Weight regain after bariatric surgery remains a challenging problem with regard to its surgical management.
PRESENTATION OF CASE
A 30 year-old-female patient with weight regain after failed laparoscopic gastric plication and previous gastric banding was evaluated in a tertiary-care university setting. Her last body mass index was calculated as 40.4 kg/m2. Preoperative ultrasonography revealed cholelithiasis. Laparoscopic sleeve gastrectomy with cholecystectomy was planned as a redo surgery. A floopy and plicated stomach with increased wall thickness of the greater curvature was seen. After adhesiolysis between the plicated part of stomach and the surrounding omental tissues, concomitant laparoscopic sleeve gastrectomy and cholecystectomy were performed. She was discharged on the 4th post-operative day without any complaint. At the postoperative 3rd month, her body mass index was recorded as 24 kg/m2.
Redo surgery of morbid obesity after failed bariatric surgery is a technically demanding issue. Type of the surgical treatment should be decided by the attending surgeon based on the morphology of the remnant stomach caused by previous operations.
As a redo surgery after failed laparoscopic gastric plication and gastric banding procedures, laparoscopic sleeve gastrectomy may be regarded as a safe and feasible approach in experienced hands.
Bariatric surgery; Sleeve gastrectomy; Gastric plication; Weight regain
Laparoscopic gastric plication appears to add security to gastric band application and reduce the incidence of slippage after this procedure.
Laparoscopic insertion of a gastric band for weight reduction is increasingly performed in obese and morbidly obese patients. Complication rates after gastric band insertion are reduced by using certain techniques.
Patients and Methods:
This was a prospective study of all patients who underwent laparoscopic adjustable gastric band (LAGB) insertion at our unit. This procedure is performed through the classical 4-port technique and the use of a liver retractor. The pars flaccida method is performed in all patients, and the gold finger, a malleable instrument, is used to guide the band through the retroesophageal window in patients with difficult anatomy. Band slippage is avoided by using 2 types of gastric plication, depending on the anatomical characteristics of the stomach. Outcomes and morbidity are recorded, and patients are followed up in outpatient clinics.
Laparoscopic adjustable gastric band (LAGB) insertion was performed in 464 patients. A single consultant surgeon performed all procedures over a 2-year period. From August 2005 through August 2007, 380 (81.89%) women and 84 (18.10%) men were included in this study. The mean age was 41 years (range, 21 to 62). The mean body mass index was 43 (range, 35 to 62). Morbidity included dysphagia, epigastric pain, port displacement, port infection, erosion, and acute respiratory distress. Only one (0.21%) case of band slippage was reported. The mean follow-up was 26 months (range, 18 to 42).
Laparoscopic gastric plication adds greater security and provides optimum gastric band placement. It is an effective method to reduce slippage after gastric band insertion.
Laparoscopic gastric band; Plication technique; Anterior slippage; Posterior slippage; Longitudinal plication; Transverse plication; Oblique plication; Gastro-gastric stitches
Introduction. Laparoscopic greater curvature plication is an operation that is gaining ground in the treatment of morbid obesity, as it appears to replicate the results of laparoscopic sleeve gastrectomy with fewer complications. Aim. Review of current literature, especially results on weight loss and complications. Method.
11 (eleven) published articles on laparoscopic gastric plication, of which 1 preclinical study, 8 prospective studies for a total of 521 patients and 2 case reports of unusual complications. Results. Reported Paracentage of EWL in all studies is comparable to Laparoscopic Sleeve Gastrectomy (around 50% in 6 months, 60–65% in 12 months, 60–65% in 24 months) and total complication rate is at 15,1% with minor complications in 10,7%, major complications in 4,4%. Reoperation rate was 3%, conversion rate was 0,2%, and mortality was zero. Conclusion. Current literature on gastric plication and its modifications is limited and sketchy at times. Low cost, short hospital stay, absence of prosthetic material, and reversibility make it an attractive option. Initial data show that LGCP is effective for short- and medium-term weight loss, complication and reoperation rates are low, and GERD symptoms are unaffected. More data is required, and randomized control trials must be completed in order to reach safe conclusions.
New symptom onset of respiratory distress without other cause, and new hemi-diaphragmatic elevation on chest radiography postcardiotomy, are usually adequate for the diagnosis of phrenic nerve paresis. The symptom severity varies (asymptomatic state to severe respiratory failure) depending on the degree of the lesion (paresis vs. paralysis), the laterality (unilateral or bilateral), the age, and the co-morbidity (respiratory, cardiac disease, morbid obesity, etc). Surgical treatment (hemi-diaphragmatic plication) is indicated only in the presence of symptoms. The established surgical treatment is plication of the affected hemidiaphragm which is generally considered safe and effective. Several techniques and approaches are employed for diaphragmatic plication (thoracotomy, video-assisted thoracoscopic surgery, video-assisted mini-thoracotomy, laparoscopic surgery). The timing of surgery depends on the severity and the progression of symptoms. In infants and young children with postcardiotomy phrenic nerve paresis the clinical status is usually severe (failure to wean from mechanical ventilation), and early plication is indicated. Adults with postcardiotomy phrenic nerve paresis usually suffer from chronic dyspnoea, and, in the absence of respiratory distress, conservative treatment is recommended for 6 months -2 years, since improvement is often observed. Nevertheless, earlier surgical treatment may be indicated in non-resolving respiratory failure. We present early (25th day postcardiotomy) right hemi-diaphragm plication, through a video assisted mini-thoracotomy in a high risk patient with postcardiotomy phrenic nerve paresis and respiratory distress. Early surgery with minimal surgical trauma, short operative time, minimal blood loss and postoperative pain, led to fast rehabilitation and avoidance of prolonged hospitalization complications. The relevant literature is discussed.
Respiratory paralysis/surgery; respiratory paralysis/etiology; dyspnea/etiology; diaphragm/surgery; phrenic nerve/injuries
The second branch of the right gastroepiploic artery can safely be used as a landmark for marking the distal extent of resection during vertical sleeve gastrectomy.
Background and Objectives:
The vertical sleeve gastrectomy is a common bariatric procedure. The operation is relatively standard, but there are still variations among surgeons. The two main variations are bougie size and extent of distal resection. Some surgeons will start the gastric resection at 2 cm proximal to the pylorus, whereas others start at 6 cm. Our hypothesis is that there are anatomic landmarks that are constant and can be used to help standardize the procedure.
Twenty-eight morbidly obese patients undergoing laparoscopic bariatric surgery (gastric bypass or sleeve gastrectomy) had the distance from the pylorus to the second branch of the right gastroepiploic artery on the inferior border of the greater curvature of the stomach measured. Body mass index, height, weight, age, and sex were also analyzed.
The study comprised 22 women and 6 men with a mean age of 46.2 years (range, 22–68 years). The mean body mass index was 43.2 kg/m2 (range, 37.2–62.4 kg/m2). The mean distance from the pylorus to the second branch of the right gastroepiploic vessel was 4.52 cm (range, 3.5–5.5 cm).
The second branch of the right gastroepiploic artery can be used as a constant anatomic landmark. It is found about 4.5 cm from the pylorus. This can be safely used as a landmark for marking the distal extent of resection during a vertical sleeve gastrectomy and obviates the need to formally measure the distance from the pylorus.
Bariatric surgery; Sleeve gastrectomy; Surgical anatomy
An operation has been devised to prevent gastro-oesophageal reflux in which a vertical partition is made parallel to the proximal gastric lesser curvature. The technique, which can be simply, safely and rapidly performed, prevents reflux in the following ways: 1. Increasing the effective length of the 'intra-abdominal oesophagus'; 2. Increasing the crural sling and mucosal flap valve effect; 3. Sharpening the angle of entry into the gastric reservoir; 4. Creating a flutter valve and markedly reducing the gastric cross-sectional area along which reflux can occur. The stomach is neither opened nor divided. The efficacy of the operation was investigated in six dogs which had their lower oesophageal sphincter excised by circular myomectomy before vertical gastric plication. Pre- and postoperative manometric and oesophageal pH studies were performed. Vertical gastric plication prevented the oesophagitis produced by circular myomectomy alone. The operation has been performed in 26 patients over a 2-year period. Assessment has been by clinical methods, ambulatory 24 h pH studies and endoscopy. Twenty-one patients were classified in Visick grades I and II and ambulatory pH recordings showed a marked reduction in reflux in 13 of 14 patients. The operation is technically simple, quick and safe to perform, being accurately and scientifically reproducible.
Plication techniques are not a panacea for deformities associated with Peyronie’s disease or congenital curvature. However, they do provide certain advantages, both theoretic and real, over competing procedures such as grafting. Depending on the technique, plication procedures have minimal risk of de novo erectile dysfunction, minimal risk of injury to the dorsal neurovascular bundle, and may be used for a variety of angulation deformities, including multiplanar curvature and severe degrees of curvature. A variety of incisions may be used, including the classic circumcision with degloving but also ventral raphe, dorsal penile inversion, and penoscrotal. These may be helpful in preventing postoperative morbidity and in sparing the prepuce if desired. Plication may also be combined with procedures such as penile prosthesis for correction of residual curvature. Lastly, despite its complications, plication techniques are very well tolerated, are relatively simple to perform and result in the very high satisfaction rates.
Peyronie’s disease; corporoplasty; plication; grafting; erection; chordee; penis
Rapid advances in endoluminal technology such as tissue placating devices offer an alternative for repair of some postbariatric surgical complications.
Background and Objectives:
As the number of bariatric operations performed increases, the number of patients requiring reoperation for failed weight loss is expected to proportionately increase. Natural orifice surgery is an alternative approach to revisional gastric bypass surgery when postoperative complications, such as dilatation of the gastrojejunostomy, gastrogastric fistula, and gastric pouch, dilation occur.
The present article reports on the safe and successful use of an endoscopic tissue plicating device in a patient found to have a dilated gastric pouch and a gastrogastric fistula 12 years after an open, nondivided RYGB.
The procedure was performed without complications and resulted in a reduced pouch size to approximately 30cc to 50cc and redirection of the flow of gastric contents through her gastrojejunostomy. The patient's early satiety returned and, 1 year postoperatively, she had incurred a 45-pound weight loss.
The morbidity and mortality of revision gastric bypass was avoided while the patient's goal of moderate weight loss was achieved. Tissue plicating devices offer an alternative for repair of some postbariatric complications. With the rapid advances in endoluminal technology and increasing experience with natural orifice surgery, the ability to successfully address surgical problems through less invasive means will continue to improve.
Bariatric surgery; Complications; Fistula; Endoscopy
In this study we aimed to evaluate the long-term outcome of diaphragmatic plication for symptomatic unilateral diaphragm paralysis.
Thirteen patients who underwent unilateral diaphragmatic plication (2 patients had right, 11 left plication) between January 2003 and December 2006 were evaluated. One patient died postoperatively due to sepsis. The remaining 12 patients [9 males, 3 females; mean age 60 (36-66) years] were reevaluated with chest radiography, flouroscopy or ultrasonography, pulmonary function tests, computed tomography (CT) or magnetic resonance imaging (MRI), and the MRC/ATS dyspnea score at an average of 5.4 (4-7) years after diaphragmatic plication.
The etiology of paralysis was trauma (9 patients), cardiac by pass surgery (3 patients), and idiopathic (1 patient). The principle symptom was progressive dyspnea with a mean duration of 32.9 (22-60) months before surgery. All patients had an elevated hemidiaphragm and paradoxical movement radiologically prior to surgery. There were partial atelectasis and reccurent infection of the lower lobe in the affected side on CT in 9 patients. Atelectasis was completely improved in 9 patients after plication. Preoperative spirometry showed a clear restrictive pattern. Mean preoperative FVC was 56.7 ± 11.6% and FEV1 65.3 ± 8.7%. FVC and FEV1 improved by 43.6 ± 30.6% (p < 0.001) and 27.3 ± 10.9% (p < 0.001) at late follow-up. MRC/ATS dyspnea scores improved 3 points in 11 patients and 1 point in 1 patient at long-term (p < 0.0001). Eight patients had returned to work at 3 months after surgery.
Diaphragmatic plication for unilateral diaphragm paralysis decreases lung compression, ensures remission of symptoms, and improves quality of life in long-term period.
Eventration of diaphragm associated with gastric volvulus is an uncommon condition.
We are reporting a case of a 60-year-old male having left sided total diaphragmatic eventration associated with chronic intermittent organo-axial gastric volvulus. The patient presented with progressive dyspnea and intermittent gastrointestinal symptoms. Plication of left hemidiaphragm with anterior gastropexy was performed through an abdominal approach. Postoperatively the patient's symptoms improved.
Symptomatic gastric volvulus associated with diaphragmatic eventration is a surgical emergency and always requires surgical repair.
New symptom onset of respiratory distress without other cause, and new hemi-diaphragmatic elevation on chest radiography postcardiotomy, are usually adequate for the diagnosis of phrenic nerve paresis. The symptom severity varies (asymptomatic state to severe respiratory failure) depending on the degree of the lesion (paresis vs. paralysis), the age, and the co-morbidity (respiratory/cardiac disease, morbid obesity, etc.) Surgical treatment (hemi-diaphragmatic plication) is indicated only in the presence of symptoms. The timing of surgery depends on the severity and the progression of symptoms. In infants and young children with postcardiotomy phrenic nerve paresis the clinical status is usually severe (failure to wean from mechanical ventilation), and early plication is indicated. Adults with postcardiotomy phrenic nerve paresis usually suffer from chronic dyspnoea, and, in the absence of respiratory distress, conservative treatment is recommended for 6 months -2 years, since improvement is often observed. Nevertheless, earlier surgical treatment is indicated in non-resolving respiratory failure. We present early hemi-diaphragmatic plication, in a high risk patient with postcardiotomy phrenic nerve paresis.
Patient and methods
A 72 year old woman, with bioprosthetic mitral valve endocarditis, native aortic valve endocarditis, and acute renal failure, underwent urgent redo mitral valve replacement and aortic valve replacement (predicted mortality Euroscore II: 23.86%). Despite good valve and cardiac function, infection control, and weaning from mechanical ventilation she had respiratory failure (dyspnoea, tachypnoea, orthopnoea, hypoxaemia, need continuous oxygen supplementation). Chest radiography revealed a new right hemi-diaphragm elevation, with severe progressing lung atelectasis. Right hemi-diaphragm postero-anterior plication was performed through a video assisted right mini-thoracotomy on the 25th postoperative day.
Early extubation was achieved, adequate respiratory function was established, chest radiography was normalized (normal right hemi-diaphragm position, right lung expansion). After mobilization and rehabilitation the patient was discharged home on the 8th day after plication.
Several techniques and approaches are employed for diaphragmatic plication (thoracotomy, video-assisted thoracoscopic surgery, video-assisted mini-thoracotomy, laparoscopic surgery). The early plication through a video assisted mini-thoracotomy was safe and effective, offering minimal surgical trauma, short operative time, minimal blood loss and postoperative pain, leading to fast rehabilitation and avoidance of prolonged hospitalization complications.
AIMS--To assess the outcome of inferior retractor plication surgery for lower lid entropion in patients with ocular cicatricial pemphigoid (OCP). This technique avoids surgery on the conjunctiva that can result in exacerbations of disease activity. METHODS--This prospective study assessed the outcomes of a standard 'Jones' type plication in 14 lids of 10 patients with OCP. Seven patients were taking systemic immunosuppression and no patients had conjunctival inflammation for the 4 months before surgery. RESULTS--Life table analysis showed a 77% chance of anatomical success at 2 years and a 54% chance of completely preventing lash-globe touch. The surgery did not cause clinical activation of conjunctival inflammation or other complications. Anatomical failure was primary (n = 2) and due to late cicatrisation (n = 1). Three further cases had restoration of normal anatomy but the patients had persistently misdirected lashes that touched the globe. CONCLUSION--This technique gives good anatomical success over long periods and is particularly safe when there is no conjunctival inflammation present before surgery.
Acquired diaphragmatic hernias are usually posttraumatic in occurrence. In patients who have blunt trauma and associated diaphragmatic hernia, the diagnosis may be missed or delayed, often leading to poor treatment outcomes. We present a rare occurrence of tension viscerothorax due to missed traumatic diaphragmatic rupture in a 25-year-old woman whose condition was complicated by gangrene and perforation of the fundus as well as questionable viability of the anterior wall of the body of the stomach. The patient had a successful emergency transabdominal suture plication of the diaphragm and gastroplasty and has remained symptomless 3 months postoperatively.
Obesity (BMI 30–35 kg/m2) and its associated disorders such as type 2 diabetes, nonalcoholic fatty liver disease, and cardiovascular disease have reached pandemic proportions worldwide. For the morbidly obese population (BMI 35–50 kg/m2), bariatric surgery has proven to be the most effective treatment to achieve significant and sustained weight loss, with concomitant positive effects on the metabolic syndrome. However, only a minor percentage of eligible candidates are treated by means of bariatric surgery. In addition, the expanding obesity epidemic consists mostly of relatively less obese patients who are not (yet) eligible for bariatric surgery. Hence, less invasive techniques and devices are rapidly being developed. These novel entities mimic several aspects of bariatric surgery either by gastric restriction (gastric balloons, gastric plication), by influencing gastric function (gastric botulinum injections, gastric pacing, and vagal nerve stimulation), or by partial exclusion of the small intestine (duodenal-jejunal sleeve). In the last decade, several novel less invasive techniques have been introduced and some have been abandoned again. The aim of this paper is to discuss the safety, efficacy, complications, reversibility, and long-term results of these latest developments in the treatment of obesity.
4 years experience on 50 cases using the Elliott’s technique for symmetrization of the contra-lateral breast in patients undergoing breast reconstruction with an anatomical prosthesis is presented in this paper.
The Elliott’s technique with its double superior and horizontal plication is a suitable and long-lasting procedure for patients with small-moderate ptotic breast and elastic skin, who wish to have a simple procedure and an immediate result with minimal scars.
breast reconstruction with prosthesis; symmetrization; mastopexy
10–40% of Roux-en-Y gastric bypass (RYGB) patients regain significant weight after Roux-en-Y gastric bypass surgery due to dilation of the pouch and/or the gastrojejunal (GJ) anastomosis. Traditional revision surgery is associated with significant morbidity (e.g. post-anastomotic GJ leak) where less invasive endoluminal procedures may represent safer alternatives. The present article reports a case of the safe and successful use of endoluminal gastric pouch plication (EGPP) using the StomaphyX™ device to correct both a dilated gastric pouch and a dilated gastrojejunostomy in a post-RYGB patient who regained significant weight.
A 12-year-old female presented with the abnormal findings on the chest PA. The chest CT revealed a retrosternal defect of the diaphragm and a fatty opacity in the pleural cavity, resulting in a diagnosis of Morgagni hernia. It was decided to undergo a laparoscopic surgery. The retrosternal defect of the diaphragm measuring 3.5 cm in diameter was found, through which a portion of the greater omentum and the fatty tissue connected with the falciform ligament were herniated into the pleural cavity. The greater omentum was pushed back into the peritoneal cavity and the fatty tissue connected with falciform ligament was excised. The mediastinal pleura was plicated and the defect of the diaphragm was repaired primarily. Immediately after the operation, the patient developed a right pneumothorax for which a chest tube was inserted. She was discharged at the post-operative third day without any further complications.
Hernia; Hernia, diaphragmatic; Morgagni hernia
In patients with severe gastroesophageal reflux disease post gastric bypass surgery, endoscopic plication with revision of the gastric pouch may be beneficial.
A new technique for endoscopic plication and revision of the gastric pouch (EPRGP) for patients who underwent gastric bypass (RGB) surgery was evaluated in patients with severe GERD, dumping syndrome, failure of weight loss, or all of these.
Patients and Methods:
Patients underwent EPRGP over a 12-month period. The StomaphyX device (Endogastric Solutions, Redmond, WA) was utilized over a standard flexible gastroscope. Patients were kept on a liquid diet for 1 week.
The study included 64 patients with a mean age of 48 years who underwent 67 procedures. EPRGP was performed an average of 5 years after RGB. The mean preoperative BMI was 39.5 kg/m2. The primary indications for the procedure were inadequate weight loss, dumping syndrome (42), and GERD (15). The mean follow-up period was 5.8 months (range, 3 to 12). The average operative time was 50 minutes, with a significant reduction with increased operator experience. There were only 2 (3%) intraoperative complications during the early period (equipment failure), which did not result in any morbidity. All symptoms from dumping syndrome or reflux improved, with no further operative-related complications. The mean weight loss was 7.3kg.
This study demonstrates the technical feasibility, safety, and efficacy of EPRGP.
Gastric bypass; Bariatric; Natural orifice; Revision; Endoscopic; Plication
Diaphragmatic paralysis in newborns is related to brachial plexus palsy. It can cause respiratory failure necessitating prolonged mechanical ventilation and subsequent extubation failure.
We present a two-hour-old male newborn with a birth weight of 4500 grams who had a right-sided brachial plexus palsy and right diaphragmatic paralysis due to shoulder dystocia. He developed respiratory distress due to isolated paralysis of the right hemi diaphragm. The clinical course was progressive, his condition worsening despite oxygen application. Physical examination, chest X-rays and M-mode ultrasonography of the diaphragm confirmed the diagnosis diaphragmatic paralysis. Surgical plication of diaphragm was done earlier than the usual time because of recurrent extubation failure. Diaphragmatic plication led to rapid improvement of pulmonary function and allowed discontinuation of mechanical ventilation in less than 3 days.
Early diaphragmatic plication enhances weaning process and may prevent or minimize the morbidity associated with long-term mechanical ventilation in a neonate with diaphragmatic paralysis.
Neonate; Diaphragmatic Paralysis; Ventilation; Mechanical; Lower Brachial Plexus Palsy
Nine cases of diaphragmatic eventration are presented in infants, seven of whom required surgery. All were seen during the first 19 months of life and seven were less than 1 year old. Although differing from other studies, our cases show a predominance of right-sided lesions. Respiratory symptoms were present in most cases, and digestive symptoms appeared in a lesser number of cases. The radiological changes were pronounced in seven of the nine cases, the dome of the diaphragm reaching to the fourth to fifth intercostal spaces. Regarding surgical technique, the authors favour diaphragmatic plication through the thorax. This gave excellent clinical and radiological results and was without mortality or complications.
Diaphragmatic eventration is a rare congenital developmental defect of the muscular portion of the diaphragm, which appears attenuated and membranous, maintaining its normal attachments and its anatomical continuity. It has been attributed to abnormal myoblast migration to the septum transversum and the pleuroperitoneal membrane. Eventration can be unilateral or bilateral, partial or complete. It is more common in males, and involves more often the left hemidiaphragm. Eventration results in diaphragmatic elevation (cephalad displacement). Most adults are asymptomatic and the diagnosis is incidentally made by chest radiography. The commonest symptom in the adults is dyspnoea, while orthopnoea, mild hypoxemia, tachypnoea, respiratory alkalosis, palpitations, and non specific gastrointestinal symptoms may be present. Surgery is indicated only in the presence of symptoms. The established surgical treatment is diaphragmatic plication. Various techniques and approaches have been employed. We present a simple surgical technique of a 3-port video assisted thoracoscopic plication of the left hemidiaphragm in the adult.
Diaphragmatic eventration; diaphragmatic eventration/surgery; diaphragm/ surgery; thoracic surgical procedures/methods; thoracoscopy
Thirty-three cases of hiatus hernia treated by operation in an 8-year period are reviewed. It is suggested that less delay in surgical intervention when a child is not responding to medical management might reduce the number of children who develop strictures as a result of gastro-oesophageal reflux and might improve the development of the child. Gastric fixation with gastrostomy not only improves the nutrition of a child before a major corrective procedure, but in a few cases may avoid more drastic operation. Though maximal acid secretion tests do not help to identify those cases likely to develop a stricture, it is, however, a useful procedure in indicating whether or not vagotomy should be added to fundal plication.
Abdominal wall plication is known to cause increased intra-abdominal pressure (IAP). Whether plication-associated increased IAP causes lower extremity venous stasis, a recognized risk factor for DVT, remains unknown. A 55 year old woman had a unilateral pedicled TRAM procedure for mastectomy reconstruction. Prior to plication, duplex ultrasound measured proximal femoral vein (PFV) cross-sectional diameter and volume-flow. PFV measurements were repeated immediately after plication and on post-operative days (POD) 1, 2, and 4. Bladder pressure was measured at similar timepoints. PFV volume-flow decreased from 0.22 L/min to 0.16 L/min (73% of baseline) immediately post-plication and reached a nadir of 0.08 L/min (36% of baseline) on POD 2. Bladder pressure increased from 13mm Hg to 19mm Hg after plication, and peaked at 31mmHg after intra-operative trunk flexion to 30°. Thus, abdominal wall placation was associated with increased intra-abdominal pressure and ultrasound-documented lower extremity venous stasis that persisted for 48 hours after surgery.
Deep venous thrombosis; pulmonary embolism; venous thromboembolism; intraabdominal pressure; abdominal compartment syndrome; plication; venous stasis; abdominoplasty; body contouring
Background: A study was undertaken to evaluate whether adults differ from children in the indications and outcome of diaphragmatic plication following phrenic nerve injury.
Methods: A retrospective study was performed of 21 patients, 10 below the age of 5 and 11 older than 37 years. The indication for surgery for all the children was failure to wean from ventilatory support. The indications for surgery in the adult group were ventilator dependency (n=4) and symptomatic dyspnoea (n=7). All patients had at least one imaging study confirming diaphragmatic paralysis. The American Thoracic Society (ATS) dyspnoea scale, pulmonary function tests, and quantitative pulmonary perfusion scans were used as evaluation parameters. At surgery the diaphragm was centrally plicated.
Results: One child died immediately after surgery due to irreversible heart failure and two children died within 2 months of surgery from ongoing complications of their original condition. These three patients were considered as selection failures. Seven children were weaned from ventilatory support within a median of 4 days (range 2–140). Only one of four ventilated adults was successfully weaned. Seven adults who underwent surgery for chronic symptoms had a marked subjective improvement of 2–3 levels in the ATS dyspnoea scale. Pulmonary function studies in the seven symptomatic adults showed a 40% improvement above baseline. Severely asymmetrical perfusion scans reverted to a normal pattern after plication.
Conclusions: Diaphragmatic plication offers a significant benefit to children with diaphragmatic paralysis and should be performed early to facilitate weaning from mechanical ventilation. While plication is of limited benefit in weaning ventilated adults, it results in significant subjective and objective lifetime improvement in non-ventilated symptomatic adults.
Diaphragmatic eventration is a rare (incidence <0.05%) congenital developmental defect of the muscular portion of the diaphragm, which maintains its normal attachments (to dorsolumbar spine, ribs, sternum). Eventration results in diaphragmatic elevation (cephalad displacement). It can be unilateral or bilateral, partial or complete. It is more common in males, and involves more often the left hemidiaphragm. Surgery is indicated only in the presence of symptoms. The commonest symptom is dyspnoea. We present a video assisted thoracoscopic plication of the left hemidiaphragm in a symptomatic patient.
Patients and methods
A 47-year old woman presented with non-specific gastrointestinal symptoms (dyspnoea and bloating after small meals, despite continuous gastrokinetic drug consumption), dyspnoea on exertion, and limited physical activity since childhood. A known left hemidiaphragm elevation (8 cm higher than the right) was confirmed on chest radiography. Intraoperatively, the hemidiaphragm appeared thin, fully deprived of muscular layer, with a cephalad displacement. A 3 port video assisted thoracoscopic posteroanterior plication of the left hemidiaphragm was performed. The plicated area was further reinforced by suturing of a bovine pericardial patch.
The patient had an excellent postoperative recovery. She was extubated in theatre, transferred to the ward without need of oxygen supplementation, received liquid oral feeding 8 hours postoperatively, underwent full mobilization and was discharged home on the 3rd postoperative day. She discontinued gastrokinetic medication (8th postoperative day). One month postoperatively the Forced Expiratory Volume in 1 second was increased by 25% and the Forced Vital Capacity by 11% in comparison to preoperative measurements. One year postoperatively she remains well; reporting increased physical activity, and absence of dyspnoea and gastrointestinal symptoms, while weight gain was noted.
Retrospective studies showed that minimally invasive plication was equally effective to open techniques, being associated with decreased morbidity, and functional improvement that is maintained for at least 4 years. Disadvantages attributed to the method include requirement of single lung ventilation and technical difficulty due to limited space by the thoracic wall and the cephalad diaphragmatic displacement. In our opinion, thoracoscopic hemidiaphragmatic plication is an excellent minimally invasive alternative to open plication, providing good early and medium term results.