Intraoperative diaphragmatic plication during initial surgery with phrenic nerve resection

Diaphragmatic palsy can result in respiratory failure, potentially alleviated by diaphragmatic plication. Nevertheless, the benefits of preventive plication during phrenic nerve resection remain uncertain. This study evaluated whether preventive plication during primary surgery involving phrenic nerve resection alleviate paradoxical diaphragmatic movement and pulmonary function loss.

Among 24,527 surgeries for lung cancer or mediastinal tumors at 11 institutions, 142 involved phrenic nerve resections. Of these, 132 patients were retrospectively analyzed. Diaphragmatic displacement and pulmonary function were assessed pre- and postoperatively. Displacement was quantified by measuring thoracic height on pre- and postoperative chest X-rays (D, D'). Diaphragmatic displacement ratio was defined as: DDR = (D'-D)/D×100.

Seventy patients (53%) underwent preventive diaphragmatic plication during the primary surgery; 62 (47%) did not. Differences were significant overall and more pronounced in those undergoing left lobectomy or more extensive resection. In this subgroup, plication was associated with a smaller change in DDR (-30.1 ± 7.7% vs. -20.2 ± 7.7%, p = 0.002), and smaller declines in percent predicted forced vital capacity (-30.5 ± 8.0% vs. -16.8 ± 17.7%, p = 0.029) and forced expiratory volume in one second (-31.6 ± 11.0% vs. -19.0 ± 14.5%, p = 0.046).

In patients undergoing left lobectomy or more extensive resections involving phrenic nerve resection, intraoperative diaphragmatic plication may help preserve postoperative pulmonary function. However, due to the small sample size and limited generalizability, these findings should be interpreted cautiously.