The Long-Term Results of Diaphragmatic Plication By Fatih Kizilcan, F. Cahit Tanyel, Akg0n His and Nebil BLiyfikpamuk~u Ankara, Turkey 9 Twelve patients who had undergone diaphragmatic plication with the diagnosis of congenital diaphragmatic eventration between 1975 to 1989 were evaluated for the long-term results of plication. Assessment of the long-term functions of the plicated diaphragms 1.5 to 11 years postop- eratively was achieved by fluoroscopic, ultrasonographic, and spirometric studies. The absence of paradoxical motion with normal localization of the diaphragms in all patients, and satisfactory motions of diaphragms in 9 patients were documented by fluoroscopy. Measurements of diaphrag- matic thicknesses showed that plicated diaphragms of all patients maintained their growths in proportion to the con- tralateral sides. Additionally, normal values of pulmonary function tests in five of six patients of suitable age for spi- rometry were obtained. All the clinical studies demonstrated that diaphragmatic plication did not interfere with further development of diaphragms, and late functional results of the plication were acceptable. This supports the choice of surgery in the treatment of diaphragmatic eventration. Copyright 9 1993 by W,B. Saunders Company INDEX WORDS: Eventration of the diaphragm. E ITHER CONGENITAL (nonparalytic) or ac- quired (paralytic) eventration of the diaphragm may require surgical treatment in children.1 Although there is a wide spectrum of signs and symptoms of diaphragmatic eventration, the patients usually present with dyspnea, recurrent pneumonia, chronic bronchitis, chest pain, cardiac arrhythmias, and func- tional disorders of the stomach. 2,3 Respiratory symp- toms requiring surgical treatment are caused by elevation of the diaphragm with resultant decreased pulmonary parenchymal volume. 2 Therefore, dia- phragmatic plication is performed in order to restore normal pulmonary parenchymal volume by replacing the diaphragm in its normal localization. A variety of plication techniques have been developed? However, the available literature does not provide detailed discussion of indications for operative treatment. Furthermore long-term functional results of diaphrag- matic plication which could affect the indications, are not well evaluated. For this reason, a clinical study has been performed to evaluate the long-term results of diaphragmatic plication in children. MATERIALS AND METHODS Twenty-five patients who had undergone diaphragmatic plica- tion during the 15-year period between 1975 and 1989 at Hacettepe University Children's Hospital were invited for assessment of the long-term results of diaphragmatic plication. Twelve patients were admitted for evaluation. Information which was obtained from the files, was summarized in Table 1. All the patients had congenital eventration. Seven patients were under 1 year of age, and the remaining five patients were between 1 and 4 year of age at the time of diaphragmatic plication. Fluoroscopic study had shown paradoxic motion in eight of the patients. The indications for diaphragmatic plication were respiratory symptoms such as tachy- pnea, dyspnea, recurrent pneumonia, chronic bronchitis in 10, and the presence of the elevated diaphragm alone in 2 patients. Seven of the patients had right and five of the patients had left diaphragmatic eventrations. While all five patients with left dia- phragmatic eventration and two patients with right diaphragmatic eventration were operated on through laparotomy incisions, five patients with right diaphragmatic eventration were operated through thoracotomy incisions. The operative technique was al- most identical in each patient regardless of the incision. The diaphragm was tented up or down with forceps depending on the approach, and 0 silk sutures were placed on a mesiolateral axis to create a taut hemidiaphragm. The redundant portion of the diaphragm was overlapped. All the patients had been discharged in good condition following uneventful postoperative courses. Clinical Investigations Patients admitted for evaluation were asked about respiratory, cardiac, and gastrointestinal symptoms. Routine physical examina- tion was performed. The position and motion of the diaphragm was examined by fluoroscopy. Diaphragmatic motion of the operated side was graded as satisfactory, moderately satisfactory, and unsatisfactory according to the contribution of various parts of the diaphragm to motion, and amplitude and direction of movement. Motion of equal amplitude with synchronous contraction in the same direction of the entire plicated hemidiaphragm compared with the contralateral normal hemidiaphragm was evaluated as satisfactory. Varying amplitudes of motion of the entire plicated hemidiaphragm, or parts of it, in the absence of paradoxical motion compared with the normal hemidiaphragm was graded as moder- ately satisfactory. The motion was graded as unsatisfactory when entire operated hemidiaphragm was immobile or showed para- doxic motion even at any parts of it. This gradation of motion gives an adequate estimation although it does not provide numerical precision. Diaphragmatic thicknesses were measured by ultrasonog- raphy at the paravertebral and topmost portion of each diaphragm. Comparisons between the findings of operated and normal sides were made by using Student's t test. Patients over 6 years of age were additionally examined by spirometry. From the Department of Pediatric Surgery, Hacettepe University Children's Hospital, Ankara, Turkey. Date accepted:August 15, 1991. Address reprint requests to F. Cahit Tanyel, MD, Haeettepe ~ocuk Cerrahisi, 06100, Sihhiye, Ankara, Turkey. Copyright 9 1993 by W.B. Saunders Company 0022-3468/93/2801-0009503.00/0 RESULTS The interval between the operation and control time ranged between 1.5 and 11 years (mean, 5.16 _+ 1.03) (Table 2). All patients were in good nutritional and developmental status. Eleven patients did not have any symptoms which might be related to 42 JournalofPediatric Surgery, Vo128, No 1 (January), 1993: pp 42-44