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Diaphragmatic paralysis and eventration in infants
Insights
Phrenic nerve injury in infants is a serious complication, especially after surgery. Plication surgery for eventration can be life-saving, but high mortality persists in complex cases.
Area of Science:
- Pediatric Surgery
- Neonatology
- Thoracic Surgery
Background:
- Eventration of the diaphragm presents significant challenges in infants.
- Congenital, birth trauma, and iatrogenic phrenic nerve injuries contribute to infant eventration.
- Associated anomalies and prematurity are common in affected infants.
Observation:
- Operative phrenic nerve injury occurred in 12 infants under 3 months, frequently during Blalock-Taussig shunt procedures.
- Plication surgery was performed on 21 infants, most with respiratory distress or ventilator dependence.
- Four patients required repeat plication; successful extubation within one week was critical for survival.
Findings:
- Plication, via thoracic or abdominal approaches, is a safe procedure.
- Mortality was high (67%) among infants undergoing plication, with eventration complications contributing to death in many cases.
- Failure to extubate within a week post-plication indicated a poor prognosis.
Implications:
- The incidence of iatrogenic phrenic nerve injury in infants undergoing lateral thoracotomy needs greater awareness.
- Eventration management in infants with significant comorbidities carries a high mortality risk, even with surgical intervention.
- Early extubation post-plication is a key indicator of successful outcomes in infant diaphragmatic eventration.
Abstract:
Twenty-six children with eventration (congenital in 10, resulting from birth trauma in four, and resulting from operative phrenic nerve injury in 12) under 15 months of age were evaluated at a single institution in a 5 year period. There was a high incidence of significant associated anomalies and prematurity. All operative phrenic nerve injuries occurred in patients under 3 months of age, and they were most common in patients undergoing Blalock-Taussig shunt. Plication (12 thoracic, nine abdominal) was performed in 21 patients, 19 of whom had respiratory distress or were ventilator dependent. Repeat plication was required in four patients. All long-term survivors were extubated within 1 week of plication. Of 21 patients undergoing plication, 14 (67%) died. Death was attributed directly to complications of eventration in three patients and was a contributing factor in nine patients. We reached the following conclusions: The incidence of operative phrenic nerve injury in infants undergoing lateral thoracotomy, particularly for Blalock-Taussig shunt, is higher than generally appreciated; plication is a safe procedure as performed by either an abdominal or thoracic approach; failure to achieve extubation within a week of plication is an ominous prognostic sign; mortality in patients with eventration in the presence of major associated conditions may be high despite plication.