Retrospective comparison of moderate and severe diaphragmatic eventration in children: Efficiency of radiological classification

INTRODUCTION: Diaphragmatic eventration (DE) is the congenital or acquired elevation of hemi-diaphragm. Indication for surgery may be paradoxical because clinical symptoms do not always correlate with radiological severity. We aimed to identify the risk factors for the necessity and the efficiency of thoracoscopic diaphragmatic plication (TDP) in children with DE.
METHODS: 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 diaphragmatic elevation levels on X-rays at admission. Severe group (SDE, n=14) had DE more than 2 vertebral bodies whereas DE was 2 vertebral bodies or less in Moderate group (MDE, n=16). 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) whereas 6 cases were asymptomatic. Acquired DE and respiratory distress were significantly higher in SDE group. Four patients (25%) in the MDE and 13 patients (92.9%) in the SDE groups required TDP (p=0.000). Total number of pneumonia was significantly higher in conservatively treated patients in the follow-up (p=0.023).
DISCUSSION AND CONCLUSION: Two vertebral bodies may be an efficient cut-off level to discriminate between MDE and SDE. Absolute indications for TDP are severe DE, acquired DE and respiratory distress at admission. Patients that are conservatively treated are more prone to pneumonia.