Centralizing the Umbilicus in Abdominoplasty: Eccentric versus Concentric Fascial Plication in Addition to Medializing at the Skin.

BACKGROUND: The umbilicus is often not a midline structure. Centralization of the umbilicus during an abdominoplasty is routinely performed at the level of the skin; however, this is associated with a high rate of postoperative reversion. The authors propose using an eccentric fascial plication centered on the true midline to maintain postoperative centralization of the umbilicus in addition to correction at the skin level. METHODS: A retrospective study was conducted of all patients between 2015 and 2019 who underwent abdominoplasty with either skin only (concentric plication) or fascial (eccentric plication) umbilical centralization. The Fisher exact test and t test were used to compare the two groups and assess differences in rates of umbilical reversion. RESULTS: A total of 71 patients were included in the study; the majority of patients were women [ n = 69 (97%)] and White [ n = 50 (70%)]. There were 28 (39%) patients who underwent concentric plication, and 43 (61%) had eccentric plication. Mean body mass index in the concentric and eccentric groups was 32 kg/m 2 and 28.5 kg/m 2 , respectively. Average follow-up was 51.6 months for concentric plication and 27.8 months for eccentric plication. Of those who received concentric plication, 10 patients (36%) had their umbilicus revert to the preoperative position; none in the eccentric plication group reverted ( P < 0.0001). CONCLUSIONS: Midline placement of the umbilicus during an abdominoplasty is important in providing symmetry to optimize aesthetics. Eccentric fascial plication maintains the centralization of the umbilicus when compared with concentric fascial plication with skin-only centralization. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Functional Disability Associated With Proximal Clavicle Resection and Pectoralis Flap Transposition for Sternoclavicular Joint Infections.

Background: Sternoclavicular joint infections (SCJI) are increasing with the opioid crisis and increased intravenous drug abuse (IVDA). Proximal clavicle resection with subsequent pectoralis muscle transposition is part of the treatment of such infections, but the long-term effects on shoulder function are not clear. Methods: This report presents a consecutive series of 15 cases of SCJI treated with proximal clavicle resection and pectoralis muscle flap coverage. Patient-reported outcomes were recorded using the Shoulder Disability Questionnaire (SDQ) developed by van der Heijden et al. Results: The average age of patients was 50 years (range, 23-73 years), with nearly half being male (7/15). Of these patients, 3 were lost to follow-up, 1 was excluded due to subsequent shoulder surgery for an unrelated problem, and another was excluded due to subsequent medical issues that precluded a reliable history. Recurrence was noted in 1 patient with ongoing IVDA. Average length of follow-up was 12 months (range, 8-19 months). The long-term shoulder disability was minimal (mean score of 6 ± 9). Among patients with IVDA, however, the long-term shoulder disability was significantly higher (mean score of 33 ± 16, P < .05). Conclusions: In cases where the SCJI was attributed to IVDA, the long-term shoulder disability score was significantly higher, despite resolution of infection. Possible explanations include the self-reporting nature of the SDQ and the well-documented issues with chronic pain in patients with opioid dependency.  Of the patients lost to follow-up, 2 of 3 had infections attributed to IVDA, highlighting the difficulty of meaningful follow-up in this vulnerable patient population.

Early effects of bougie size on sleeve gastrectomy outcome.

BACKGROUND: When performing sleeve gastrectomy, a bougie (32 to 60 French) is used. We evaluated 2 different bougie sizes on early postoperative outcomes and long-term weight loss. METHODS: A 1-year prospective study was conducted on patients undergoing sleeve gastrectomy. In the first 6 months, patients had 32-French bougies (Group 1); in the second 6 months, they had 36-French bougies (Group 2). RESULTS: We evaluated 131 patients. No intraoperative complications or mortality occurred. Postoperatively, Group 1 (n = 72) had a longer hospital stay (1.6 ± .8 vs 1.3 ± .5 days, P = .04) and used more Ondansetron for nausea than Group 2 (n = 59) (6.7 ± 8.0 vs 5.3 ± 4.5 mg, P = .2, respectively). Ten (14%) patients in Group 1 returned to the emergency department compared with 5 (9%) in Group 2. One-year percent excess weight loss was similar (73.0 ± 20.6% vs 71.1 ± 20.9%, P = .73, respectively). CONCLUSIONS: The smaller bougie resulted in a longer hospital stay, with tendency toward increased nausea, more emergency department visits, and readmissions. Long-term weight loss was not affected.

Gastrointestinal bleeding with the HeartMate II left ventricular assist device.

BACKGROUND: Continuous flow left ventricular assist devices (CF-LVADs) have yielded improved outcomes compared with pulsatile flow devices for patients on long-term support. However, significant rates of gastrointestinal bleeding (GIB) have been observed during CF-LVAD support. METHODS: From March 2006 through March 2011, 86 patients with chronic heart failure underwent implantation of a CF-LVAD (HeartMate II; Thoratec Corp., Pleasanton, CA). Records were reviewed to determine the prevalence of post-implant GIB, location of the bleeding site and associated morbidity and mortality. Uni- and multivariate analyses were conducted to identify independent predictors of GIB. RESULTS: GIB occurred in 19 patients (22.1%) with a duration of support that ranged from 5 to 456 days. Sources of GIB included small bowel and rectum in 6 patients each, large bowel in 2 patients and stomach in 1 patient. No definite source was identified in 4 patients. There were no deaths referable to GIB. Recurrent GIB occurred in 4 patients. History of a GIB prior to LVAD implant was the only variable significantly different between patients with and without post-implant GIB (21.1% vs 10.4%, p = 0.016), and was the only independent predictor of GIB (OR = 2.24, 95% CI 2.121 to 2.435, p = 0.004). CONCLUSIONS: Gastrointestinal bleeding is a frequent source of morbidity for patients on HeartMate II LVAD support but does not significantly impact survival. As implantation of CF-LVADs with non-pulsatile flow gains popularity for both bridge-to-transplant and destination therapy, a better understanding of the pathophysiology of GIB in these patients will be needed for minimizing this complication.