Right hemidiaphragm paralysis after EA & TEF repair.

Things happen

Uncommon event of a common procedure

Dr. Abdur Rakib Talukder, MRCS

• 36 weeks, male, weighing 2 kg; NSVD.

• Diagnosed as a case of EA & TEF, accepted from other

Hospital.

• No other association was diagnosed.

X-Ray at Birth

Isolating TEF

• Operated at 4th day of life.

• Ligation of TEF & primary

anastomosis.

• Extra pleural approach.

• Minimal dissection.

• Extubated on 4th POD .

• Dye study on 7th POD.

Post Repair Upper GI Dye Study

No anastomotic leak. Right hemi diaphragm was up.

Fluroscopy

• Paralysis of right hemi diaphragm diagnosed.

• Initial trial of conservative management was

planned.

Summary

• Extrapleural approach (postero-lateral incision).

• Chest tube not placed.

• Easy extubation (4th POD).

• Established feeds on 7th POD & feeding was well tolerated.

• Maintaining Oxygen Saturation >95% in room air.

• He was discharged home after 2 weeks.

• At the age of 2 months he was presented to local hospital ER

and was admitted due to H/O shortness of breath, cough &

poor feeding for previous 2 weeks.

• Transferred to our hospital for further management.

Chest X-Ray on admission

• Child was admitted in PICU with a diagnosis of Aspiration

Pneumonia.

• IV antibiotics with supportive measures were started.

• He was on Oxygen 1L/min through Nasal canula.

After resolving Pneumonia

• Conservative management continued.

• End of the 6 week:

He was oxygen dependent (>2L/min),

Persistent tachypnoea,

Not gaining weight,

Requiring regular nebulization & CPT to maintain a clear air way.

Decision was taken for surgical intervention.

Plication of Diaphragm

• Right sided posterolateral

thoracotomy at 8th intercostal

space.

• Dome of diaphragm high up.

Plication of Diaphragm

Grasping diaphragm. Plicating using Pledgeted suture.

Plication of Diaphragm

Plication in 6 rows each 4 folds.

Lung Expansion

Post Op X-Ray

Eventration of right hemi Diaphragm following

EA & TEF repair

1st case Report

• Paralysis of the right hemidiaphragm following primary

anastomosis for oesophageal atresia and tracheo-oesophageal

fistula.

Man D, Wheildon MH, Eckstein HB

Z Kinderchiv 1982;37: 32-3

Anatomy Right Phrenic Nerve

• Phrenic nerve root C3–C5,

• At the thoracic inlet: the right phrenic

nerve is behind the innominate vein and

crosses in front of pulmonary hilum

beside internal mammary artery,

descends to the right of the superior

vena cava, anterior to the lung.

• Finally: descends along the inferior

vena cava toward the diaphragm, branch

just proximal to the diaphragm into small

terminal branches.

Incidence

• The 10% of infants and children those undergoing cardiac

surgery develop Phrenic nerve injury .

Phrenic nerve injury in infants and children undergoing cardiac surgery.

Q Mok, R Ross-Russell, D Mulvey, M Green, and E A Shinebourne

Department of Paediatric Cardiology, Royal Brompton National Heart and Lung Hospital, London.

Pathogenesis

• Two types:

• Congenital eventration: results from inadequate development

of the muscle or absence of the phrenic nerves.

• Acquired eventration: injury to the phrenic nerve, resulting

from either a traumatic birth or thoracic surgery for congenital

heart disease.

• The loss of contractility leads to muscle atrophy with elevation

of the hemidiaphragm

• Cause of Per Operative Phrenic Nerve Injury: stretching,

crushing, transection, and hypothermia.

• Cardiac surgery, chiropractic manipulation, trauma or

anesthetic blocks at neck, right subclavian vein catheterization,

ICT insertion.

• Metastasis.

Elevated hemidiaphragm after cardiac operations: incidence, prognosis and

relationship to the use of topical ice slush.

Curtis JJ, Weerachai N, Walls J, Ann Thorac Surg 48:764, 1989 [PMID 2596912]

Investigation

• Electrophysiologic examination.

• Fluroscopy.

Fluroscopy

• Sniff test:

• Paradoxical upward motion on affected side.

• Normal excursion of 1-2 ribs:

• Breathe in, diaphragm down.

• Breathe out, diaphragm up.

• Paralyzed – paradoxical motion:

• Breathe in, diaphragm up.

• Breath out, diaphragm down.

Management

• Management of eventration of diaphragm secondary to phrenic

nerve injury must be individualized and depends on the

incapacity of the individual.

Medical

Surgical

Medical Management

• When paralysis is thought to be potentially reversible and the

patient is asymptomatic, it may be managed conservatively.

Malek & Abdulrahman Al-Bassam, http://faculty.ksu.edu.sa/5564/Publications/Forms/AllItems.aspx

• Diaphragmatic plication reserved for those patients who fail to

regain diaphragmatic function after 4 to 6 wks trial of

conservative management.

Right phrenic nerve injury as a complication of tracheoesophageal fistula repair.

Henderson PW, Spigland NA.

Division of Pediatric Surgery, Weill Cornell Medical College, New York, USA.

Pediatr Crit Care Med. 2010 Sep;11(5):e52-4.

Indication for surgery

• Failure of conservative treatment measures.

Recurrent chest infection.

Oxygen dependency.

Failure to thrive.

Lap/Open

• Open thoracotomy is the preferred approach.

• Minimally invasive diaphragm plication techniques have

emerged as equally effective and less morbid alternatives to

open plication.

Diaphragm plication for eventration or paralysis: a review of the literature.

Groth SS, Andrade RS.

Department of Surgery, University of Minnesota, USA.

Ann Thorac Surg. 2010 Jun;89(6):S2146-50.

Phrenic Nerve Reconstruction

• Tried in adult but no published report in neonate/pediatric.

Pacing of Diaphragm • Pacing of the diaphragm requires an intact phrenic nerve.

• Indications: Bilateral Paralysis, central alveolar

hypoventilation and high cervical spinal cord injury (Ondine's

curse); intractable hiccups and end-stage chronic obstructive

pulmonary disease.

• Phrenic nerve pacing was partially successful in 36%.

Phrenic nerve stimulation: the Australian experience.

Khong P, Lazzaro A, Mobbs R.

Department of Neurosurgery, Prince of Wales Hospital, Australia.

Conclusion

• 1st case of Right Diaphragmatic Paralysis after repair of EA &

TEF was published in 1982.

• Related complication was published in 2007.

• Possible mechanism for our case could be stretching/

?Aberrant course of Right Phrenic Nerve.

Things do happen