Raising the bar, lowering the diaphragm: a new era in diaphragmatic plication.
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ABSTRACT:
SUBMITTER: Lampridis S
PROVIDER: S-EPMC10407503 | biostudies-literature | 2023 Jul
REPOSITORIES: biostudies-literature
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Raising the bar, lowering the diaphragm: a new era in diaphragmatic plication.
Journal of thoracic disease 20230620 7
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Project description:Background: Diaphragm eventration (DE) represents a frequent problem with consecutive major impacts on respiratory function and the quality of life of the patients. The role of diaphragmatic plication (DP) is still underestimated. The aim of the present study is to evaluate the efficacy of minimally-invasive surgical diaphragmatic plication for the management of unilateral diaphragmatic eventration, to the best of our knowledge, this is the largest series reported in the literature using a non-resectional technique. Methods: All patients with unilateral diaphragmatic paralysis admitted for diaphragmatic plication (DP) between January 2008 and December 2022 formed the cohort of this retrospective analysis. DP procedure was done to plicate the diaphragm without resection or replacement with synthetic materials. Patients were divided into two groups: Group I included patients who underwent DP through an open thoracotomy, and Group II included patients who underwent DP through video-assisted thoracoscopic surgery (VATS). Data from all patients were collected prospectively and subsequently analyzed retrospectively. Patients’ characteristics, lung function tests, radiological findings, type of surgical procedures, complications, and postoperative follow-up were compared. The primary outcome measure was the postoperative result (deeper position of the paralyzed diaphragm) and improvement of dyspnea. The secondary outcome was lung function values over a long-term follow-up. Results: The study included a total of 134 patients who underwent diaphragmatic plication during the study period. 94 (71.7%) were males, mean age of 64 (SD ± 14.0). Group I (thoracotomy group) consisted of 46 patients (35 male). Group II (VATS-group) consisted of 88 patients (69 male). The majority of patients demonstrated impaired lung functions (n = 126). The mean length of diaphragmatic displacement was 8 cm (SD ± 113.8 cm). The mean duration of the entire procedure, including placement of the epidural catheter (EDC), was longer in group I than in group II (p = 0.016). This was also observed for the mean length of the surgical procedure itself (p = 0.031). Most patients in group I had EDC (n = 38) (p = 0.001). Patients in group I required more medication for pain control (p = 0.022). A lower position of the diaphragm was achieved in all patients (p < 0.001). The length of hospital stay was 7 (SD ± 4.5) days in group I vs. 4.5 (SD ± 3.2) days in group II (p = 0.036). Minor complications occurred in 3% (n = 4) in group I vs. 2% (n = 3) in group II. No mortality was observed in any of the groups. Postoperative follow-up of patients at 6, 12, and 24 months showed a significant increase in forced vital capacity (FVC) up to 25% (SD ± 10%–35%) (p = 0.019), in forced expiratory volume in 1 s (FEV1) up to 20% (SD ± 12%–38%) in both groups (p = 0.026), also in the diffusion capacity of carbon monoxide (DLCO) up to 15% (SD ± 10%–20%) was noticed in both groups. Chronic pain symptoms were noted in 13% (n = 6) in group I vs. 2% (n = 2) in group II (p = 0.014). Except for one patient in group II, no recurrence of DE was observed. Conclusions: Diaphragm plication is an effective procedure to reduce debilitating dyspnea and improve lung function in patients suffering from diaphragm eventration. Minimally invasive diaphragmatic plication using VATS procedures is a safe and feasible procedure for the management of unilateral diaphragmatic paralysis. VATS-DP is superior to open procedure in terms of pain management and length of hospital stay, hence, accelerated recovery is more likely. Careful patient selection is crucial to achieving optimal outcomes. Prospective studies are needed to validate these results.
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| S-EPMC8575844 | biostudies-literature
Project description:Diaphragm paralysis can cause significant shortness of breath. This condition can be treated with diaphragm plication. We illustrate two cases where we used a knotless suture and total portal thoracoscopic technique to successfully plicate the diaphragm. A 70-year-old female with right-sided and a 44-year-old male with left-sided diaphragm paralysis. Both patients had a sniff test that showed paradoxical movement of the diaphragm. The port placements during the procedure were different due to the laterality but both patients had three 5-mm ports and one 12-mm port for the procedure. Plication was performed using the Endo Stitch knotless suture. Both patients went home on post-operative Day 1 without any complications. After 1 month, both patients had significant improvement in shortness of breath with resolution of the diaphragm elevation.
| S-EPMC5798015 | biostudies-literature
Project description:There are several established lipid-modifying agents, including statins, fibrates, niacin, and ezetimibe, that have been shown in randomized clinical outcome trials to reduce the risk of having an atherosclerotic cardiovascular event. However, in many people, the risk of having an event remains unacceptably high despite treatment with these established agents. This has stimulated the search for new therapies designed to reduce residual cardiovascular risk. New approaches that target atherogenic lipoproteins include: 1) inhibition of proprotein convertase subtilisin/kexin type 9 to increase removal of atherogenic lipoproteins from plasma; 2) inhibition of the synthesis of apolipoprotein (apo) B, the main protein component of atherogenic lipoproteins; 3) inhibition of microsomal triglyceride transfer protein to block the formation of atherogenic lipoproteins; 4) inhibition of adenosine triphosphate citrate lyase to inhibit the synthesis of cholesterol; 5) inhibition of the synthesis of lipoprotein(a), a factor known to cause atherosclerosis; 6) inhibition of apoC-III to reduce triglyceride-rich lipoproteins and to enhance high-density lipoprotein (HDL) functionality; and 7) inhibition of cholesteryl ester transfer protein, which not only reduces the concentration of atherogenic lipoproteins but also increases the level and function of the potentially antiatherogenic HDL fraction. Other new therapies that specifically target HDLs include infusions of reconstituted HDLs, HDL delipidation, and infusions of apoA-I mimetic peptides that mimic some of the functions of HDLs. This review describes the scientific basis and rationale for developing these new therapies and provides a brief summary of established therapies.
| S-EPMC4813424 | biostudies-literature
Project description:BackgroundPatients who are symptomatic from diaphragmatic dysfunction may benefit from diaphragmatic plication. We recently modified our plication approach from open thoracotomy to robotic transthoracic. We report our short-term outcomes.MethodsWe conducted a single-institution retrospective review of all patients who underwent transthoracic plications from 2018, when we began using the robotic approach, to 2022. The primary outcome was short-term recurrence of diaphragm elevation with symptoms noted before or during the first planned postoperative visit. We also compared proportions of short-term recurrences in patients that underwent plication with extracorporeal knot-tying device alone versus those that used intracorporeal instrument tying (alone or supplemental). Secondary outcomes included subjective postoperative improvement of dyspnea at follow-up visit and by postoperative patient questionnaire, chest tube duration, length of stay (LOS), 30-day readmission, operative time, estimated blood loss (EBL), intraoperative complications, and perioperative complications.ResultsForty-one patients underwent robotic-assisted transthoracic plication. Four patients experienced recurrent diaphragm elevation with symptoms before or during their first routine postoperative visit, occurring on POD 6, 10, 37, and 38. All four recurrences occurred in patients whose plications were performed with the extracorporeal knot-tying device without supplemental intracorporeal instrument tying. Proportion of recurrences in the group that used extracorporeal knot-tying device alone was significantly greater than the recurrences in the group that used intracorporeal instrument tying (alone or supplemental) (P=0.016). The majority (36/41) reported clinical improvement postoperatively and 85% of questionnaire respondents also agreed they would recommend the surgery to others with similar condition. The median LOS and of chest tube duration were 3 days and 2 days, respectively. There were two patients with 30-day readmissions. Three patients developed postoperative pleural effusion necessitating thoracenteses and 8 patients (20%) had postoperative complications. No mortalities were observed.ConclusionsWhile our study shows the overall acceptable safety and favorable outcomes in patients undergoing robotic-assisted transthoracic diaphragmatic plications, the incidence of short-term recurrences and its association with the use of extracorporeally knot-tying device alone in diaphragm plication warrant further investigation.
| S-EPMC10183526 | biostudies-literature
Project description:Hyperlipidemia is a well-established risk factor for developing cardiovascular disease (CVD). The recent American College of Cardiology and American Heart Association guidelines on lipid management emphasize treatment of individuals at increased risk for developing CVD events with 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) at doses proven to reduce CVD events. However, there are limited options for patients who are either intolerant to statin therapy, develop CVD despite being on maximally tolerated statin therapy, or have severe hypercholesterolemia. Recently the Food and Drug Administration approved two novel medications for low-density lipoprotein (LDL)-cholesterol reduction: Evolocumab and Alirocumab. These agents target and inactivate proprotein convertase subtilsin-kexin type 9 (PCSK9), a hepatic protease that attaches and internalizes LDL receptors into lysosomes hence promoting their destruction. By preventing LDL receptor destruction, LDL-C levels can be lowered 50%-60% above that achieved by statin therapy alone. This review explores PCSK-9 biology and the mechanisms available to alter it; clinical trials targeting PCSK9 activity, and the current state of clinically available inhibitors of PCSK9.
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| S-EPMC4630548 | biostudies-literature
Project description:BackgroundDiaphragm plication is an effective and safe procedure for patients with symptomatic, acquired diaphragm paralysis. Improvements in dyspnea scores, ventilation perfusions and exercise capacity has been reported. Unfortunately, no continuous measurements of lung functions at 3 to 5 years' follow-up have been recorded. This study was designed to assess the long-term effects and potential mechanism of diaphragm plication for non-malignant diaphragmatic paralysis patients, especially in relation to patients' subjective and objective improvement.MethodsThis study retrospectively reviewed the medical records of 36 adult patients with diaphragmatic paralysis treated with diaphragm plication by thoracotomy at the Tianjin Chest Hospital from 1992 to 2016. The adult patients were carefully selected based on etiology and a combination of clinical manifestation, pulmonary function testing, and chest imaging characteristics. Patients' preoperative pulmonary functions, forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC) in the supine and sitting positions were recorded. Survival information was obtained at follow-ups continuously conducted with 8 patients for 4 years after surgery.ResultsThe main symptoms were lifestyle-limiting dyspnea and orthopnea, and a few patients also had digestive symptoms. The mean body mass index of patients was 26.02±2.19. The etiology was trauma in 3 patients, and surgery in 5 patients. The operated diaphragm was found to be lower than the contralateral diaphragm in the first 3 months after surgery; however, from the 4th month, both sides of the diaphragm were basically at the same level. Additionally, 31 patients (86.11%) showed an improvement in subjective symptoms, especially digestive symptoms preoperatively. The averages of FVC and FEV1 increased by 26.8% and 24.3%, respectively, in patients 6 months after diaphragmatic plication, and from the 18th month, lung function declined gradually, returning to preoperative levels in the 4th year.ConclusionsDiaphragmatic plication can obviously improve the lung function and subjective symptoms of patients in the short term, but from the 18th month, lung function declined gradually to preoperative levels in the 4th year indicated that its long-term effect on lung function is poor. The major purpose of diaphragmatic plication is to balance the position of the heart and abdominal organs, and thus to improve patients' symptoms to a certain extent.
| S-EPMC9562536 | biostudies-literature
Project description:Lipid risk factors for cardiovascular disease depend in part on lifestyle, but optimum control of lipids often demands additional measures. Low-density lipoprotein (LDL) doubtless contributes causally to atherosclerosis. Recent human genetic findings have substantiated a number of novel targets for lipid-lowering therapy including apolipoprotein C-III, angiopoietin-like protein 3 and 4, apolipoprotein V, and ATP citrate lyase. These discoveries coupled with advances in biotechnology development afford new avenues for management of LDL and other aspects of lipid risk. Beyond LDL, new treatments targeting triglyceride-rich lipoproteins and lipoprotein(a) have become available and have entered clinical development. Biological and RNA-directed agents have joined traditional small-molecule approaches, which themselves have undergone considerable refinement. Innovative targeting strategies have increased efficacy of some of these novel interventions and markedly improved their tolerability. Gene-editing approaches have appeared on the horizon of lipid management. This article reviews this progress offering insight into novel biological and therapeutic discoveries, and places them into a practical patient care perspective.
| S-EPMC9448630 | biostudies-literature