

Unique Identifier 16631685
Status MEDLINE
Authors Freeman RK. Wozniak TC. Fitzgerald EB.

Authors Full Name Freeman, Richard K. Wozniak, Thomas C. Fitzgerald, Edward B.
Institution Department of Thoracic and Cardiovascular Surgery, St. Vincent Hospital, Indianapolis, Indiana, USA. ***@****

Title Functional and physiologic results of video-assisted thoracoscopic diaphragm plication in adult patients with unilateral diaphragm paralysis.
Source Annals of Thoracic Surgery. 81(5):1853-7; discussion 1857, 2006 May.
Abstract BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.
Publication Type Journal Article. Multicenter Study.