Thorac Cardiovasc Surg
DOI: 10.1055/s-0041-1735496
Original Thoracic

Results of the Diaphragmatic Plication Database: 10 Years' Experience

1   Department of Thoracic Surgery, University Witten Herdecke Faculty of Health, Witten, Germany
2   Lung Clinic Merheim/Thoracic Surgery, Kliniken der Stadt Köln gGmbH, Koln, Germany
Thomas Galetin
1   Department of Thoracic Surgery, University Witten Herdecke Faculty of Health, Witten, Germany
2   Lung Clinic Merheim/Thoracic Surgery, Kliniken der Stadt Köln gGmbH, Koln, Germany
Sarah Bettina Schwarz
3   Department of Pneumology, University Witten Herdecke Faculty of Health, Witten, Germany
4   Lungclinic Merheim/Pneumology, Kliniken der Stadt Köln gGmbH, Koeln, Germany
Tim Mathes
5   Institut für Forschung in der operativen Medizin (IFOM), Universität Witten/Herdecke Fakultät für Gesundheit, Witten, Nordrhein-Westfalen, Germany
Aris Koryllos
1   Department of Thoracic Surgery, University Witten Herdecke Faculty of Health, Witten, Germany
2   Lung Clinic Merheim/Thoracic Surgery, Kliniken der Stadt Köln gGmbH, Koln, Germany
Alberto Lopez-Pastorini
1   Department of Thoracic Surgery, University Witten Herdecke Faculty of Health, Witten, Germany
2   Lung Clinic Merheim/Thoracic Surgery, Kliniken der Stadt Köln gGmbH, Koln, Germany
Frank Beckers
6   Department of Thoracic Surgery, St Vinzenz Hospital, Koeln, Germany
Erich Stoelben
1   Department of Thoracic Surgery, University Witten Herdecke Faculty of Health, Witten, Germany
2   Lung Clinic Merheim/Thoracic Surgery, Kliniken der Stadt Köln gGmbH, Koln, Germany
› Author Affiliations


Background Unilateral diaphragmatic paralysis or paresis (UDP) in adults is an often overlooked disease which relevantly impairs the patient's lung function and quality of life. Particularly in idiopathic UDP, there is no evidence for conservative therapy and only little evidence for surgical therapy.

Methods The method involves retrospective single-center analysis of patients with UDP persistent for at least 1 year who were operated by diaphragmatic resection, plication, and augmentation with a polypropylene mesh. The patients were tested for lung and diaphragmatic function, six-minute walk test (6MWT), and blood gas analysis before, 3 and 12 months after surgery.

Results In total, 85 patients received surgery for UDP. The most frequent reasons for UDP were idiopathic (67%), iatrogenic (mainly cardiac and cervical spine surgery; 24%), and trauma (9%). The mean operation time was 84 ± 24 minutes, the length of hospital stay 8.4 ± 3.9 days, chest tubes were removed after 11.7 ± 4.1 days. Overall morbidity was 42%, mortality 0%. Forced expiratory volume in one second (FEV1) in supine position improved by 12.4% absolute, vital capacity by 11.8% absolute, and sniff nasal inspiratory pressure by 1.4 kPa 12 months after surgery (p <0.001 each). Total lung capacity increased by 6.8% absolute at 12 months (p = 0.001) The 6MWT distance improved by 45.9 m at 3 months and 50.9 m at 12 months (p = 0.001, each).

Conclusion Surgical therapy for UDP is highly effective in the long term. The superiority over conservative treatments needs to be evaluated prospectively with standardized physiotherapeutic protocols. FEV1 in supine position and 6MWT are easy to perform tests and represent statistically and patient-relevant outcomes.

Supplementary Material

Publication History

Received: 16 November 2020

Accepted: 07 June 2021

Article published online:
15 October 2021

© 2021. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

  • References

  • 1 Windisch W, Schönhofer B, Magnet FS, Stoelben E, Kabitz H-J. Diagnosis and treatment of diaphragmatic dysfunction. Pneumologie 2016; 70 (07) 454-461
  • 2 Riley EA. Idiopathic diaphragmatic paralysis; a report of eight cases. Am J Med 1962; 32: 404-416
  • 3 Freeman RK, Wozniak TC, Fitzgerald EB. Functional and physiologic results of video-assisted thoracoscopic diaphragm plication in adult patients with unilateral diaphragm paralysis. Ann Thorac Surg 2006; 81 (05) 1853-1857 , discussion 1857
  • 4 Graham DR, Kaplan D, Evans CC, Hind CR, Donnelly RJ. Diaphragmatic plication for unilateral diaphragmatic paralysis: a 10-year experience. Ann Thorac Surg 1990; 49 (02) 248-251 , discussion 252
  • 5 Ashkir ZM, Tsaknis G. A rash and a rare cause of unilateral diaphragmatic paralysis. BMJ Case Rep 2017; 2017: bcr2016218440
  • 6 Elefteriades J, Singh M, Tang P. et al. Unilateral diaphragm paralysis: etiology, impact, and natural history. J Cardiovasc Surg (Torino) 2008; 49 (02) 289-295
  • 7 Higgs SM, Hussain A, Jackson M, Donnelly RJ, Berrisford RG. Long term results of diaphragmatic plication for unilateral diaphragm paralysis. Eur J Cardiothorac Surg 2002; 21 (02) 294-297
  • 8 Qureshi A. Diaphragm paralysis. Semin Respir Crit Care Med 2009; 30 (03) 315-320
  • 9 Celik S, Celik M, Aydemir B, Tunckaya C, Okay T, Dogusoy I. Long-term results of diaphragmatic plication in adults with unilateral diaphragm paralysis. J Cardiothorac Surg 2010; 5: 111
  • 10 Ridyard JB, Stewart RM. Regional lung function in unilateral diaphragmatic paralysis. Thorax 1976; 31 (04) 438-442
  • 11 Han KY, Bang HJ. Exercise therapy for a patient with persistent dyspnea after combined traumatic diaphragmatic rupture and phrenic nerve injury. PM R 2015; 7 (02) 214-217
  • 12 Kotwicki T, Jozwiak M. Conservative management of neuromuscular scoliosis: personal experience and review of literature. Disabil Rehabil 2008; 30 (10) 792-798
  • 13 Versteegh MIM, Braun J, Voigt PG. et al. Diaphragm plication in adult patients with diaphragm paralysis leads to long-term improvement of pulmonary function and level of dyspnea. Eur J Cardiothorac Surg 2007; 32 (03) 449-456
  • 14 Groth SS, Rueth NM, Kast T. et al. Laparoscopic diaphragmatic plication for diaphragmatic paralysis and eventration: an objective evaluation of short-term and midterm results. J Thorac Cardiovasc Surg 2010; 139 (06) 1452-1456
  • 15 Ricoy J, Rodríguez-Núñez N, Álvarez-Dobaño JM, Toubes ME, Riveiro V, Valdés L. Diaphragmatic dysfunction. Pulmonology 2019; 25 (04) 223-235
  • 16 Krieger LM, Krieger AJ. The intercostal to phrenic nerve transfer: an effective means of reanimating the diaphragm in patients with high cervical spine injury. Plast Reconstr Surg 2000; 105 (04) 1255-1261
  • 17 Kaufman MR, Elkwood AI, Rose MI. et al. Reinnervation of the paralyzed diaphragm: application of nerve surgery techniques following unilateral phrenic nerve injury. Chest 2011; 140 (01) 191-197
  • 18 Kawashima S, Kohno T, Fujimori S. et al. Phrenic nerve reconstruction in complete video-assisted thoracic surgery. Interact Cardiovasc Thorac Surg 2015; 20 (01) 54-59
  • 19 World Medical Association. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA 2013; 310 (20) 2191-2194
  • 20 Meyer FJ, Borst MM, Buschmann H-C. et al. Exercise testing in respiratory medicine—DGP recommendations. Pneumologie 2018; 72 (10) 687-731
  • 21 Defosse J, Schieren M, Loop T. et al. The German Thorax Registry: implementation of an established tool of perioperative health care research. Zentralbl Chir 2017; 142 (03) 330-336
  • 22 R Core Team. R: A Language and Environment for Statistical Computing. Vienna: R Foundation for Statistical Computing; 2019
  • 23 Seely AJE, Ivanovic J, Threader J. et al. Systematic classification of morbidity and mortality after thoracic surgery. Ann Thorac Surg 2010; 90 (03) 936-942 , discussion 942
  • 24 Bohannon RW, Crouch R. Minimal clinically important difference for change in 6-minute walk test distance of adults with pathology: a systematic review. J Eval Clin Pract 2017; 23 (02) 377-381
  • 25 Caleffi-Pereira M, Pletsch-Assunção R, Cardenas LZ. et al. Unilateral diaphragm paralysis: a dysfunction restricted not just to one hemidiaphragm. BMC Pulm Med 2018; 18 (01) 126
  • 26 Steier J, Lunt A, Hart N, Polkey MI, Moxham J. Observational study of the effect of obesity on lung volumes. Thorax 2014; 69 (08) 752-759
  • 27 Bin Asaf B, Kodaganur Gopinath S, Kumar A, Puri HV, Pulle MV, Bishnoi S. Robotic diaphragmatic plication for eventration: a retrospective analysis of efficacy, safety, and feasibility. Asian J Endosc Surg 2021; 14 (01) 70-76
  • 28 Taberham RJ, Raza A, Alzetani A. et al. VATS plication of the diaphragm: a descriptive observational 10-year Southampton experience. Innovations (Phila) 2017; 12 (06) 398-405
  • 29 Gaissert HA, Trulock EP, Cooper JD, Sundaresan RS, Patterson GA. Comparison of early functional results after volume reduction or lung transplantation for chronic obstructive pulmonary disease. J Thorac Cardiovasc Surg 1996; 111 (02) 296-306 , discussion 306–307
  • 30 Kosse NJ, Windisch W, Koryllos A. et al. Development of the Diaphragmatic Paralysis Questionnaire: a simple tool for patient relevant outcome. Interact Cardiovasc Thorac Surg 2021; 32 (02) 244-249
  • 31 Kaufman MR, Elkwood AI, Brown D. et al. Long-term follow-up after phrenic nerve reconstruction for diaphragmatic paralysis: a review of 180 patients. J Reconstr Microsurg 2017; 33 (01) 63-69
  • 32 Kaufman MR, Bauer T, Onders RP. et al. Treatment for bilateral diaphragmatic dysfunction using phrenic nerve reconstruction and diaphragm pacemakers. Interact Cardiovasc Thorac Surg 2021; 32 (05) 753-760
  • 33 Kaufman MR, Elkwood AI, Colicchio AR. et al. Functional restoration of diaphragmatic paralysis: an evaluation of phrenic nerve reconstruction. Ann Thorac Surg 2014; 97 (01) 260-266