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J Thorac Cardiovasc Surg 2001;122:1235-1237
© 2001 The American Association for Thoracic Surgery
Brief Communications |
From the Clinic for Plastic and Reconstructive Surgerya and Surgery,b University of Innsbruck, Innsbruck, Austria.
Received for publication March 22, 2001. Accepted for publication April 14, 2001. Address for reprints: Thomas Schoeller, MD, Department of Plastic and Reconstructive Surgery, University of Innsbruck, Anichstraße 35, A-6020 Innsbruck, Austria (E-mail: Thomas.Schoeller{at}uibk.ac.at).
Unilateral phrenic nerve paralysis is a common lesion in cardiothoracic surgery that usually results in minimal morbidity but may be symptomatic in patients with borderline lung function.
1,2 In such symptomatic cases plication of the paralyzed hemidiaphragm has been previously suggested to alleviate dyspnea by reducing paradoxic movement of the paralyzed hemidiaphragm. 3 We believed, however, that optimal treatment of diaphragmatic dysfunction caused by tumor infiltration of the phrenic nerve might be immediate microsurgical phrenic nerve reconstruction after curative resection of the tumor.
To our knowledge, this strategy and its feasibility have not been described previously. We here report on our initial experience with this concept.
Clinical summary
A 75-year-old woman with a 2-month history of recurrent dyspnea during exercise was referred for diagnostic workup. A chest radiograph demonstrated paralysis of the left hemidiaphragm (Figure 1), most likely caused by a tumor in the anterior mediastinum with infiltration of the left phrenic nerve, as shown by computed tomographic scan (Figure 2).
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Because the patient's early signs of dyspnea were more likely caused by phrenic nerve paralysis than by direct tumor compression, immediate phrenic nerve reconstruction with a sural nerve graft from the right calf was considered. End-to-end nerve coaptation was performed with an epineural microsurgical 8-0 Ethilon interrupted suture (Ethicon, Inc, Somerville, NJ) at both graft ends. The nerve suture was secured with 0.5 mL of topically applied fibrin glue. The sural nerve graft was taken 3 cm longer than the original phrenic nerve defect to allow extracardiac excursions after partial pericardial resection (Figure 3). Because the patient was already weaned from cardiopulmonary bypass and the beating heart thus did not allow the use of a microscope, reconstruction was performed with magnifying loupes. Histologic and immunohistochemical examination revealed a malignant thymoma (World Health Organization type C) with clear resection margins. The postoperative course was uneventful.
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Discussion
The consequences of phrenic nerve injury are variable and depend to a large extent on the individual patient's condition, particularly pulmonary function and age. Pathologic conditions may range from an asymptomatic radiographic abnormality (the phrenic nerve can even be harvested with negligible morbidity as a source for brachial plexus reconstruction in otherwise healthy patients) 4 to severe pulmonary dysfunction and even mortality in patients with primarily reduced lung function. According to the literature, diaphragmatic plication appears to be the most effective option for patients severely compromised by phrenic nerve injury.
The case presented here demonstrates that irreversible symptomatic hemidiaphragmatic paralysis can be efficiently treated by direct reconstruction with a nerve graft, which is probably less invasive than plication of the diaphragm. This method, however, is recommended only for cases of short-lasting paralysis, because irreversible denervation of a muscle occurs within 1 year after onset of paralysis through motor endplate disintegration. We therefore suggest immediate microsurgical phrenic nerve repair whenever a phrenic nerve lesion is diagnosed either in the context of resection or operative complication under the following conditions: (1) An adequate time frame must be provided to allow complete reinnervation considering that a nerve regenerates at a velocity of 1 mm per day from the proximal nerve coaptation site to the motor endplate in the diaphragm; (2) thoracotomy is performed for other reasons; (3) the patient's general condition must allow an extra operating time of at least 30 minutes for reconstruction without increasing the risk.
This report proves—to our knowledge for the first time—the feasibility of immediate phrenic nerve reconstruction after resection of a malignant tumor. It further shows that the technique of microsurgical repair with sural nerve transfer can be applied safely in phrenic nerve injury with nearly negligible donor-site morbidity. 5 We believe that in selected cases a nerve graft is an excellent means of reanimating the diaphragm and thus completely restoring the patient's ventilation.
References
This article has been cited by other articles:
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  M. Ohta, N. Ikeda, H. Tanaka, A. Matsumura, H. Ohsumi, and K. Iuchi Satisfactory Results of Diaphragmatic Plication for Bilateral Phrenic Nerve Paralysis Ann. Thorac. Surg., September 1, 2007; 84(3): 1029 - 1031. [Abstract] [Full Text] [PDF]
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 M. Yoshitani, S. Fukuda, S.-i. Itoi, S. Morino, H. Tao, A. Nakada, Y. Inada, K. Endo, and T. Nakamura Experimental repair of phrenic nerve using a polyglycolic acid and collagen tube J. Thorac. Cardiovasc. Surg., March 1, 2007; 133(3): 726 - 732. [Abstract] [Full Text] [PDF]
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