Right phrenic nerve injury as a complication of tracheoesophageal fistula repair.

OBJECTIVE

To report a rare case of right hemidiaphragmatic paralysis after tracheoesophageal fistula repair, and successful nonoperative management.

DESIGN

Case report and literature review.

SETTING

Pediatric intensive care unit in an academic, tertiary care medical center.

PATIENT: A neonate born to a G1P1Ab0 mother was diagnosed with tracheoesophageal fistula in the immediate postnatal period. He underwent gastrostomy and colostomy with mucous fistula on day 1 of life, and definitive repair of his esophageal atresia and tracheoesophageal fistula via a right posterolateral thoracotomy and a retropleural approach on day 6 of life. The patient failed several attempts at postoperative extubation, and a radiograph on day 11 of life revealed a persistently elevated right hemidiaphragm.

INTERVENTION: Nonoperative management with noninvasive positive-pressure ventilation.

MEASUREMENTS AND MAIN

RESULTS

Restoration of normal diaphragmatic motion.

CONCLUSIONS

This case highlights two important points to be considered when tracheoesophageal fistula repair is performed in infants. First, phrenic nerve injury should be included in the differential diagnosis of any patient who has difficulty being weaned from the ventilator in the postoperative period after tracheoesophageal fistula repair. Second, when paralysis of the hemidiaphragm does occur, patients should receive an initial trial of nonoperative management, with diaphragmatic plication reserved for those patients who fail to regain diaphragmatic function after 4 to 6 wks.