title: Video-assisted thoracoscopic diaphragm plication using a running suture technique is durable and effective.
abstract: Surgeons have hesitated to adopt minimally invasive diaphragm plication techniques because of technical limitations rendering the procedure cumbersome or leading to early failure or reduced efficacy. We sought to demonstrate efficacy and durability of our thoracoscopic plication technique using a single running suture.
  
  
  
  We retrospectively reviewed patients who underwent our technique for diaphragm plication since 2008. We used a single, buttressed, double-layered, to-and-fro running suture with additional plicating horizontal mattress sutures as needed.
  
  
  
  Eighteen patients underwent thoracoscopic plication from 2008 to 2015. There were no operative mortalities and 2 unrelated late deaths. Median hospital stay was 3 days (range, 1-12). Atrial fibrillation occurred in 1 patient (5.5%), pneumonia occurred in 2 patients (11%), reintubation occurred in 1 patient (5.5%), and ileus occurred in 1 patient (5.5%). Of 14 patients with complete follow-up, median follow-up was 29.4 months (range, 3.4-84.7). Significant increases between preoperative and postoperative pulmonary function tests (% predicted values) were found for mean forced expiratory volume in 1 second (73.5% ± 3.5% to 88.8% ± 4.5%, P = .002) and mean forced vital capacity (70.6% ± 3.5% to 82.3% ± 3.5%, P = .002). Preoperative mean Baseline Dyspnea Index was 8.1 ± 0.7. Mean Transitional Dyspnea Index 6 months postoperatively was 7.1 ± 0.6 (moderate to major improvement). Transitional Dyspnea Index at last contact (median 29.4 months postoperatively) was 7.2 ± 0.6 (P = .38). Compared with previously published results, this is at least equivalent.
  
  
  
  Thoracoscopic diaphragm plication with a running suture is safe and achieves excellent early and long-term improvements. This addresses technical challenges of tying multiple interrupted sutures by video-assisted thoracoscopic surgery without any apparent compromise to efficacy or durability.
authors.affiliation: Division of Thoracic Surgery, Stanford University School of Medicine, Palo Alto, Calif. Electronic address: ddemosmd@outlook.com.
authors.forename: David S
authors.initials: DS
authors.lastname: Demos
authors.affiliation: Division of Thoracic Surgery, Stanford University School of Medicine, Palo Alto, Calif.
authors.forename: Mark F
authors.initials: MF
authors.lastname: Berry
authors.affiliation: Division of Thoracic Surgery, Stanford University School of Medicine, Palo Alto, Calif; Veterans Affair Palo Alto Health Care System, Palo Alto, Calif.
authors.forename: Leah M
authors.initials: LM
authors.lastname: Backhus
authors.affiliation: Division of Thoracic Surgery, Stanford University School of Medicine, Palo Alto, Calif; Veterans Affair Palo Alto Health Care System, Palo Alto, Calif.
authors.forename: Joseph B
authors.initials: JB
authors.lastname: Shrager
mesh_terms: D000368:Aged; D003964:Diaphragm / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D005260:Female; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000209:etiology; D020127:Recovery of Function; D012133:Respiratory Paralysis / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D012189:Retrospective Studies; D012307:Risk Factors; D013536:Suture Techniques; D020775:Thoracic Surgery, Video-Assisted / Q000009:adverse effects; D013997:Time Factors; D016896:Treatment Outcome
keywords: minimally invasive diaphragm plication running suture technique; thoracoscopy eventration; video-assisted thoracoscopic surgery