Vertical Plication Research Articles

Vertical Gastric Plication: Is it Ready for Prime-Time?

The incidence of obesity has been increasing steadily, with approximately 10% of the world’s population meeting the criteria (1). The limited success of lifestyle and pharmaceutical interventions has resulted in an increased interest in bariatric surgery, as it is the only proven modality for achieving sustainable weight loss, and impacting survival in the clinically severe obese (BMI ≥ 40 or ≥ 35 with severe co-morbid disease) (2). In general, bariatric surgical intervention involves either a restrictive or mal-absorptive mechanism, to achieve weight loss. The two most renowned and successful procedures are; the Roux-en-Y gastric bypass and the biliopancreatic diversion with duodenal switch, and these use both routes. However, both of these procedures have potentially life threatening post-operative complications, mainly entailing leakage at anastomoses sites, thus making them less than ideal interventions. Gastric banding, sleeve gastrectomy and now recently gastric plication, are other bariatric surgeries that are essentially restrictive procedures, which are becoming more popular (3). Of the restrictive procedures, Laparoscopic Sleeve Gastrectomy (LSG) and Laparoscopic Total Gastric Vertical Plication (LTGVP) are relatively similar. Both involve decreasing the greater curvature of the stomach, and creating a gastric reservoir resembling a vertical tube (3). In general, LSG accomplishes this goal with staple lines and removal of a gastric section, while LTGVP achieves it with suture lines, without the need for a gastric section. The advantages of both procedures consist of; not introducing a foreign object into the body, preserving the stomach’s pylorus, and avoiding dumping syndrome (2). However, there are some advantages enjoyed only by plication. Since LTGVP does not involve the removal of gastric material, it has the ability to be reversible, which could make it a more ideal surgical procedure for some patients (4). Another reported benefit of LTGVP is that it decreases the risk of fistula formation at the gastroesophageal junction. It is important to recognize that these stated surgical advantages of LTGVP rely on the operator’s competency at minimally invasive techniques, in this case to perform manual laparoscopic suturing (4). This article highlights the promise that LTGVP has shown in achieving significant weight loss and reduction of comorbid conditions. Golpaie et al. have produced a well-organized study design that involved a multidisciplinary team. The drawbacks of this study were that; only * Corresponding author: Shahzeer Karmali, Center for the Advancement of Minimally Invasive Surgery, Department of Surgery, Division of General Surgery, University of Alberta, Room 405 CSC, 10240 Kingsway Ave., AB T5H 3V9, Edmonton, Canada, Tel: +1-7807356650, Fax: +1-7807356652, E-mail: shahzeer@ualberta.ca

Insulin Resistance and Lipid Profile in Morbidly Obese Patients After Laparoscopic Total Gastric Vertical Plication

In recent years sleeve (vertical) gastrectomy has been increasingly used as a stand-alone procedure, effecting significant weight reduction, resolution of obesity comorbidities and minor nutritional deficits at 5 years of follow-up (1, 2). Sleeve gastrectomy has also been shown to have comparable early changes in gastro-intestinal hormones as the more complicated Roux-en-Y gastric bypass surgery for morbidly obese type II diabetic subjects (3). The new procedure of laparoscopic total gastric vertical plication (LTGP), used by Golpaie et al. has similarities with sleeve gastrectomy in deriving its bariatric effect through reduction of stomach capacity (4). It is thus timely that LTGP is being investigated as an alternative to sleeve gastrectomy. Unsurprisingly, Golpaie et al. have found that significant weight loss and improvement in lipid profile and insulin resistance occurred within six weeks of LTPG in 15 patients (4). As pointed out by Talepour et al. technical details of LTGP i.e. anterior versus greater curvature plication and remnant stomach capacity needs clearer definition (5). These authors have also pointed out possible cost advantage, reversibility and lower leakage complications with LTPG. These need to be verified by a larger experience. Nevertheless, there is the potential disadvantage of the sequestrated plicated part of the stomach being out of reach for gastroscopic surveillance and hence delay in diagnosis of subsequent pathology. This would be a consideration, especially in East Asia where there is a high incidence of gastric cancer.

Laparoscopic Total Gastric Vertical Plication and Metabolic Changes

In recent years bariatric surgery has become very popular in concomitance with the recent epidemic of obesity and the large diffusion of the laparoscopic techniques. Besides, the gastric bypass that has been performed for more than 40 years and remains the gold standard of bariatric surgery while the other techniques, such as the gastric banding and more recently, the sleeve gastrectomy (SG) have been introduced to the technical armamentarium of the bariatric surgeon. The rationale behind the introduction of a new procedure should rely on the possibility of achieving the weight loss with the consequences of improvement in obesity-related comorbid conditions and quality of life while reducing the complexity of surgery and the inherent immediate and longterm complications (1). The SG has been rapidly accepted by the bariatric surgeons worldwide in consideration of the several advantages that it offers over the gastric bypass as it implies an easy surgical technique that does not involve any digestive anastomosis, eliminates the risk of internal hernia, preserves the pylorus, renders the whole digestive tract accessible to endoscopy, eliminates the risk of dumping syndrome and peptic ulcer, and allows normal absorption of nutrients, vitamins, minerals, and drugs with respect to the gastric bypass. On the other hand, the SG carries a risk of leak at the oesogastric junction that varies in the hands of experienced surgeons (> 500 procedures) between 0.6 and 3.9 % (mean 1.06%) (2). The evolution of the staple line leak in the SG may last several months and be very difficult to manage. The laparoscopic total vertical plication (LTVP) of the stomach that Golpaie et al. describes in the article published in the recent issue of the Minimally Invasive Surgical Sciences is a further simplification of the SG that should theoretically reduce the risk of high leak that is the true Achill’s heal of the SG (3). The rationale of the LTVP relies on the vertical plication of the stomach along the greater curvature to restrict the capacity of the stomach. Cost reduction associated with the use of the stapler to cut the stomach as Published by Kowsar Corp, 2012. cc 3.0.

Changes in Lipid Profile and Insulin Resistance in Morbidly Obese Patients Following Laparoscopic Total Gastric Vertical Plication

Implication for health policy/practice/research/medical education: Our findings shows that laparoscopic total gastric vertical plication results significant body weight reduction in morbidly obese subjects and it is associated with an improvement of the lipid and glucose metabolism, but it seems that we need further and longer time researches to clarify other metabolic changes after LTGVP. Our results may be useful for treatment of these high risk groups in practice.

Do Waistline and Umbilical Position Really Change after Abdominoplasty?

Sir: Do the horizontal and vertical dimensions of the trunk truly change after abdominoplasty? Previous studies have focused on the umbilical position during preoperative evaluation, but alterations in waistline size, trunk dimensions, and umbilical position following abdominoplasty have not been evaluated thoroughly.1,2 This study sought to investigate these changes following traditional full abdominoplasty. Baseline measurements were obtained preoperatively that included waist circumference at the level of the umbilicus and distances from the xiphoid to the umbilicus and from the umbilicus to the most superior aspect of the labia majora (Fig. 1). Eleven female patients with abdominal lipodystrophy ranging in age from 28 to 72 years were treated with a standard full abdominoplasty procedure over a 6-month period (June of 2005 to January of 2006) by a single surgeon (A.M.), according to previously published methods at the Manhattan Eye, Ear and Throat Hospital.3,4 Postoperative measurements at 1 week and 6 months were then recorded.Fig. 1.: Measurements obtained preoperatively and postoperatively. W, waist circumference at the level of the umbilicus; XU, distance from the xiphoid to the umbilicus; UV, distance from the umbilicus to the superior aspect of the labia majora. (Courtesy of Thanapong Waitayawinyu.)All 11 patients completed the study without complications. There were statistically significant net reductions in waist diameter (net mean decrease of 5.0 cm at 7 days and 7.9 cm at 6 months), xiphoid to umbilical distance (net mean decrease of 2.2 cm at 7 days and 2.8 cm at 6 months), and umbilicus to labia majora distance (net mean decrease of 4.4 cm at 7 days and 5.09 cm at 6 months) (Table 1).Table 1: Measurements of Waist Circumference, Xiphoid to Umbilicus, and Umbilicus to Superior Aspect of Labia MajoraVan Uchelen et al. evaluated the long-term durability of plication with ultrasonography. Six percent of the patients felt that their waist had gained in size, 60 percent felt it was unchanged, and 33 percent felt their waists had become slimmer.5 Our study is limited because of the small study group and does not take into account changes in diet or exercise or use fixed bony reference points. However, the data demonstrate consistent reductions in waist diameter (net mean decrease of 5.0 cm at 7 days and 7.9 cm at 6 months), xiphoid to umbilical distance (net mean decrease of 2.2 cm at 7 days and 2.8 cm at 6 months), and umbilicus to labia majora distance (net mean decrease of 4.4 cm at 7 days and 5.09 cm at 6 months). Comparison of preoperative and postoperative circumferential waist measurements revealed a significant decrease following plication that tightens the rectus fascia in the horizontal vector and persists because of the continual resolution of postoperative edema. This study also shows that the position of the umbilicus is displaced cephalically following abdominoplasty. Vertical plication and the superior pull of the tightened skin flap shortens the distance between the xiphoid and the umbilicus. Finally, our data display the decrease in distance between the umbilicus and the labia majora postoperatively. Removal of excess abdominal tissue below the umbilicus decreases the distance between the two points. The vertical pull of the infraumbilical rectus plication combines with the former to pull on the mons, which rejuvenates the aging vulva by unraveling and elevating the mons ptosis. This study demonstrates reductions in waist diameter and vertical trunk dimensions along with changes in umbilical position after abdominoplasty that persist at 6 months after surgery. DISCLOSURE The authors have no financial interests to declare in relation to the content of this article. Simon H. Chin, M.D. W. Jason Martin, M.D. Department of Plastic Surgery; Manhattan Eye, Ear and Throat Hospital; Institute of Plastic and Reconstructive Surgery; New York University School of Medicine Alan Matarasso, M.D. Department of Plastic Surgery; Albert Einstein College of Medicine, and Manhattan Eye, Ear and Throat Hospital; New York, N.Y.

Vertical Plication of Attenuated Orbital Septum

Aesthetic surgery for correction of the lower lid bulge can be classified into 3 groups of subtractive surgery, redraping, and repositioning. The authors present a new repositioning technique with vertical plication of the orbital septum for correction of lower lid bulge. This procedure was performed on 30 individuals during a 3-year period between March 2003 and March 2006. The length of follow-up varied from 3 months to 1 year, with an average of 6 months. There was no lower lid retraction or ectropion. Contour was smooth without any visible deformation or palpable suture line along the vertical plication. In the follow-up visits of minimum of 3 months, no recurrence of bulge was present and the scar was inconspicuous. Vertical plication of the orbital septum is an effective way to reposition the orbital fat inside the orbit. It anatomically corrects lower lid bulge, preserves the orbital fat pad and the vertical dimension of the lower lid, and provides a smooth contour in the periorbital area without the need to penetrate the orbital septum or manipulate the fat pad. Morbidity is minimal and transient, and the results are satisfactory. We suggest this technique for correction of lower lid bulge when there is excess lower lid skin and a subciliary approach is selected.

Neoumbilicoplasty Is a Useful Adjuvant Procedure in Abdominoplasty

Neoumbilicoplasties are indicated in congenital conditions associated with umbilical agenesis, umbilical loss due to inflammatory destruction, excision of skin cancer involving the umbilical stump and in surgical procedures for herniorrhaphy, as well as in the rare condition of umbilical endometriosis. Neoumbilicoplasty is an adjuvant procedure that may be necessary during abdominoplasty with wide myofascial plication, or repair of concomitant hernias of the abdominal wall. The present article justifies sacrificing the umbilicus followed by neoumbilicoplasty in patients with significant wide myofascial plication or concomitant hernias of the abdominal wall. Seventeen patients underwent a combination of abdominoplasty and wide (greater than 10 cm) vertical plication of the myofascial complex and required neoumbilicoplasty. The male to female ratio was 1:16; mean age was 44 years, mean weight 94.1 kg and mean height 160.2 cm. Characteristic body morphology included gross trunk obesity with a prominent anterior abdominal wall.The female patients were multiparous. Sacrificing the umbilici followed by neoumbilicoplasty was required in patients with umbilical hernias and patients who had divarication of the rectus abdominis muscles with short umbilical stumps. Nine patients had concomitant ventral hernias (52.94%) and eight patients had divarication of the rectus abdominis muscles with short umbilical stumps (47.05%). The mean perioperative myofascial plication distance was 15.41 cm and the gap closure required three to five rows of sutures. Neoumbilicoplasty is a useful adjuvant procedure during abdominoplasty with wide myofascial plication or repair of concomitant hernias of the abdominal wall.

Neoumbilicoplasty is a useful adjuvant procedure in abdominoplasty

Neoumbilicoplasties are indicated in congenital conditions associated with umbilical agenesis, umbilical loss due to inflammatory destruction, excision of skin cancer involving the umbilical stump and in surgical procedures for herniorrhaphy, as well as in the rare condition of umbilical endometriosis.Neoumbilicoplasty is an adjuvant procedure that may be necessary during abdominoplasty with wide myofascial plication, or repair of concomitant hernias of the abdominal wall. The present article justifies sacrificing the umbilicus followed by neoumbilicoplasty in patients with significant wide myofascial plication or concomitant hernias of the abdominal wall.Seventeen patients underwent a combination of abdominoplasty and wide (greater than 10 cm) vertical plication of the myofascial complex and required neoumbilicoplasty. The male to female ratio was 1:16; mean age was 44 years, mean weight 94.1 kg and mean height 160.2 cm. Characteristic body morphology included gross trunk obesity with a prominent anterior abdominal wall.The female patients were multiparous. Sacrificing the umbilici followed by neoumbilicoplasty was required in patients with umbilical hernias and patients who had divarication of the rectus abdominis muscles with short umbilical stumps.Nine patients had concomitant ventral hernias (52.94%) and eight patients had divarication of the rectus abdominis muscles with short umbilical stumps (47.05%). The mean perioperative myofascial plication distance was 15.41 cm and the gap closure required three to five rows of sutures.Neoumbilicoplasty is a useful adjuvant procedure during abdominoplasty with wide myofascial plication or repair of concomitant hernias of the abdominal wall.

Evaluation of a novel endoluminal stapling procedure to restrict the lower esophageal sphincter and reduce reflux

An effective, safe, and long-lasting endoluminal treatment for gastroesophageal reflux disease (GERD) would be an attractive prospect. We developed an endoluminal technique to restrict and tighten the lower esophageal sphincter (LES), by using a transoral endoscopic stapling device in a porcine model. Pre-interventional evaluation comprised endoscopy, manometry, and 48-hour pH measurement of the distal esophagus using the catheterless BRAVO pH capsule. By placing the endoluminal stapling device at the LES and firing a 2.5-cm staple line, a vertical plication was created. In five pilot pigs (phase 1), plications were placed in various locations at the LES. In another five pigs (phase 2), plications were placed uniformly at the mid level of the LES on the lesser curvature side. Measurements were repeated 2 weeks after the procedure. Necropsy and histological analysis were performed. Endoluminal stapling was successfully completed in all animals. In phase 2, the median procedure time was 15 minutes (range 10-55 minutes). LES pressure increased from 10.5 mmHg (+/- 2.5 mmHg) to 14.3 mmHg (+/- 3.8 mmHg) (P = 0.038). Median percentage of time with pH below 4 decreased from 6.6% (range 2.9%-48.8%) to 2.2% (range 0%-10.4%) (P = 0.043). Histology showed the staple line involving the muscular layer in all pigs. A gap was present in the central part of the staple line in three pigs resulting in a mucosa-muscular bridge of tissue. This bridge did not influence the results. This novel endoluminal technique is feasible and safe in a porcine model over 2 weeks. It is appealing due to its simplicity and ease of application. Further studies aimed at eliminating the gap in the staple line and investigating more animals over longer survival periods are needed.

Coronary blood supply of the inferior wall of the right ventricle in hearts with Ebstein malformation: relevance to vertical plication

Vertical plication of the atrialized chamber in Ebstein malformation has been subject to debate. A major argument against it is risk of coronary arterial injury; however, the coronary anatomy in the malformation remains incompletely investigated. We examined 17 autopsied hearts with the malformation. Special attention was paid to the coronary blood supply of the right ventricular inferior wall, focusing on the course of the posterior descending branch and its relationship with the interventricular septum. The right coronary artery was dominant in 11 cases (65%); the remaining 6 had left dominance. In 6 right-dominant hearts, the right coronary artery gave rise to the branch before reaching the crux of the heart. This early takeoff caused the entire branch to be deviated rightward. Another 2 right-dominant hearts showed rightward deviation of the branch course after an initial short segment along the septum. In contrast, in 2 left-dominant hearts, the left circumflex artery ran beyond the crux and then gave rise to the branch, again resulting in rightward deviation of the branch. These deviations allowed the branch to run on the thin walled part of the right ventricular inferior wall where endocardial stitches are placed during typical vertical plication. The posterior descending branch was frequently (10/17, 59%) deviated toward the right side relative to the interventricular septum in hearts with Ebstein malformation. Because of this and the thinness of the atrialized ventricular wall, care should be taken to the branch even with superficial endothelial stitches.

Pseudotumors after Primary Abdominal Lipectomy as a New Sequela in Patients with Abdominal Apron

Malnutrition and overweight is a common problem in modern societies. Primary abdominal lipectomy is a standard surgical tool in patients with these problems. However, unknown secondary problems result from recent advances in obesity surgery. Plication of the anterior musculoaponeurotic wall is a widely and commonly used operative technique during abdominoplasty. Many different plication techniques have been published. So far no common standard and long-term effectiveness is proven. In addition, there is no sufficient literature dealing with the postoperative risks of plication of the musculoaponeurotic wall. Four patients with development of pseudotumors were reviewed. All four patients received 12 months in advance a primary abdominal lipectomy including a vertical plication of the musculoaponeurotic wall. All four patients were females with mean age of 61 years and mean body mass index (BMI) of 37 kg/m(2). All four patients had developed a pseudotumor of the abdomen as a long-term complication more than 12 months after primary abdominal lipectomy including a vertical plication of the anterior rectus sheath. One should be aware of the potential long-term risk of secondary postoperative hematoma formation, with or without partial necrosis of the anterior rectus sheath after vertical plication of the anterior musculoaponeurotic wall. Viewed clinically and radiologically, such sequelas may appear as pseudotumor like masses and require immediate revision.

Long-term follow-up after repair of Ebstein's anomaly

We studied the long-term results of vertical plication repair of Ebstein's anomaly according to Carpentier. Between 1988 and 2007, 28 patients (mean age 28.8+/-15.7 years, range 4-58 years) underwent vertical plication repair of Ebstein's anomaly. At operation the anomaly was classified according to Carpentier. In three patients (11%) a cavopulmonary shunt was added at the repair on the indication of impaired right ventricular function. There was no operative mortality. Early mortality was 3.6% (one patient). Actuarial survival and actuarial freedom from reoperation at 19 years were 96% (95% CI; 96-97%) and 72% (95% CI; 53-92%), respectively. Six patients required reoperation, with a successful re-repair in three patients. Mean duration of follow-up was 10.7+/-6.5 years. One year postoperatively, tricuspid incompetence had decreased significantly (p<0.001), as had New York Heart Association (NYHA) functional class (p<0.001). In addition, exercise tolerance had increased (70+/-19% to 92+/-9% of predicted values, p<0.05). Both tricuspid function and NYHA functional class remained essentially unchanged at the end of follow-up, indicating durable haemodynamic and functional results. This study demonstrates favourable long-term results following vertical plication repair of Ebstein's anomaly with low mortality, acceptable morbidity and good haemodynamic and functional results.

Laparoscopic Total Gastric Vertical Plication in Morbid Obesity

The aim of this study was to introduce a new technique, total gastric vertical plication (TGVP), as a restrictive operation. It has the same result of weight loss as others with minimal risk of complication and very low cost, especially in developing countries. This technique was used by one surgeon in private hospitals during 3 years in Tehran, Iran. Patients were placed in the supine position with a 30-degree reverse Trendelenburg position. Trocars were inserted based on an ergonomic assessment (three 5 mm and one 10 mm). After the release of the greater curvature, continuous sutures were used with 00 nylon from the fondus to 3 cm of the pylorus. A vertical plication was performed in one or two layers. Distance between the stitch and lesser curvature was 2 cm in the anterior and posterior and between each stitch, all of them getting extra mucosal (far away from acid effect) owing to mild tension on the sutures that cut mucosa and put on a submucosa layer. TGVP was performed in 100 cases (mean age, 32; standard error of the mean = 2.1); mostly female (F/M = 76/24) and with average body mass index of 47 (36-58). The mean weight loss in our patients was 21.4% of excessive weight loss (EWL) 1 month after the operation, 54% after 6 months (72 cases), 61% after 12 months (56 cases), 60% after 24 months (50 cases), and 57% after 36 months (11 cases). The average time of follow-up was 18 months. The mean time of operation was 98 (70-152) minutes and all of the patients were discharged from the hospital after an average of 1.3 days (range, 1-4). The main postoperative complications were permanent vomiting, intracapsular liver hematoma, hypocalcemia at early postoperative period, hepatitis, leakage at the suture line, and acute gastric perforation. The volume of the stomach in this condition was 100 cc, but just one half of it was effective. If more than 50 cc was used, a painful condition would occur. The percentage of EWL in this technique is comparable to other restrictive methods, but EWL appears more rapidly. Early postoperative complications of this method are minimal, without any important late complications. This technique needs more expertise and is more time consuming. A long-term follow-up is advised.

Triple Plication in Miniabdominoplasty

A novel method for plication of the abdominal fascia in miniabdominoplasty addresses abdominal laxity and improves the waistline. The design comprises a vertical plication of the rectus fascia from xiphoid to pubis and fusiform plication of the oblique fascias with limited undermining and scars, all in the setting of a miniabdominoplasty. The procedure was performed for 10 women undergoing surgery between January and December 2004. The technique resulted in improved tension of the entire abdomen, a decreased perimeter of the waist, and improved uniformity in the contour of the anterior and lateral view, avoiding the epigastric bulking generated when infraumbilical vertical plication is used alone. There were few minor and no major complications. At the follow-up assessment 6 months to 2 years after surgery, there was no loss of the improved muscle-aponeurotic tension or abdominal contour. Triple plication of the fascia provides a good method for improving both the waistline and abdominal laxity in the setting of a miniabdominoplasty.

P69: The report of laparoscopic total gastric vertical plication in morbid obesity in iran

P69: The report of laparoscopic total gastric vertical plication in morbid obesity in iran

Lower Abdominal Bulge After Deep Inferior Epigastric Perforator Flap (DIEP) Breast Reconstruction

The etiology of lower abdominal bulge following breast reconstruction with the DIEP flap is uncertain. Most studies report an incidence that ranges from 0.7% to 5%. The purpose of this study was to review a set of factors that may predispose to a lower abdominal bulge. This was a retrospective review of 123 women who had breast reconstruction with the DIEP flap over a 4-year period. The reconstruction was unilateral in 93 women and bilateral in 30 women, totaling 153 flaps. Etiologic factors that were evaluated included patient age, diabetes mellitus, tobacco use, previous abdominal operations, unilateral or bilateral reconstruction, previous childbirth, aponeurotic plication to improve the natural abdominal contour, and use of Marlex mesh. A lower abdominal bulge occurred in 5 of the 123 women (4%), 2 following 30 bilateral reconstructions (6.6%) and 3 following 93 unilateral reconstructions (3.2%). Analysis of the factors for all women demonstrated diabetes mellitus in 1 (0.8%), tobacco use in 9 (7.3%), a prior abdominal operation in 55 (44.7%), previous childbirth in 95 (77%), aponeurotic plication in 49 (40%), and use of Marlex mesh in 4 (3.3%). Statistical analysis did not show any significant association between the explanatory factors and the occurrence of a lower abdominal bulge, except for a weak trend in women who had not been pregnant (P = 0.08). The results of this study demonstrate that the occurrence of a lower abdominal bulge following the DIEP flap is a random event that can occur in anyone. Pregnancy may confer a preventative effect as the collagen fibers strengthen to overcome the stretching forces. Techniques for prevention and treatment include intraoperative assessment of the anterior rectus sheath, use of an adjuvant material for reinforcement if unstable, and vertical plication for bulge repair.

Early and medium-term results for repair of ebstein anomaly

ObjectivesWe evaluated the early and medium-term single-center results for primary repair of Ebstein anomaly in both adults and children. MethodsThe records were reviewed of patients undergoing repair of Ebstein anomaly at the Children's Hospital of New York from September 1990 to September 2002. Functional, demographic, and echocardiographic parameters were studied both preoperatively and postoperatively, along with functional status and adverse events. The repair technique involved vertical plication of the atrialized ventricle and valve leaflet reimplantation after clockwise rotation. ResultsA total of 25 patients (19 children and 6 adults) underwent repair. The average age was 14.2 ± 15.9 years, and the average follow-up was 4.1 ± 3.4 years. Three patients required reoperation for right ventricular overload (1 child) and progressive, severe tricuspid regurgitation (2 adults); both adults received tricuspid valve replacements, one at 4 years and the other at 8 years post-repair. Three patients had radiofrequency ablation procedures performed intraoperatively. Ten patients (40%) had moderate-to-severe tricuspid regurgitation perioperatively. However, 18 children (95%) and 5 adults (83%) demonstrated significant improvement in exercise capacity late postoperatively. Two children died suddenly 11 months and 4 years after repair. DiscussionEbstein repair has good functional outcomes in children despite residual tricuspid regurgitation, likely because of reduction in right ventricular volume loading and relative annular and ventricular plasticity. Adult patients did not demonstrate the same durability of valve repair and frequently required tricuspid valve replacement. Intraoperative radiofrequency ablation represents an important adjunctive treatment for intractable arrhythmias, which may now represent relative indications for operative intervention.

The long-term durability of plication of the anterior rectus sheath assessed by ultrasonography.

The purpose of this study was to assess the long-term durability of a standard vertical plication of the anterior rectus sheath. For this purpose, 70 women who had undergone this procedure as part of an abdominoplasty were sent a questionnaire, their records were studied, and they were invited back to the clinic for an examination using ultrasound. A total of 63 patients returned the questionnaire, and 40 were willing to attend a follow-up consultation and ultrasound investigation. The presence of rectus diastasis was assessed by ultrasound (a real time scanner with a 7.5-MHz linear probe). The study showed that after a follow-up of 32 to 109 months (mean, 64 months), standard plication of the abdominal wall with absorbable material led to residual or recurrent diastasis in 40 percent of the patients. It also confirmed that vertical plication only is not enough to improve the waistline and may eventually lead to epigastric bulging.

Refinements in transverse rectus abdominis myocutaneous flap breast reconstruction: projection and contour improvements.

A surgical procedure with the transverse rectus abdominis myocutaneous (TRAM) flap for breast reconstruction is presented using parameters from the opposite normal breast to achieve a better cone shape in the new breast to project the nipple-areola complex. This cone projection is obtained through a vertical plication of both skin/fat halves of the TRAM flap and with two supraumbilical fat flaps to avoid cone collapse. The infraclavicular and axillary regions are filled with a de-epithelialized "fish-fin" cutaneous-fat or fat-only flap, which is placed as a lateral TRAM extension. The de-epithelialized lateral extremity of the TRAM flap folded over itself gives a mound shape to the lateral aspect of the new breast, and the inverted umbilical stalk attached to the TRAM flap imitates a nipple. This procedure is based on six breast reconstructions with a 2-year follow-up. The procedure is a simple, safe, and versatile way to mimic the opposite breast. It is mostly indicated for thin patients who have small to moderate breasts without ptosis or hypertrophy who refuse breast implants or request a mastopexy or reduction mammaplasty on the opposite normal breast during the same procedure.

PII: S0003-4975(00)01393-X

Surgical treatment outcome of symptomatic neonates suffering from Ebstein’s anomaly is rather disappointing, regardless the type of management be it medical therapy or operation. Doctor Knott-Craig’s approach, based upon three cases only, provides an alternative, which includes aggressive medical preparation and surgical repair with two ventricles. This innovative surgical technique associates subtotal closure of the atrial septal defect, extensive resection of the right atrium, and vertical plication of the atrialized chamber. Good results have been observed with a 5 years maximum follow-up. In many centers, such patients would be treated with medical therapy and the outcome would be poor results. The indication issue for a temporary bicavo-pulmonary shunt in neonates with Ebstein’s anomaly is not yet solved. Unloading the right ventricle has the theoretical advantage of improving pulmonary artery flow in case of pulmonary artery atresia. This procedure could be performed without cardiopulmonary bypass. It could delay a hazardous intra-cardiac repair, despite the three successful cases presented by the authors. Undoubtedly, an operative treatment should be carried out in symptomatic neonates because medical treatment has no chance of success. However, the recommendation for a repair indication in case of an asymptomatic neonate could be discussed. The decreasing of fetal pulmonary artery resistances during the first 6 months of life offers a potential clinical improvement. Surgical treatment could then be indicated at a later stage under better conditions.