Treating Intractable Hiccups by Clipping the Phrenic Nerve Using VATS

Revolutionary concept! My questions though are: 1. If both hemidiaphragms were rising on fluoroscopy during hiccups why would clipping one phrenic be sufficient and effective? Of course I understand why the authors would not have clipped both phrenics. 2. Why clip? How about use of long lasting local anesthetics? 3. And why going VAT and not a simple injection in the neck or even a crush of phrenic in front of the scalene muscle, like they used to perform for tuberculosis cavities collapse therapy. I guess if regeneration of axons is hoped for the closure the clip is applied to the diaphragm the faster the muscle re-stablishes its innervation. I look forward to seeing the work published as a series. Thank you for sharing!

Hello Dr. Antaki, I am pleased to receive your comments and I hope to provide you with the best possible answer. The evidence on this subject is poor, because although many patients (especially those with cancer or neurological problems) often have this condition, in many of them it goes unnoticed due to the severity of the primary disease. In our case, although the patient had mobile activity of both hemidiaphragms, the one of greater importance in fluoroscopy was the right one, for this reason it was decided to start with the clipping of this nerve, preserving the functionality of the contralateral one, as other authors have described and contrary to what we would think it would be ineffective, with the intervention of only one side was enough to control the problem, we will see in the follow-up if this changes in time. We are a thoracic surgery group, we do not have experience in performing nerve blocks and when we consulted with the interventional radiology team, they did not have it either in the case of the phrenic nerve, given the prolonged clinical picture and the impact on the patient's quality of life, we preferred to go for a slightly more invasive but from our point of view more effective option. Finally, the procedure could have been performed at the cervical level, but for us, a thoracoscopy with phrenic nerve clipping is a short procedure with easy recovery, where we have the opportunity to directly visualize the nerve and be sure that we can safely remove the temporary clipping done with the metal clip. I hope I have been able to answer your interesting questions adequately and when we have the opportunity to have some more cases, we will go for the publication of the series as you comment. Thank you for viewing our publication.

Thanks for your presentation. What is the possiblity of injury to the nerve,lung or perhaps the heart due to adhesions that may occur when retracting the clip? Is this the only case ?