Diaphragmatic Eventration After COVID-19 Disease: Evaluation of Plication via VATS and Changes in Respiratory Functions
COVID-19 Hastalığı Sonrası Diyafram Eventrasyonu: VATS Aracılığıyla Plikasyonun Değerlendirilmesi Ve Solunum Fonksiyonlarındaki Değişiklikler
Onur Derdiyok1
1Şişli Hamidiye Etfal Training and Research Hospital, Department of Thoracic Surgery, Istanbul, Türkiye
ABSTRACT
Objective: Diaphragmatic eventration after COVID-19 infection is a rare condition that can seriously and adversely affect respiratory functions and requires surgical intervention. This research aimed to elucidate whether VATS diaphragm plication is an effective treatment option for improving pulmonary functions in patients with diaphragmatic eventration developed secondary to COVID-19.
Method: This prospective research enrolled 54 patients who underwent diaphragm plication via VATS procedure. demographic and anthropometric measurements such as weight, age, and BMI were recorded before and after surgery. All patients underwent preoperative and postoperative pulmonary function tests (PFTs). These tests included standard pulmonary function tests such as spirometry, peak expiratory flow (PEF), and forced expiratory volume in the first second (FEV1). An experienced respiratory physiotherapist performed the tests.
Results: There was a statistically significant difference between the patients' preoperative FEV1 measurement and postoperative FEV1 measurement (p <0.05). The FEV1 value of the patients increased in the postoperative period. Postoperative pulmonary function tests showed a significant improvement in all patients. FEV1 values of all patients increased postoperatively by an average of 23% (p <0.05). Similarly, significant improvements were observed in other pulmonary function parameters.
Conclusion: VATS diaphragm plication may be an effective treatment option in improving pulmonary functions and alleviating clinical symptoms in patients with diaphragmatic eventration developed after the COVID-19 infection.
Keywords: Diaphragm Plication, Diaphragm Eventration, Video-Assisted Thoracic Surgery (VATS), COVID-19, Pulmonary Functions.
ÖZET
Amaç: COVID-19 enfeksiyonundan sonra diyafram evantrasyonu, solunum fonksiyonlarını ciddi ve olumsuz etkileyebilen ve cerrahi müdahale gerektiren nadir bir durumdur. Bu araştırma, VATS diyafram plikasyonunun COVID-19'a ikincil olarak gelişen diyafram evantrasyonu olan hastalarda pulmoner fonksiyonları iyileştirmek için etkili bir tedavi seçeneği olup olmadığını açıklamayı amaçlamaktadır.
Yöntem: Bu prospektif araştırmaya, VATS prosedürü ile diyafram plikasyonu uygulanan 54 hasta dahil edildi. Kilo, yaş ve BMI gibi demografik ve antropometrik ölçümler ameliyattan önce ve sonra kaydedildi. Tüm hastalara ameliyat öncesi ve sonrası pulmoner fonksiyon testleri (PFT) uygulandı. Bu testler, spirometri, pik ekspiratuar akım (PEF) ve birinci saniyedeki zorlu ekspiratuar hacim (FEV1) gibi standart pulmoner fonksiyon testlerini içeriyordu. Testler deneyimli bir solunum fizyoterapisti tarafından gerçekleştirildi.
Bulgular: Hastaların ameliyat öncesi FEV1 ölçümü ile ameliyat sonrası FEV1 ölçümü arasında istatistiksel olarak anlamlı bir fark vardı (p<0,05). Hastaların FEV1 değerleri postoperatif dönemde arttı. Postoperatif pulmoner fonksiyon testleri tüm hastalarda anlamlı bir iyileşme gösterdi. Tüm hastaların FEV1 değerleri postoperatif ortalama %23 arttı (p<0,05). Benzer şekilde diğer pulmoner fonksiyon parametrelerinde de anlamlı iyileşmeler gözlendi.
Sonuç: VATS diyafram plikasyonu, COVID-19 enfeksiyonundan sonra gelişen diyafram evantrasyonu olan hastalarda pulmoner fonksiyonları iyileştirmede ve klinik semptomları hafifletmede etkili bir tedavi seçeneği olabilir.
Anahtar Kelimeler: Diyafram Plikasyonu, Diyafram Evantrasyonu, Video Yardımlı Torasik Cerrahi (VATS), COVID-19, Pulmoner Fonksiyonlar.
INTRODUCTION
The COVID-19 pandemic has caused severe health problems and severely and adversely impacted healthcare systems worldwide. In addition to respiratory infections, rarely-seen respiratory complications of the pandemic have also been reported. Among them, diaphragmatic eventration developed after the onset of COVID-19 disease conveys critical importance (1).
Diaphragmatic paralysis and eventration are rare. It is a clinical picture that can sometimes be encountered incidentally while being examined for another reason, is often on the left, and can be easily diagnosed. In the presence of unilateral diaphragmatic paralysis or eventration, adult patients may be minimally symptomatic or asymptomatic in terms of breathing. In contrast, surgical plication is indicated in adult patients only when symptoms are present (2). Plication is a surgical method used for paralysis and eventration of the diaphragm, and in all cases, diaphragm eventration is repaired surgically. Surgical plication prevents paradoxical movement during inspiration by tightening and stabilising the atrophic, thin, loose and elevated diaphragm (3). In patients with symptomatic unilateral diaphragmatic paralysis or eventration, plication prevents the abdominal organs from shifting to the ipsilateral thorax during inspiration. Thus, intrathoracic negative pressure is sufficient to inflate the contralateral lung. Atelectasis and intrapulmonary shunts improve. The patient gains better exercise performance and lung function (4).
Diaphragmatic eventration after COVID-19 infection is a rare condition that can seriously and adversely affect respiratory functions. The diaphragm acts as the primary muscle of respiration and ensures the regular functioning of respiratory functions. Therefore, any deformation or dysfunction of the diaphragm can lead to severe consequences, such as respiratory failure (5). During the COVID-19 pandemic, an increase in the incidence rates of diaphragmatic eventration in respiratory infections, especially pneumonia, was observed. In COVID-19 patients, the prolonged intensive care processes and the necessity of mechanical ventilation may trigger this complication by increasing the stress imposed on the diaphragm (6).
In this context, the diagnosis and treatment of diaphragmatic eventration developed after the onset of COVID-19 disease have become critical issues. Surgical intervention may be required in patients who do not respond to medical treatment and whose respiratory functions are severely affected. In this study, we investigated the efficacy of video-assisted thoracic surgery (VATS) diaphragm plication and postoperative changes in pulmonary functions in patients with diaphragmatic eventration after the onset of COVID-19 disease (7).
Within the scope of this research, we aimed to elucidate whether VATS diaphragm plication is an effective treatment option for improving pulmonary functions in patients with diaphragmatic eventration developed secondary to COVID-19. The evaluation and subsequent use of this technique might be an important step in improving patients' quality of life and long-term health outcomes.
METHOD
A total of 54 patients who underwent diaphragm plication via VATS procedure were enrolled in this prospective research. Seventeen patients were excluded because they had diaphragm plication after coronary artery bypass graft (CABG). Among the remaining 37 patients, 14 individuals were excluded as they did not have a confirmed diagnosis of COVID-19. Of the 23 patients with a history of COVID-19, nine patients had a history of trauma, and 3 patients were excluded from our study because previous radiological images were not available. The study was conducted on 11 male patients diagnosed with diaphragmatic eventration that developed during the COVID-19 epidemic.
All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008. Our institution has granted ethics committee approval on protocol number 4029, and informed consent has been obtained from all participants.
The patient's preoperative and postoperative clinical parameters were recorded. These parameters included dyspnea, chest pain, cough, amnestic disorders, myalgia, and dysesthesia. In addition, demographic and anthropometric measurements such as weight, age, and BMI were recorded before and after surgery. All patients underwent preoperative and postoperative pulmonary function tests (PFTs). These tests included standard pulmonary function tests such as spirometry, peak expiratory flow (PEF), and forced expiratory volume in the first second (FEV1). An experienced respiratory physiotherapist performed the tests.
Statistical Analysis
Patient data collected within the scope of the study were analysed with the IBM Statistical Package for the Social Sciences (SPSS) for Windows 26.0 (IBM Corp., Armonk, NY) package program. Frequency and percentage for categorical data and mean and standard deviation for continuous data were given as descriptive values. For comparisons between groups, the “Independent Sample T–test” was used for two groups, and the “Pearson Chi-Square Test” was used to compare categorical variables. The results were considered statistically significant when the p-value was less than 0.05.
RESULTS
Eleven male patients aged between 23 and 35, with a mean age of 28, were included in this prospective research. The mean weight was 80±13 kg, and the mean body mass index (BMI) was 27±4 kg/m2. All patients had been diagnosed with COVID-19 infection, as confirmed by RT–PCR results. The smoking rate was 54.5% (n=6). While diabetes, hypertension, and trauma were not observed in any of the patients, 90.9% (n=10) had shortness of breath and chest pain, 45.5% (n=5) had cough, and one patient had asthma/allergy. The preoperative clinical parameters of the patients were focused on symptoms such as dyspnea, chest pain, cough, amnestic disorders, myalgia and dysesthesia. Preoperative symptoms were tabulated, and the distribution of patients for each symptom was analysed in detail. Demographic and clinical characteristics of the patients are presented in (Table 1).
Table 1. Distribution of Demographic and Clinical Findings of Patients
|
Variables (n=11) |
n (%) |
Mean±SD |
Median (Min-Max) |
|
Gender |
|
|
|
|
Male |
11 (100) |
|
|
|
Age |
|
27.5±3.3 |
27 (23-35) |
|
BMI |
|
26±2.1 |
26 (23-31) |
|
Smoking |
6 (54.5) |
|
|
|
PA Ac X-ray COVID-19 Duration (months) |
|
2.4±0.9 |
2 (1-4) |
|
CT Findings (months) |
|
2.8±1.1 |
3 (1-5) |
|
Diabetes |
0 (0) |
|
|
|
Hypertension |
0 (0) |
|
|
|
Breath |
10 (90.9) |
|
|
|
Cough |
5 (45.5) |
|
|
|
Chest pain |
10 (90.9) |
|
|
|
Trauma |
0 (0) |
|
|
|
Asthma/Allergy |
1 (9.1) |
|
|
|
Surgery |
1 (9.1) |
|
|
|
Covid |
11 (100) |
|
|
|
Direction |
|
|
|
|
Right |
1 (9.1) |
|
|
|
Sun |
10 (90.9) |
|
|
SD: standard deviation; PA: postero-anterior.
The distribution of the patients' first-second forced expiratory volume (FEV1) values measured before and after the operation is denoted in Table 2. When the table was examined, it was determined that there was a statistically significant difference between the patients' preoperative FEV1 measurement and postoperative FEV1 measurement (p<0.05). The FEV1 value of the patients increased in the postoperative period.
Table 2. Evaluation of Patients' Pre- and Post-Operative FEV1 Measurements
|
Variable |
Before the operation |
After the operation |
p-value |
|
FEV1 |
|
|
<0.001 |
|
Mean±SD |
55.7±2 |
68.4±2.1 |
|
|
Median (Min-Max) |
55 (52-58) |
68 (65-72) |
SD: standard deviation.
Postoperative pulmonary function tests showed a significant improvement in all patients. FEV1 values of all patients increased postoperatively by an average of 23% (p<0.05). Similarly, significant improvements were observed in other pulmonary function parameters.
