CDE is characterized by incomplete muscle regeneration.Subsequent abnormally elevated diaphragm muscles cause abnormal movement of the affected hemidiaphragm during respiration. It can occur locally or affect the entire diaphragm.In this study, there were 90 males (72%), 35 females (28%), 78 children (62.4%) on the right side, and 47 children (37.6%) on the left side. We observed that the incidence was higher in male children, and the incidence on the right side was higher than that on the left side.CDE can be associated with other developmental defects, and associated comorbidities include congenital hypoplastic lung, congenital heart disease, pectus excavatum,cleft palate, hypospadias, cryptorchidism, and congenital torticollis[4].77 patients in this group were combined with other malformations, congenital heart disease (19, 15.2%) and congenital hypoplastic lung (16, 12.8%) were the main relevant abnormalities in this study.The above facts is difficult to determine whether CDE is accompanied by other malformations or other malformations with this disease.Its numerous accompanying malformations suggest that the cause of the teratology is difficult to explain with a single etiology, and may be similar to the cause of other congenital malformations.
The main symptom of CDE is the compression of the lower lobe of the lungs due to the increase of intra-abdominal organs. After compression, the mediastinum can also cause the mediastinum to move on the health side and reduce the health side lung function accordingly. In unilateral CDE, the lung capacity and total lung capacity is reduced by 20% - 30%[5].Bilateral diaphragmatic eventration reduces the lung functions even more seriously, especially in the supine position[6].The treatment principle of CDE is to restore the normal anatomical position and tension of the diaphragm, the method is to strengthen the weak diaphragm,the goal is to maintain the normal volume of the lungs and the process of lung ventilation.Whether asymptomatic patients need surgical correction has been controversial for a long time.In this group of 17 children who did not undergo surgical treatment,11 patients received 1-6 years of follow-up and did not see decrease in diaphragm position. Therefore, we believe that symptomatic children need timely surgical treatment. Yazici M et al.'s study also considered symptomatic children, usually require surgery [7].Therefore, we believe that the indications for surgery are as follows:①relative to the normal position,the diaphragm is displaced upwards by 3 intercostals and above.②The diaphragm eventration caused obvious compression on the affected side of the lung, and obvious shortness of breath,asthma and other respiratory distress symptoms.③Frequent lung infections, hypoxemia, and even abnormal breathing exercise.④During the follow-up, the diaphragm continued to rise and the eventration was aggravated.
The traditional treatment method of CDE is diaphragmatic plication performed either by laparotomy or thoracotomy.However, with the development of minimally invasive technology, thoracoscopy is gradually applied in the treatment of CDE [8-10].We believe that children with right diaphragm eventration and intrapulmonary malformation need to be corrected through the thoracotomy approach as the first choice, because it is not affected by the intestinal canal, full exposure, easy to operate, can see the phrenic nerve and reduce postoperative intestinal paralysis.The laparotomy is suitable for children with left diaphragmatic eventration, inability to distinguish between diaphragmatic eventration and diaphragmatic hernia, and considering gastrointestinal malformation.Because the left chest is the heart, there is a high risk of thoracotomy. The use of subcostal incision is conducive to the repair of the hernia and the discovery of possible intestinal malformations.However, in the open group, we used thoracotomy for 4 children with left side diaphragmatic eventration, and achieved satisfactory clinical results. Therefore, we believe that the choice of approach is mainly based on the characteristics of the patient’s diaphragmatic disease and which approach the surgeon prefers Familiarity.The preoperative diagnosis of 9 children in this group was unknown, and diaphragmatic hernia and other gastrointestinal tract malformations were found during the operation, so the choice of preoperative approach was particularly important.We resect the weak diaphragm in the diaphragm via the thoracoabdominal route and sutured the diaphragm intermittently with non-absorbable sutures to make the cut diaphragm imbricate to strengthen the weak area of the diaphragm.The advantage of this technique is that it increases the tension of the diaphragm to evenly distribute the tension throughout the repair area.
With the development of minimally invasive technology, thoracoscopy is gradually used in the treatment of CDE.We compared the effect of open surgery and thoracoscopy in the treatment of CDE in children.The operation time, chest drainage time, postoperative mechanical ventilation time, postoperative hospital stay and postoperative CCU admission time in the thoracoscopy group were shorter than those in the open group, and the difference between the two groups was statistically significant (P<0.05). We consider the possible reasons as follows:①Thoracoscopic surgery adopts three hole method, which is less traumatic and less prone to bleeding. The recovery of children is faster after operation.②The technique of thoracoscopy is skilled, and the operator and assistant cooperate with each other.③We used barbed wire to sew continuously without knot, which greatly shortens the operation time and is obviously better than the open surgery.
In this group of 41 children without other thoracoabdominal malformations that need to be corrected, we used thoracoscopic diaphragm plication.Various techniques of diaphragmatic plication have also been employed. All techniques aim to reduce the abundant diaphragmatic surface and lower the diaphragmatic dome.Various suturing methods have been used, including interrupted horizontal mattress sutures, multiple parallel U sutures, figure of eight sutures, continuous running sutures, and endostaplers. Various non absorbable but also absorbable sutures have been used. We used barbed wire to suture the diaphragm from the outside to the inside in a continuous imbricated fashion to strengthen the diaphragm.Combined with the literature and our experience, compared with ordinary absorbable suture, continuous suture of the diaphragm with barbed wire has the following advantages:①Starting from the second stitch, it is not easy to slip after tightening the suture.One stitch is sewn to tighten one stitch, and no knot is needed during the suture process,which greatly shortens the operation time.②The diaphragms were sutured continuously by barbed wire to make the diaphragms stretch evenly from the center to all directions, and the tension distribution was uniform, so that the movement of the diaphragms was more coherent, and the diaphragms would not be ischemic due to over tight suturing, nor would the suture relax to cause recurrence.③The barbed wires suture is close, less bleeding, wireless knot, absorbable, wireless knot reaction and residual suture. There is a view that continuous suture may compromise the safety of the suture and the loosening of the knot may affect the folding of the entire diaphragm, but there is no evidence to support this view [11].A. Parlak, et al., and others adopted double-purse suture method to strengthen the diaphragm, achieving better clinical effect [12].The usual advantages of thoracoscopy, such as reduced postoperative pain, satisfactory appearance and rapid recovery, are also applicable to our surgery, and should be the preferred treatment for CDE.