Retrospective Comparison of Moderate and Severe Diaphragmatic Eventration in Children: Efficiency of Radiological Classification

Diaphragmatic eventration (DE) is defined as the elevation of the hemidiaphragm without defects of continuity. The generally accepted concept of its management includes conservative and surgical treatment options for asymptomatic and symptomatic cases respectively. Respiratory symptoms such as pneumonia and dyspnea constitute the common indications for surgical intervention; however, these symptoms do not always correlate with the severity of the pathology and hence the decision for surgery may sometimes be challenging. Thoracoscopic diaphragmatic plication (TDP) has been performed on children for decades and has been shown to be effective and safe previously (1-3). However, no classification or a surgical approach algorithm has been proposed for this anomaly to date. The purpose of this report is to identify the factors for the necessity and the efficiency of TDP in children with DE. Aim: Diaphragmatic eventration (DE) is a congenital or acquired elevation of the hemi-diaphragm. The indications for surgery may be challenging because clinical symptoms do not always correlate with radiological severity. We aim to identify the factors for the necessity and the efficiency of thoracoscopic diaphragmatic plication (TDP) in children with DE. Materials and Methods: A retrospective cross-sectional analysis of patients treated for DE (April 2006-August 2017) was performed. Demographics, type of DE, laterality, associated malformations and clinical symptoms were evaluated. Patients were grouped in two groups (moderate and severe) according to their diaphragmatic elevation levels on X-ray at admission. The severe DE group (SDE, n=14) had a DE of more than 2 vertebral bodies whereas the DE was 2 vertebral bodies or less in the moderate DE group (MDE, n=16). The groups were then compared regarding the necessity of TDP. The efficiency of TDP was analyzed by comparison of the outcome of patients who underwent TDP with that of conservative management. Results: There were 30 DE cases with a median age of 13.75 months. DE was acquired in 5 patients. The right side was the dominant side (21/30). The most common clinical symptoms were pneumonia (21) and respiratory distress (7) while 6 cases were asymptomatic. Acquired DE and respiratory distress were significantly higher in the SDE group. Four patients (25%) in the MDE group and 13 patients (92.9%) in the SDE group required TDP (p=0.000). The total number of cases of pneumonia was significantly higher in the conservatively treated patients in the follow-up (p=0.023). Conclusion: Two vertebral bodies may be an efficient cut-off level to discriminate between MDE and SDE. Absolute indications for TDP are SDE, acquired DE and respiratory distress at admission. Patients that are conservatively treated are more prone to pneumonia.