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  Table of Contents  
Year : 2014  |  Volume : 51  |  Issue : 6  |  Page : 45-48

A retrospective study of diaphragmatic motion, pulmonary function, and quality-of-life following video-assisted thoracoscopic lobectomy in patients with nonsmall cell lung cancer

Department of Thoracic Surgery, The Affiliated Hospital of Qingdao University, Qingdao 266003, China

Date of Web Publication24-Feb-2015

Correspondence Address:
Dr. W Jiao
Department of Thoracic Surgery, The Affiliated Hospital of Qingdao University, Qingdao 266003
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0019-509X.151991

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 » Abstract 

Background: Diaphragmatic dysfunction and its negative physiologic disadvantages are less commonly reported in patients with lung cancer video-assisted thoracoscopic lobectomy. The aim of this study was to investigate the outcomes of this complication on pulmonary function and quality-of-life in patients following video-assisted thoracoscopic lobectomy. Objectives: The aim of this study was to investigate potential benefits on pulmonary function and quality-of-life with normal diaphragmatic motion. Materials and Methods: A retrospective study was conducted in 64 patients with nonsmall cell lung cancer after video-assisted thoracoscopic lobectomy. The population were divided into groups 1 (with diaphragmatic paralysis, n = 32) and group 2 (without diaphragmatic paralysis, n = 32) according diaphragmatic motion after postoperatively 6 months. And then, we investigated the difference between the two groups on pulmonary function and quality-of-life. Results: (1) At 6 months after resection, the patients in group 1 had lost 25% of their preoperative forced expiratory volume in the 1 s (FEV 1 ) (P < 0.001), and the patients in group 2 had lost 15% of their preoperative FEV 1 (P < 0.001). And the other spirometric variables in group 1 were significantly worse than that of group 2 (P < 0.001). (2) The most frequently reported postoperative symptoms were fatigue, coughing, dyspnea, and thoracotomy pain in two groups. Of all the symptom scales, only the dyspnea scale showed a significant difference which subject has a higher proportion and scale compared to control. Conclusions: The present study indicates that unilateral diaphragmatic paralysis following video-assisted thoracoscopic lobectomy caused adverse effects on postoperative pulmonary function and quality-of-life.

Keywords: Lung cancer, lobectomy, pulmonary function, quality of life, thoracoscopic

How to cite this article:
Jiao W, Zhao Y, Wang M, Wang Z, Yang R, Wang Y, Luo Y, Shen Y. A retrospective study of diaphragmatic motion, pulmonary function, and quality-of-life following video-assisted thoracoscopic lobectomy in patients with nonsmall cell lung cancer. Indian J Cancer 2014;51, Suppl S2:45-8

How to cite this URL:
Jiao W, Zhao Y, Wang M, Wang Z, Yang R, Wang Y, Luo Y, Shen Y. A retrospective study of diaphragmatic motion, pulmonary function, and quality-of-life following video-assisted thoracoscopic lobectomy in patients with nonsmall cell lung cancer. Indian J Cancer [serial online] 2014 [cited 2022 Dec 3];51, Suppl S2:45-8. Available from:

 » Background Top

Diaphragmatic paralysis is a well-documented complication of cardiac operation, but less commonly reported after video-assisted thoracoscopic lobectomy in lung cancer patients. Lung resections lead to permanent loss of pulmonary function and have some impact on quality-of-life. [1],[2] If other intraoperative injury exist, for example, phrenic nerve injury, the outcomes will inevitably become more complicated.

The damage of unilateral phrenic nerve causes diaphragmatic paralysis and serious respiratory disorder due to diaphragmatic weakness, inspiratory pressure decreasing, paradoxical motion of the affected diaphragm and a similar shift of the mobile mediastinum. [3],[4],[5] Diaphragmatic paralysis following lung resection is a consequence of phrenic nerve injury or division because of dissection, contusion, stretch, intentional crush, and hyperthermic scorch. Unilateral diaphragmatic paralysis (UDP) following pulmonary resection is often unrecognized cause of dyspnea. The actual incidence of diaphragmatic dysfunction may be underestimated as many patients may have no noticeable and specific symptom.

Moreover, it is well-known that the common technique is crushing the phrenic nerve intentionally or injecting drugs by a controlled method to eliminate residual air space after lung resection. [6],[7] This will lead to a paralysis of the diaphragm, consecutively to an elevation and reduction of intrapleural space. Although reducing residual air space could theoretically be useful in preventing several complications such as prolonged air leak, bronchopleural fistula and empyema, persistent diaphragm paralysis may also cause other respiratory problem. Function of the unilateral hemidiaphragm has an adverse effect on postpneumonectomy lung function, [8],[9] however, there is very little information available about postoperative pulmonary function and quality-of-life of UDP following video-assisted thoracoscopic lobectomy. The purpose of this study was to evaluate long-term postoperative adverse outcomes in patients with UDP following video-assisted thoracoscopic pulmonary resection.

 » Materials and Methods Top

Study population

The records of 64 patients who underwent lobectomy for lung cancer from January 2011 to December 2011 were retrospectively reviewed. 32 cases had a confirmation of diaphragmatic paralysis by a fluoroscopy examination. All patients underwent lobectomy and mediastinal lymphadenectomy via., video-assisted thoracoscopic. At the time of surgery, there were no statistical differences between the group UDP and the group no-UDP in baseline clinical characteristics [Table 1]. No specific postoperative rehabilitation program was provided for all patients, but the smokers were encouraged to stop. The medical research committee approved the study protocol. Each patient gave informed consent to participate in the study.
Table 1: Baseline clinical characteristics for patients under video-assisted thoracoscopic lobectomy

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Pulmonary function tests

Spirometry (Jaeger, German) was performed in the sitting position in all patients at approximately 6 months after operation. The following parameters were assessed: Forced expiratory volume in 1 s (FEV 1 ), forced vital capacity (FVC), total lung capacity (TLC), diffusing capacity of the lung for carbon monoxide (DLCO), and an arterial blood sample (arterial oxygen tension [PaO 2 ], and arterial carbon dioxide tension [PaCO2]).

Assessment of quality-of-life

Quality-of-life was assessed using Lung Cancer Symptom Scale (LCSS). The LCSS is a site-specific quality-of-life instrument, primarily measuring the physical and functional dimensions for individuals with lung cancer. [10],[11] This rating scale consists of two instruments, one for patients and a counterpart optional one for health professionals as observers. The patient scale consists of nine items: Six measuring major symptoms for lung cancer (appetite loss, fatigue, cough, dyspnea, hemoptysis, pain), and three summary items related to total symptom distress, normal activity status, and overall quality-of-life. Visual analog scales with 100 mm lines are used to measure the intensity of patient's responses. Scores are from 0 (corresponding to the best rating) to 100 (representing the worst rating). The proportion of patients who have a specific symptom is defined as the percentage of patients who reported a symptom scale scoring >0. LCSS was administered to all patients within 6 months postoperatively.

Dyspnea evaluation

All patients reported the severity of dyspnea on performing daily activities before and after pulmonary resection with and without UDP. The severity of subjective dyspnea was assessed by the Medical Research Council dyspnea score. [12] The patient's condition is rated from 1 (unimpaired) to 5 (severely impaired). The higher the score is, the worse the severity of dyspnea is [Table 2].
Table 2: The MRC dyspnea scale

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Statistical analysis

Descriptive statistics is reported as median values and ranges. Statistical analysis was performed using t-test and Chi-square test. Statistics significance was taken at P < 0.05. All statistical analyses were performed using the SPSS statistical package (version 10.0, SPSS Inc., Chicago, IL, USA).

 » Results Top

  • All patients in two groups have no elevation of the diaphragm on chest X-ray preoperatively. They showed UDP by a sniff-test during fluoroscopy examination at 6 months after operation. In the two groups, the variables (FEV 1 , FVC, TLC, and DLCO) decreased significantly from preoperative to 6 months after the operation (P < 0.05), especially in the UDP group. In the two group, arterial blood gas analysis (PaO 2 and PaCO 2 ) remain stable from preoperative to 6 months after pulmonary resection (P > 0.05) [Table 3]
    Table 3: Postoperative pulmonary function in patients with UDP at 6 months after video-assisted thoracoscopic pulmonary resection

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  • Quality-of-life: All 32 patients successfully completed the questionnaires at 6 months after operation. Mean scores and standard deviation of the LCSS are shown in [Table 4]. Both UDP group and control group reported good quality-of-life. The most frequently reported symptoms were fatigue, coughing, dyspnea, and thoracotomy pain. Of all the symptom scales, only the dyspnea scale showed statistically significant which patients in UDP group have a higher proportion and scale compared to patients in the control group at 6 months postoperatively (P < 0.05).
    Table 4: Reported scores of the LCSS in patients with UDP at 6 months after video-assisted thoracoscopic pulmonary resection

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 » Discussions Top

Typical causes of diaphragm paralysis include neuromuscular diseases, phrenic nerve conduction abnormality, and phrenic nerve injury during surgical procedures. In our cases with lung cancer, the trauma to the phrenic nerve is due to division or injury during the dissection of adhesions. At the time of lobectomy, there are extensive adhesions secondary to underlying disease process or previous surgical procedures, which may complicate the dissection. Another common reason is intentional resection of macroscopically suspicious invaded phrenic nerve in order to get an optimal tumor-free margin despite our subjects having no elevation of diaphragm or other phenomenon to imply tumor invasion of phrenic nerve before operation.

It is well-known that phrenic nerve transection would result in permanent UDP and produce respiratory problems due to aforementioned mechanism. [3],[4],[5] Symptoms may include dyspnea, orthopnea, nocturnal arterial oxygen desaturation, and desaturation on exercise. Methods to evaluate diaphragmatic function include assessment of movement of hemidiaphragms by physical examination of chest wall and abdominal movement during inspiration, measurement of vital capacity differences from the upright and supine positions, fluoroscopy or ultrasound, transdiaphragmatic pressures by an esophageal balloon, and phrenic nerve stimulation and diaphragmatic electromyography.

In our study, the time-point at 6 months was chosen to evaluate the permanent functional loss after video-assisted thoracoscopic lobectomy because beyond 6 months to 2 years there is no significant further improvement in pulmonary function tests. Bolliger et al. and Nezu et al. showed that lobectomy leads to about 10% permanent loss in pulmonary function tests but no loss in exercise capacity. [1],[13] Several reports suggested that lobectomy patients suffered a significant reduction (15%) of functional reserve at 6 months postoperatively, with almost equal deterioration between lung function and exercise capacity. [14],[15] Maziak et al. reported that, at 6 months after lung transplantation, 6 patients with UDP had an FEV 1 of at least 60% and total lung capacities exceeding 78%. [16] Based on a comparison of our results, we know that in UDP group, all functional variables (FEV 1 , FVC, TLC, and DLCO) decreased significantly from preoperative to 6 months after the operation and significantly more so than in group of control. It reflects impaired ventilation due to UDP and could not recover fully normal till 6 months after video-assisted thoracoscopic lobectomy.

Functional recovery of diaphragm paralysis is difficult to predict and may occur years after the onset of the paralysis. Chuang demonstrated that permanent UDP will result in an approximately 8% decrease in pulmonary function tests in patients after phrenic nerve transfer and/or multiple intercostal nerve transfer for the repair of avulsed brachial plexus injury. [17] Gayan-Ramirez et al. showed that functional recovery occurred in 43% of the patients with diaphragm paralysis after 12 months and 52% after 24 months. [18]

In adults with sufficient respiratory reserve, UDP may not be symptomatic despite the ventilatory losses. Recovery of ipsilateral respiratory function might have been due to compensation of the lung and rib cage compliance and recruitment of extradiaphragmatic respiratory muscles to increase ventilation, but the extent of such compensation was unknown now. Gu et al. proposed that the phrenic nerve has spontaneous impulses, and breathing may stimulate the discharge of a nerve impulse. [19],[20] Hence, they suggested that functional rehabilitation, for example, shoulder extension followed by shrugging and deep breathing, is important and be emphasized after phrenic nerve division. For many patients, the risk of an impaired quality-of-life after surgery is an important consideration when deciding whether to proceed with surgery. Several reports suggest that the pulmonary resection was found to have a negative influence on the quality-of-life with subsequent partial recovery over time. [21],[22],[23]

Several factors may contribute to the fact that younger children are more vulnerable to respiratory complications after loss of diaphragm function: The relative weakness of the intercostal muscles, greater compliance of the chest wall, horizontal orientation of the rib cage, and increased mobility of the mediastinum. [24],[25] However, most adults with UDP seems can maintain good ventilation and gas exchange at rest and during exercise, probably through compensatory mechanisms such as an increase in motor output to the intercostal muscles and the normal hemidiaphragm. Our study showed that most patients with or without UDP did experience pain, fatigue, dyspnea, and coughing. But it was found with the majority suffering a mild degree in two groups at 6 months after operation. Of all the symptom scales, only the dyspnea scale showed statistical difference which patients in group UDP have a higher proportion compared to patients in control. According to our results, UDP has no other significant disadvantage on quality-of-life except for mild dyspnea on exertion.

 » Conclusion Top

In summary, the present study indicates that UDP following video-assisted thoracoscopic lobectomy caused adverse effects on postoperative pulmonary function and quality-of-life.

 » References Top

Bolliger CT, Jordan P, Solèr M, Stulz P, Tamm M, Wyser C, et al. Pulmonary function and exercise capacity after lung resection. Eur Respir J 1996;9:415-21.  Back to cited text no. 1
Handy JR Jr, Asaph JW, Skokan L, Reed CE, Koh S, Brooks G, et al. What happens to patients undergoing lung cancer surgery? Outcomes and quality of life before and after surgery. Chest 2002;122:21-30.  Back to cited text no. 2
Verin E, Marie JP, Tardif C, Denis P. Spontaneous recovery of diaphragmatic strength in unilateral diaphragmatic paralysis. Respir Med 2006;100:1944-51.  Back to cited text no. 3
Welvaart WN, Paul MA, van Hees HW, Stienen GJ, Niessen JW, de Man FS, et al. Diaphragm muscle fiber function and structure in humans with hemidiaphragm paralysis. Am J Physiol Lung Cell Mol Physiol 2011;301:L228-35.  Back to cited text no. 4
Hart N, Nickol AH, Cramer D, Ward SP, Lofaso F, Pride NB, et al. Effect of severe isolated unilateral and bilateral diaphragm weakness on exercise performance. Am J Respir Crit Care Med 2002;165:1265-70.  Back to cited text no. 5
Iverson LI, Mittal A, Dugan DJ, Samson PC. Injuries to the phrenic nerve resulting in diaphragmatic paralysis with special reference to stretch trauma. Am J Surg 1976;132:263-9.  Back to cited text no. 6
Carboni GL, Vogt A, Küster JR, Berg P, Wagnetz D, Schmid RA, et al. Reduction of airspace after lung resection through controlled paralysis of the diaphragm. Eur J Cardiothorac Surg 2008;33:272-5.  Back to cited text no. 7
Deslauriers J, Ugalde P, Miro S, Deslauriers DR, Ferland S, Bergeron S, et al. Long-term physiological consequences of pneumonectomy. Semin Thorac Cardiovasc Surg 2011;23:196-202.  Back to cited text no. 8
Ugalde P, Miro S, Provencher S, Quevillon M, Chau L, Deslauriers DR, et al. Ipsilateral diaphragmatic motion and lung function in long-term pneumonectomy patients. Ann Thorac Surg 2008;86:1745-51.  Back to cited text no. 9
Hollen PJ, Gralla RJ, Kris MG, Potanovich LM. Quality of life assessment in individuals with lung cancer: Testing the Lung Cancer Symptom Scale (LCSS). Eur J Cancer 1993;29A Suppl 1:S51-8.  Back to cited text no. 10
Hollen PJ, Gralla RJ, Kris MG, McCoy S, Donaldson GW, Moinpour CM. A comparison of visual analogue and numerical rating scale formats for the Lung Cancer Symptom Scale (LCSS): Does format affect patient ratings of symptoms and quality of life? Qual Life Res 2005;14:837-47.  Back to cited text no. 11
Bestall JC, Paul EA, Garrod R, Garnham R, Jones PW, Wedzicha JA. Usefulness of the Medical Research Council (MRC) dyspnoea scale as a measure of disability in patients with chronic obstructive pulmonary disease. Thora×1999;54:581-6.  Back to cited text no. 12
Nezu K, Kushibe K, Tojo T, Takahama M, Kitamura S. Recovery and limitation of exercise capacity after lung resection for lung cancer. Chest 1998;113:1511-6.  Back to cited text no. 13
Win T, Groves AM, Ritchie AJ, Wells FC, Cafferty F, Laroche CM. The effect of lung resection on pulmonary function and exercise capacity in lung cancer patients. Respir Care 2007;52:720-6.  Back to cited text no. 14
Nagamatsu Y, Iwasaki Y, Hayashida R, Kashihara M, Nishi T, Yoshiyama K, et al. Factors related to an early restoration of exercise capacity after major lung resection. Surg Today 2011;41:1228-33.  Back to cited text no. 15
Maziak DE, Maurer JR, Kesten S. Diaphragmatic paralysis: A complication of lung transplantation. Ann Thorac Surg 1996;61:170-3.  Back to cited text no. 16
Chuang ML, Chuang DC, Lin IF, Vintch JR, Ker JJ, Tsao TC. Ventilation and exercise performance after phrenic nerve and multiple intercostal nerve transfers for avulsed brachial plexus injury. Chest 2005;128:3434-9.  Back to cited text no. 17
Gayan-Ramirez G, Gosselin N, Troosters T, Bruyninckx F, Gosselink R, Decramer M. Functional recovery of diaphragm paralysis: A long-term follow-up study. Respir Med 2008;102:690-8.  Back to cited text no. 18
Gu YD, Ma MK. Use of the phrenic nerve for brachial plexus reconstruction. Clin Orthop Relat Res 1996;323:119-21.  Back to cited text no. 19
Xu WD, Gu YD, Lu JB, Yu C, Zhang CG, Xu JG. Pulmonary function after complete unilateral phrenic nerve transection. J Neurosurg 2005;103:464-7.  Back to cited text no. 20
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Pompili C, Brunelli A, Xiumé F, Refai M, Salati M, Sabbatini A. Predictors of postoperative decline in quality of life after major lung resections. Eur J Cardiothorac Surg 2011;39:732-7.  Back to cited text no. 22
Handy JR Jr, Asaph JW, Douville EC, Ott GY, Grunkemeier GL, Wu Y. Does video-assisted thoracoscopic lobectomy for lung cancer provide improved functional outcomes compared with open lobectomy? Eur J Cardiothorac Surg 2010;37:451-5.  Back to cited text no. 23
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  [Table 1], [Table 2], [Table 3], [Table 4]

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