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 Table of Contents     
ORIGINAL ARTICLE
Year : 2018  |  Volume : 14  |  Issue : 4  |  Page : 273-276
 

A practical technique in laparoscopic diaphragm pacing surgery: Retrospective analyse of 43 patients


1 Department of Thoracic Surgery, Medical Faculty, Dokuz Eylul University, Izmir 35340, Turkey
2 Department of Pulmonary Diseases, Medical Faculty, Dokuz Eylul University, Izmir 35340, Turkey

Date of Submission29-Aug-2017
Date of Acceptance07-Dec-2017
Date of Web Publication3-Sep-2018

Correspondence Address:
Dr. Volkan Karacam
Department of Thoracic Surgery, Medical Faculty, Dokuz Eylul University, Balcova, Izmir 35340
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmas.JMAS_165_17

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 ¤ Abstract 

Introduction: Diaphragm pacing stimulation (DPS) is a treatment method used in respiratory failure occurs in diseases such as high-level cervical spinal cord injury, central hypoventilation syndrome and amyotrophic lateral sclerosis.
Materials and Methods: A total of 43 patients, who had undergone DPS implantation surgery were evaluated retrospectively. The patients were divided into two groups according to the surgical technique (Group 1: classical surgical technic and Group 2: modified surgical technic) applied. The patients with previous abdominal surgery or percutaneous endoscopic gastrostomy were excluded from the study.
Results: The mean operation duration was significantly shorter in modified DPS implantation technic (105.1 min in Group 1 and 87.4 min in Group 2) (P < 0.001). Capnothorax is seen 11% of the cases in classical surgery procedure. In the modified group, capnothorax was not observed. Pneumothorax rate was found similar in both groups. Post-operative atelectasis was determined 16% of the cases in classical surgery procedure and also in the modified group atelectasis was not observed. The complications were higher in classical surgery procedure group but not differed statistically in this study. Total hospitalisation duration was significantly shorter in the modified surgical technique group compared to the other group (8.0 days in Group 1 and 6.0 days in Group 2) (P = 0.03).
Conclusion: With modification in DPS implantation surgery, shorter operation and hospitalisation durations, and less complications may be achieved.


Keywords: Amyotrophic lateral sclerosis (ALS), diaphragm pacing surgery, surgical technic


How to cite this article:
Karacam V, Sanli A, Tertemiz KC, Ulugun I. A practical technique in laparoscopic diaphragm pacing surgery: Retrospective analyse of 43 patients. J Min Access Surg 2018;14:273-6

How to cite this URL:
Karacam V, Sanli A, Tertemiz KC, Ulugun I. A practical technique in laparoscopic diaphragm pacing surgery: Retrospective analyse of 43 patients. J Min Access Surg [serial online] 2018 [cited 2018 Nov 20];14:273-6. Available from: http://www.journalofmas.com/text.asp?2018/14/4/273/222430



 ¤ Introduction Top


Diaphragm pacing stimulation (DPS) is a treatment method used in respiratory failure which develops in the course of diseases such as high-level cervical spinal cord injury, central hypoventilation syndrome and amyotrophic lateral sclerosis.[1],[2] For DPS to be effective, a non-injured phrenic nerve and a functional diaphragm are required.[1] Currently, the indications for the use of DPS are gradually increasing.[3]

By providing negative pressure ventilation with the diaphragm such as normal physiology, DPS may replace mechanical ventilation and reduce the need for mechanical ventilation or may postpone the requirement for mechanical ventilation.[2] In the long-term, it has been shown that it also reduces respiratory infections and health expenses, and improves the quality of life.[2]

In patients with poor performance status, morbidity and mortality increase as the duration of time to surgery prolongs. Accordingly, post-operative complications, intensive care necessity, duration of hospitalisation, and cost increase. The most frequent complication of intra-abdominal interventions is peritoneal adhesions which occur up to 93% following abdominal surgery.[4] These adhesions may cause serious complications and prolongs the duration of the surgery; increasing the costs, particularly in re-operations.[5],[6],[7],[8]

We observed that patients with intra-abdominal adhesions due to previous abdominal surgery had a prolonged operation duration and increased complications during DPS implantation procedure. Therefore, we developed a modification of the surgical technique that would reduce the contacting the peritoneal surfaces during DPS surgery and shorten the operation duration. In this study, we aimed to evaluate the effects of these modifications on the operation duration, and the early intra-operative and post-operative complications.


 ¤ Materials and Methods Top


The data of a total of 54 patients, who had undergone DPS implantation surgery between April 2012 and June 2014 in our clinic were evaluated retrospectively.

Patients

The demographic characteristics of the patients, indications for DPS procedure, the operation duration, intra-operative and post-operative complications, history of previous abdominal surgery and percutaneous endoscopic gastrostomy (PEG) status were evaluated. The operation duration was defined as the period from the beginning until the end of the surgery.

The patients were divided into two groups according to the surgical technique applied.

  • Group 1: Patient who had undergone classical surgical procedure
  • Group 2: Patient who had undergone modified surgical procedure.


Surgical procedure

The classical surgical procedure

As described before in detail by Onders et al.,[2],[3] the patients were placed in the supine position, with the arms open in both directions, and the head in 30 degrees elevated position. The laparoscopic procedure began with the entry of a 10 mm port and the camera from the supra-umbilical region. This was followed by placement of the right and left subcostal 5 mm ports. Then, the motor regions of the diaphragms that responded efficiently to the electrical stimulations were determined. After observing an efficient contraction of the diaphragm, the falciform ligament was longitudinally transected with a hook cautery. Finally, a 12 mm epigastric port was placed, through which the application tools would pass and two electrodes were implanted onto both diaphragms (NeuRx, Synapse Biomedical, Oberlin, Ohio). For easy entry of the application tool, the free tips of the electrodes were left in the abdomen. After all, electrodes were implanted, the tips were removed with the help of the Endo-Dissector, through the epigastric port. Then, the system was tested. The fifth electrode was left in place subcutaneously as the anode electrode and all were connected to the system. After all incisions were sutured, the system was re-tested.

Modified surgical procedure

The first modification – to incise the falciform ligament non-longitudinally, only a 3 cm window was opened so that the applicator could pass to the opposite diaphragm [Figure 1]. The second modification – 15 mm epigastric trocars were used instead of 12 mm trocars, for the entry. In this way, the free tip of each electrode implanted onto the diaphragm could be removed from the abdomen with the applicator [Figure 2].
Figure 1: The first modification: To incise the falciform ligament non-longitudinally, only a 3 cm window

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Figure 2: The second modification: 15 mm epigastric trocars were used instead of 12 mm trocars, for the entry

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Exclusion

Patients with previous abdominal surgery or PEG were excluded from the study.

Statistical analyses

Statistical analyses were performed using the SPSS (Statistical Package for Social Sciences) 22.0 software package (IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp.). Mean and standard deviation or median and minimum-maximum values were expressed according to the demographic data. Groups according to the surgical procedure were compared by using t-test for parametric data. Categorical data were evaluated by Chi-square or Fisher's exact test. The value of P < 0.05 was considered statistically significant.


 ¤ Results Top


A total of 54 patients who had undergone DPS implantation. The indications for DPS are presented in [Table 1]. Eleven patients with previous abdominal surgery or PEG were excluded from the study. A total of 43 patients were included in the study. Thirteen patients (30.2%) were female and 30 (69.8%) were male. The mean age was 50.3 ± 15.6. The mean duration of operation was 96.0 ± 14.5. There were 18 (41.9%) patients in Group 1 and 25 (58.1%) patients in Group 2. Age, gender, comorbidities and primary DPS indications were similar between two groups (P > 0.05). The mean operation duration was significantly shorter in Group 2 (105.1 ± 13.8 min in Group 1 and 87.4 ± 9.9 min in Group 2) (P < 0.001).
Table 1: Indications for diaphragm pacing stimulation

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Intraoperative complications occurred in 5 (11.6%) patients [Table 2], and complication rates were lower in Group 2, but it is not statistically significant (P = 0.382). There was no operative or early post-operative mortality. No serious complication was observed in Group 1. In Group 2, small bowel perforation occurred in a 7-year-old patient due to applicator needle insertion. This patient underwent open surgical repair on the 4th post-operative day. Intraoperative tube thoracostomy was performed on two patients (4.6%) who developed pneumothorax during implantation of the electrodes. Capnothorax was detected in two patients (4.6%) on the post-operative control chest X-ray and treated with the intrapleural catheter.
Table 2: Intraoperative complications according to the groups

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Post-operative complications developed in 5 (11.6%) patients and complication rates were lower in group 2, but it is not statistically significant (P = 0.066). In 3 patients who developed post-operative atelectasis, early bedside fibreoptic bronchoscopy was performed and the atelectasis was resolved. Dislocation of the anode electrode was corrected by re-insertion of the electrodes under local anaesthesia. Complications such as wound infection, deep vein thrombosis or pulmonary embolism did not occur in any patient. The distributions of the post-operative complications are demonstrated in [Table 3].
Table 3: Post-operative complications according to the groups

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The total hospitalisation period (clinic and Intensive Care Unit [ICU] stay) was found to be significantly shorter in Group 2, compared to Group 1. The comparison of the groups in terms of post-operative clinic, ICU and total hospital follow-up are displayed in [Table 4].
Table 4: Comparison of the groups in terms of clinic, Intensive Care Unit and the total follow up period

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 ¤ Discussion Top


The DPS implantation procedure duration may vary depending on the patient characteristics and the surgeon's experience who would perform the surgery. Onders et al. determined a mean procedure duration as 98 min.[9] In this study, we determined the mean operation duration as 105.1 ± 13.8 min in Group 1, to whom we used the 12 mm trocar. The reason for the prolonged operation duration may be related to the learning curve which is included in this group. In Group 2, we used the 15 mm trocar and did not incise the falciform ligament longitudinally. This modification of the technique shortened the mean operation duration to 87.4 ± 9.9 min. In this study, we demonstrated that minimally modification in DPS implantation procedure should shorten the duration of the surgery. Shorter implantation duration can provide lower intra-operative and post-operative complications in these cases.

According to the FDA records, the incidence of serious complications related to the pacing system or the procedure was reported as 3.4%.[10] The most frequent complication during DPS implantation is the capnothorax, resulting from CO2 influx from the abdomen into the pleural space, with an incidence of 19%.[11],[12] In another paper, Onders et al. did not observe diaphragm, lung, intraabdominal solid organ or bowel injuries, bleeding or any other complication that would require open surgery. Severe infection and capnothorax were observed in 1% and 30% of the patients, respectively.[2] In another study including five cases, capnothorax was observed in two cases.[12] In this study, capnothorax is seen 11% of the cases in classical surgery procedure. In the modified group, capnothorax was not observed. Pneumothorax rate was found similar in both groups. Post-operative atelectasis was determined 16% of the cases in classical surgery procedure and also in the modified group atelectasis was not observed. Post-operative atelectasis was regressed aspiration of the secretions with fibre optic bronchoscopy and pneumonia was not observed in this study. The complications were higher in classical surgery procedure group but not differed statistically in this study. This would be related to a limited number of the cases.



When we take the hospitalisation duration into consideration, the total hospitalisation duration was significantly shorter in the modified surgical technique group compared to the other group. The prolonged hospital stay would be related with the higher rates of intra-operative and post-operative respiratory complications.


 ¤ Conclusion Top


As a result, with modification in DPS implantation surgery, shorter operation and hospitalisation durations, and less complications may be achieved. In further studies with modified DPS implantation technic in the large case group can demonstrate the reduction of the complications statistically significant.

Ethics

The study was conducted according to good clinical practice and the Declaration of Helsinki. Protocol approval was obtained from an independent local ethics committee.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 ¤ References Top

1.
Ducko CT. Clinical advances in diaphragm pacing. Innovations (Phila) 2011;6:289-97.  Back to cited text no. 1
    
2.
Onders RP, Elmo M, Khansarinia S, Bowman B, Yee J, Road J, et al. Complete worldwide operative experience in laparoscopic diaphragm pacing: Results and differences in spinal cord injured patients and amyotrophic lateral sclerosis patients. Surg Endosc 2009;23:1433-40.  Back to cited text no. 2
    
3.
Onders RP, Elmo M, Kaplan C, Katirji B, Schilz R. Extended use of diaphragm pacing in patients with unilateral or bilateral diaphragm dysfunction: A new therapeutic option. Surgery 2014;156:776-84.  Back to cited text no. 3
    
4.
Brochhausen C, Schmitt VH, Planck CN, Rajab TK, Hollemann D, Tapprich C, et al. Current strategies and future perspectives for intraperitoneal adhesion prevention. J Gastrointest Surg 2012;16:1256-74.  Back to cited text no. 4
    
5.
Lower AM, Hawthorn RJ, Ellis H, O'Brien F, Buchan S, Crowe AM, et al. The impact of adhesions on hospital readmissions over ten years after 8849 open gynaecological operations: An assessment from the Surgical and Clinical Adhesions Research Study. BJOG 2000;107:855-62.  Back to cited text no. 5
    
6.
Van Der Krabben AA, Dijkstra FR, Nieuwenhuijzen M, Reijnen MM, Schaapveld M, Van Goor H, et al. Morbidity and mortality of inadvertent enterotomy during adhesiotomy. Br J Surg 2000;87:467-71.  Back to cited text no. 6
    
7.
Coleman MG, McLain AD, Moran BJ. Impact of previous surgery on time taken for incision and division of adhesions during laparotomy. Dis Colon Rectum 2000;43:1297-9.  Back to cited text no. 7
    
8.
Ray NF, Larsen JW Jr., Stillman RJ, Jacobs RJ. Economic impact of hospitalizations for lower abdominal adhesiolysis in the United States in 1988. Surg Gynecol Obstet 1993;176:271-6.  Back to cited text no. 8
    
9.
Onders RP, Elmo M, Kaplan C, Katirji B, Schilz R. Final analysis of the pilot trial of diaphragm pacing in amyotrophic lateral sclerosis with long-term follow-up: Diaphragm pacing positively affects diaphragm respiration. Am J Surg 2014;207:393-7.  Back to cited text no. 9
    
10.
Summary of Safety and Probable Benefit (SSPB). Available from: http://www.accessdata.fda.gov/cdrh_docs/pdf10/H100006b.pdf. [Last accessed on 2017 Aug 15].  Back to cited text no. 10
    
11.
Amirjani N, Kiernan MC, McKenzie DK, Butler JE, Gandevia SC. Is there a case for diaphragm pacing for amyotrophic lateral sclerosis patients? Amyotroph Lateral Scler 2012;13:521-7.  Back to cited text no. 11
    
12.
Tedde ML, Onders RP, Teixeira MJ, Lage SG, Ballester G, Brotto MW, et al. Electric ventilation: Indications for and technical aspects of diaphragm pacing stimulation surgical implantation. J Bras Pneumol 2012;38:566-72.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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