Dysfonctions et paralysies diaphragmatiques : de la physiopathologie au traitement chirurgical Diaphragmatic palsy and dysfunction: From physiology to surgery

Summary The clinical presentations of diaphragm dysfunctions vary according to etiologiesand unilateral or bilateral diseases. Elevation of the hemidiaphragm from peripheral origins,the most frequent situation, requires a surgical treatment only in case of major functionalimpact. Complete morphological andfunctional analyses of the neuromuscular chain res-piratory tests allow the best selection of patients to be operated. The surgical procedure maybe proposed only when the diaphragm dysfunction is permanent and irreversible. Diaphragmplication for eventration through a short lateral thoracotomy, or sometimes by videothoraco-scopy, is theonly procedure for retensioning hemidiaphragm. This leads to a decompressionof intrathoracic organs and a repositioning of abdominal organs without effect on the hemidia-phragm activecontraction.Morbidityandmortalityratesafterdiaphragmplicationareverylow,more due to the patient’s general condition than to surgery itself. Functional improvementsafter retensioning for most patients with excellent long-term results validate this procedurefor symptomatic patients. In case of bilateral diseases, very few bilateral diaphragm plicationshave been reported. Some patients with diaphragm paralyses from central origins become per-manently dependent on mechanical ventilation whereas their lungs, muscles and nerves areintact. In patients selected by rigorous neuromuscular tests, a phrenic pacing may be proposedto wean them from respirator. Two main indications have been validated: high-level tetraplegiaabove C3and congenital alveolar hypoventilation from central origin. After progressive recon-ditioning of the diaphragm muscles following phrenic pacing at thoracic level, more than 90% ofpatients can be weaned from respirator within a few weeks. This weaning improves the qualityof life with more physiological breathing, restored olfaction, better sleep and better speech.The positive impact of diaphragm stimulation has also been evaluated in other degenerativeneurological diseases, particularly the amyotrophic lateral sclerosis. For either central or per-ipheral diaphragm dysfunctions, a successful surgical treatment lies on a strict preoperativeselection of patients.© 2013 Elsevier Masson SAS. All rights reserved.