Comparison of Mid-Term Clinical Outcomes of Different Surgical Approaches in Symptomatic Diaphragmatic Eventration

Idiopathic megacolon complicated by life-threatening giant megacolon and respiratory failure due to diaphragmatic eventration: A case report

INTRODUCTION AND IMPORTANCE

Giant megacolon requiring emergency surgery is rare. Eventration of the diaphragm associated with giant megacolon is also uncommon.

CASE PRESENTATION

We report a 66-year-old male who presented with abdominal distention and progressive dyspnea. After resuscitation following cardiopulmonary arrest, the patient underwent emergent subtotal abdominal colectomy. Eventration of the diaphragm was found postoperatively and his respiratory condition was insufficient to allow liberation. Plication of both diaphragms was performed through left and right thoracotomy via the 8th intercostal space. Postoperatively the patient made a full recovery.

CLINICAL DISCUSSIONS

Chronic constipation is a common health condition. A life-threatening condition secondary to chronic constipation is a rarely documented complication. Diaphragmatic eventration that was caused due to chronic megacolon in symptomatic patients requires surgical treatment.

CONCLUSIONS

We describe a patient with giant megacolon and diaphragmatic eventration secondary to idiopathic megacolon. The patient underwent subtotal colectomy and diaphragmatic plication and recovered fully.

Diaphragmatic plication for diaphragmatic eventration caused by chronic constipation: a case report

Diaphragmatic eventration in an adult patient is a rare condition. We describe a case of an elderly patient with hemidiaphragm dysfunction caused due to chronic constipation. A 67-year-old woman with a medical history of descending colon cancer that was treated 24 years before undergoing partial colectomy was admitted to our hospital with complaints of progressive shortness of breath and dyspnea on exertion for the past few months. She had no past history of any trauma. The patient had previously been suffering from chronic constipation after surgery. Physical examination revealed distension and incisional hernia of the abdomen. Chest X-ray demonstrated the high position of the left dome of the diaphragm with the megacolon gas. Chest and abdominal computed tomographic scans disclosed left diaphragmatic displacement containing the stomach and megacolon and abdominal incisional hernia. We performed open laparotomy, repair of abdominal incisional hernia using mesh, and diaphragmatic plication with nonabsorbable polyester suture and pledgets. Postoperative imaging confirmed the significant improvement of the patient's left lung space and clinical resolution of her respiratory symptoms. We describe the case of a patient with diaphragmatic eventration that was caused due to chronic constipation who underwent successful surgical repair.

Innovative and Contemporary Interventions of Diaphragmatic Disorders

The diaphragm is an inconspicuous fibromuscular septum, and disorders may result in respiratory impairment and morbidity and mortality when untreated. Radiologists need to accurately diagnose diaphragmatic disorders, understand the surgical approaches to diaphragmatic incisions/repairs, and recognize postoperative changes and complications. Diaphragmatic defects violate the boundary between the chest and abdomen, with the risk of herniation and strangulation of abdominal contents. In our surgical practice, patients with diaphragmatic hernias present acutely with incarceration and/or strangulation. Bochdalek hernias are commonly diagnosed in asymptomatic older adults on computed tomography; however, when viscera or a large amount of fat herniates into the chest, surgical intervention is strongly advocated. Morgagni hernias are rare in adults and typically manifest acutely with bowel obstruction. Patients with traumatic diaphragm injury may have an acute, latent, or delayed presentation, and radiologists should be vigilant in inspecting the diaphragm on the initial and all subsequent thoracoabdominal imaging studies. Almost all traumatic diaphragm injury are surgically repaired. Finally, with porous diaphragm syndrome, fluid, air, and tissue from the abdomen may communicate with the pleural space through diaphragmatic fenestrations and result in a catamenial pneumothorax or large pleural effusion. When the underlying disorder cannot be effectively treated, the goal of surgical intervention is to establish the diagnosis, incite pleural adhesions, and close diaphragmatic defects. Diaphragmatic plication may be helpful in patients with eventration or acquired injuries of the phrenic nerve, as it can stabilize the affected diaphragm. Phrenic nerve pacing may improve respiratory function in select patients with high cervical cord injury or central hypoventilation syndrome.

Right Diaphragmatic Eventration with an Intrathoracic Kidney: Case Report and Review of the Literature

We aimed to review the publications on the diagnosis of diaphragmatic eventration and report on the clinical presentation and surgical treatment of a female patient aged 17 years. The present case, though quite infrequent, shows the presence of an ectopic thoracic kidney on the right side. The clinical features included dry cough, chest pain, respiratory distress, and bronchial spasms for 4 years; additionally, the patient had episodes of bronchial asthma since her childhood. The right hemithorax presented invasion of the thin loops, right colon, and kidney. The treatment approach was laparoscopic followed by thoracotomy using a dual mesh. The intrathoracic kidney remained in place. The outcome was satisfactory. Diaphragmatic eventration associated with thoracic renal ectopia is a very rare entity, considering the age, sex, and right location of the condition. It represents a clinical and diagnostic challenge; clinicians, radiologists, and surgeons must be alert with a high degree of suspicion in order to correlate symptoms and imaging findings and understand the etiopathogenesis. In addition, they should plan an adequate and individualized surgical repair making use, as far as possible, of the minimally invasive procedures that are currently used.

[Diaphragm relaxation surgery]

AIM

To develop examination algorithm and to determine the indications for various options for surgical treatment.

MATERIAL AND METHODS

It is presented analysis of surgical treatment of 25 patients with unilateral diaphragm relaxation for the period from 1963 to 2016. There were 15 men and 10 women aged from 39 to 65 years. Diagnosis included predominantly radiological methods. All patients were operated openly through thoracotomy. Procedure consisted of creation of new diaphragmatic cupola at the usual level with two flaps of diaphragm and prosthesis between them. In 12 (48%) patients who were operated before 1990 xenopericardial patch was used. Further, synthetic materials (Teflon, polypropylene) were preferred.

RESULTS

Postoperative morbidity and mortality was 20% (n=6) and 4% (n=1) respectively. Long-term results were followed-up within terms from 8 months to 12 years. Recurrent relaxation was absent. Most of patients had improved dyspnea, increased vital capacity and FEV1 in long-term period. Certain and general values of SF-36 life quality questionnaire were high in long-term postoperative period and similar to those in general population.