Case report
Unilateral diaphragmatic paralysis after laparoscopic cholecystectomy
Parálisis diafragmática unilateral tras colecistectomía laparoscópica
E. Díez Castillo
, S. Telletxea Benguria, K. Intxaurraga Fernández, B. Esnaola Iriarte
Corresponding author
Servicio de Anestesiología y Reanimación y Terapéutica del Dolor, Hospital de Galdakao-Usansolo, Galdakao, Vizcaya, Spain
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Díez Castillo, S. Telletxea Benguria, K. Intxaurraga Fernández, B. Esnaola Iriarte" "autores" => array:4 [ 0 => array:4 [ "nombre" => "E." "apellidos" => "Díez Castillo" "email" => array:1 [ 0 => "elisa.diezcastillo@osakidetza.eus" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "S." "apellidos" => "Telletxea Benguria" ] 2 => array:2 [ "nombre" => "K." "apellidos" => "Intxaurraga Fernández" ] 3 => array:2 [ "nombre" => "B." "apellidos" => "Esnaola Iriarte" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Anestesiología y Reanimación y Terapéutica del Dolor, Hospital de Galdakao-Usansolo, Galdakao, Vizcaya, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Parálisis diafragmática unilateral tras colecistectomía laparoscópica" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Laparoscopic cholecystectomy has become increasingly popular in the last decade. Because it is less invasive compared to conventional open surgery, it is less stressful for the patient and causes minimal postoperative pain, thus reducing hospital stay and associated costs.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> However, the large number of laparoscopic interventions performed have brought to light new complications that were rarely encountered in open surgery, such as spontaneous pneumothorax, biliary granulomas or diaphragmatic paralysis,<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">2,3</span></a> which was observed in our patient.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of an 82-year-old cognitively preserved man who led an active life, with no known allergies or toxic habits. His history was significant for hypertension under treatment with amlodipine and valsartan, untreated hyperuricaemia, and a hiatus hernia under treatment with omeprazole. He also underwent 6-monthly check-ups in the pulmonology department due to chronic obstructive pulmonary disease (COPD) under treatment with inhalers (corticosteroids and anticholinergics). Follow-up CT scans showed bronchiectasis in the middle and lower right lobes, with a certain atelectic component, in addition to right pachypleuritis for at least 8 years. Baseline dyspnoea was grade I/IV.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The patient presented at the emergency department for abdominal pain, and was rapidly diagnosed with acute gangrenous cholecystitis. The same day he underwent laparoscopic cholecystectomy with standard pneumoperitoneum pressure (12–14<span class="elsevierStyleHsp" style=""></span>mmHg). Surgery, which lasted 90<span class="elsevierStyleHsp" style=""></span>min, was performed under balanced general anaesthesia and was uneventful. After meeting Post-Anaesthesia Recovery Unit discharge criteria, the patient was transferred to the general surgery service for monitoring.</p><p id="par0020" class="elsevierStylePara elsevierViewall">In the first 12<span class="elsevierStyleHsp" style=""></span>h after surgery, he suddenly presented dyspnoea and distress associated with thoracoabdominal asynchrony, with oxygen saturation 85% measured by pulse oximetry (with 4<span class="elsevierStyleHsp" style=""></span>l/min via nasal prongs). Arterial blood gas was measured and supportive treatment was started with 100% supplemental oxygen via a bag valve mask. Observing no improvement, we decided to transfer the patient to the critical care unit (CCU) for respiratory support with non-invasive mechanical ventilation. The arterial blood gas analysis showed acute hypercapnic respiratory failure, and the chest radiograph showed volume loss in the right hemithorax, with no pneumothorax or clear consolidations.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Ventilatory support was started with BIPAP non-invasive mechanical ventilation (Vision 60), with failure of respiratory muscles in the first few hours, prompting us to perform orotracheal intubation. The next day, in view of the improvement in the patient's symptoms, blood gas values, and work of breathing, he was extubated, without incident, but presented sudden-onset respiratory failure a few hours later. We observed a reduction in respiratory movements in the right hemithorax, with minimal breath sounds in that lung. Given his progressive worsening, the patient was re-intubated. Right lung ultrasound performed immediately after intubation showed absence of contraction and muscle shortening in the right diaphragm during inspiration. This prompted us to perform electromyography, which showed normal motor unit action potentials on the left side, while the contralateral side was compatible with right phrenic paralysis. The neurological study was completed, ruling out motor neuron disease, myopathies or demyelinating diseases. We also performed contrast-enhanced chest CT scan, which showed obstructive atelectasis in the apical and posterior segments of the middle and right upper lobes, with mucoid impaction. Bronchoalveolar lavage with saline solution was performed through the endotracheal tube.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The patient remained in the CCU for 1 month, with several failed attempts at weaning that led to reintubation due to respiratory failure, and ultimately required percutaneous tracheostomy. He was finally weaned from mechanical ventilation by very slow, progressive decreases in ventilatory support through the tracheostomy, and intense respiratory physiotherapy. After several days without requiring ventilatory support, he was discharged to the pulmonology and neurology service for monitoring. The patient remained totally asymptomatic for 6 months, so no additional studies were required.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall">Diaphragmatic dysfunction is a rare cause of respiratory failure, and should be considered in patients with unexplained dyspnoea. It can manifest as chest muscle weakness with a slight decrease in the ability to generate pressure, or even complete loss of diaphragm function (paralysis), ranging from decreased physical performance to acute respiratory failure at rest in some cases. It can be seen in the context of systemic diseases that affect diaphragmatic contractility (myopathies, metabolopathies, malnutrition, viriasis) or in processes that interfere with innervation, such as mediastinal tumours, trauma, iatrogenic injury (central catheter placement, regional anaesthesia) or surgery, fundamentally cardiothoracic. During cardiothoracic surgery, nerves can be damaged by direct section, stretching, or by hypothermia fluid administered for cardioplegia, which causes demyelination of nerve fibres.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Nevertheless, some cases of phrenic neuropathy after abdominal surgery causing respiratory complications have been reported in recent years. The mechanism of injury is unknown. There is evidence to suggest that diaphragmatic deterioration after upper abdominal surgery can be due to reflex inhibition of the efferent activity of the phrenic nerve due to the irritation of splanchnic nerve afferent fibres, rather than due to contractile failure or surgery-induced abdominal wall injury.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">6,7</span></a> In patients undergoing laparoscopic abdominal surgery, the stretching that occurs during pneumoperitoneum appears be the cause of transient nerve neuroapraxia.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">3</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Unilateral diaphragmatic paresis/paralysis is often asymptomatic in healthy people, or manifests as a slight decrease in tolerance to physical exercise. However, patients with underlying pathology such as obesity, neuromuscular or cardiac diseases, or COPD, may present sudden or recurrent dyspnoea at rest, which is more typical of bilateral phrenic paralysis. Therefore, concomitant diseases should be ruled out in patients with unilateral phrenic paralysis and clinical signs of distress. In patients with COPD, pulmonary hyperinflation caused by air trapping affects diaphragmatic function by suboptimal diaphragmatic shortening and, to a lesser extent, mechanical deterioration. This help us understand how increased work of breathing in COPD patients can sometimes call for ventilatory support, as was the case in our patient.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The evolution of phrenic paralysis will mainly depend on the cause and underlying diseases, if any. For example, after infection or trauma, the paralysis will be self-limiting in up to 60% of cases, although there have been cases in which weakness has persisted for up to 3 years. Prognosis is worse in patients with phrenic paralysis secondary to spinal cord injuries or neurological diseases.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">4</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Diagnosis of phrenic paralysis can often be challenging, and there must be a high index of suspicion in patients with unexplained respiratory failure. There are several methods for evaluating diaphragm function. Chest radiograph, for example, can show elevation of the diaphragm and atelectasis of the basal segments, but it has low specificity (44%). The picture is usually clearer if the image is captured during inspiration and expiration, when very little volume change is observed. However, it is important to note that a normal radiograph will not rule out diaphragmatic dysfunction, while an elevated hemidiaphragm is not always indicative of nerve damage.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">8</span></a> In our patient, the radiograph showed a normal diaphragm but a large area of atelectasis in the right lung, larger than preoperative levels, with no pneumothorax or clear consolidations.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The CT scan, magnetic resonance imaging or fluoroscopy are excellent diagnostic techniques in this context, but require the transfer of critical patients, and are therefore of no use in certain situations.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Point of care ultrasound is an accessible, safe and effective test that gives a direct view of diaphragmatic function. A high frequency linear transducer is placed between the 8th to 10th intercostal space at the level of the anterior axillary to observe the presence of normal lung sliding. The diaphragm can be evaluated by moving the transducer caudally. Diaphragmatic thickness alone has little significance, since it can be altered chronically by age or weight. Instead, changes in diaphragm thickness during the respiratory cycle, or the diaphragmatic thickening fraction (which shows the difference between diaphragm thickness at inspiration and the end of expiration) should be evaluated, as this will show the diaphragm's pressure generating capacity.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">9,10</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Measuring transdiaphragmatic pressure using balloon probes located in the oesophagus and stomach is considered a standard test for the study of this pathology. However, it is only available in a few hospitals, and cannot detect unilateral paralysis due to the compensatory pressure exerted by the other hemidiaphragm. Spirometry can be very useful from a functional point of view. In healthy individuals, there is a 3%–5% change in vital capacity in the supine position. This increases to 10% in the case of unilateral diaphragmatic paralysis, and more than 30% in the case of bilateral involvement. Electromyography during quiet breathing or with phrenic nerve stimulation can also detect paresis or paralysis of the diaphragm, and permits a differential diagnosis between neuropathy and myopathy. However, artefacts are common in this test, due to poor placement of the electrodes and the activity of adjacent muscles.</p><p id="par0075" class="elsevierStylePara elsevierViewall">The treatment of this pathology is increasingly focussed on treating the underlying cause. Generally, ventilatory support will be indicated in patients with PCO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>45<span class="elsevierStyleHsp" style=""></span>mmHg in arterial blood, persistent O<span class="elsevierStyleInf">2</span> saturation ≤88%, or in patients in whom evolution is progressive, as in the case of neuromuscular diseases.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">4</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">In some patients with persistent symptoms, dependent on ventilatory assistance, diaphragmatic plication can increase vital capacity and total lung capacity by 20%, decreasing paradoxical breathing. The timing of this technique has not been clearly established, and it is rarely used in surgery-induced unilateral paralysis, due to its reversibility.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">More modern techniques, such as phrenic nerve stimulation, intramuscular diaphragmatic stimulation, or gene transfer in the case of myopathy, may be useful for patients with central causes presenting with bilateral paralysis.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0090" class="elsevierStylePara elsevierViewall">Diaphragmatic dysfunction is an underdiagnosed cause of dyspnoea, and should always be considered in the differential diagnosis of unexplained dyspnoea. Unilateral diaphragmatic paralysis secondary to laparoscopic cholecystectomy is a rare complication. However, in patients with certain pathologies, it can require ventilatory assistance, and can delay or lead to weaning failure, and ultimately cause significant delays in hospital discharge. The high index of suspicion, and the availability of imaging tests such as ultrasound, permit early diagnosis and start of therapeutic measures, thereby avoiding major complications.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Funding</span><p id="par0095" class="elsevierStylePara elsevierViewall">This study was not funded by grants from the public sector, trade sector or non-profit entities.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conflicts of interest</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1196205" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1114603" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1196204" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1114602" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Funding" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-11-29" "fechaAceptado" => "2019-01-18" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1114603" "palabras" => array:4 [ 0 => "Cholecystectomy" 1 => "Laparoscopy" 2 => "Diaphragm paralysis" 3 => "Phrenic nerve" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1114602" "palabras" => array:4 [ 0 => "Colecistectomía" 1 => "Laparoscopia" 2 => "Parálisis diafragma" 3 => "Nervio frénico" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Laparoscopic cholecystectomy is currently assumed to be the <span class="elsevierStyleItalic">standard gold</span> treatment of acute biliary tract pathology. Despite its many advantages compared to classical open surgery, it is not without complications.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The case is presented of an 82 year-old male patient who, after the diagnosis of cholecystitis gangrenous, was urgently intervened using laparoscopic cholecystectomy. During the first 24<span class="elsevierStyleHsp" style=""></span>h after the surgery, he had an episode of acute respiratory failure, for which he was admitted to the Resuscitation Unit. Studies performed later showed a paralysis of the right diaphragm that was probably related to the surgery.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">La colecistectomía laparoscópica supone hoy en día el tratamiento <span class="elsevierStyleItalic">gold estándar</span> de la patología aguda de la vía biliar. A pesar de las numerosas ventajas que presenta respecto a la cirugía abierta clásica, no está exenta de complicaciones.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Presentamos el caso de un paciente varón de 82 años que tras el diagnóstico de colecistitis gangrenosa es intervenido de urgencia de colecistectomía laparoscópica, presentando en las primeras 24<span class="elsevierStyleHsp" style=""></span>h del postoperatorio un episodio de insuficiencia respiratoria aguda, motivo por el cual ingresa en reanimación. Los estudios realizados <span class="elsevierStyleItalic">a posteriori</span> mostraron una parálisis del hemidiafragma derecho, probablemente relacionada con la cirugía.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Díez Castillo E, Telletxea Benguria S, Intxaurraga Fernández K, Esnaola Iriarte B. 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