Frequency and patterns of early recanalization after vasectomy

Background

Our understanding of early post-vasectomy recanalization is limited to histopathological studies. The objective of this study was to estimate the frequency and to describe semen analysis patterns of early recanalization after vasectomy.

Methods

Charts displaying serial post-vasectomy semen analyses were created using the semen analysis results from 826 and 389 men participating in a randomized trial of fascial interposition (FI) and an observational study of cautery, respectively. In the FI trial, participants were randomly allocated to vas occlusion by ligation and excision with or without FI. In the cautery study, sites used their usual cautery occlusion technique, two with and two without FI. Presumed early recanalization was based on the assessment of individual semen analysis charts by three independent reviewers. Discrepancies were resolved by consensus.

Results

Presumed early recanalization was characterized by a very low sperm concentration within two weeks after vasectomy followed by return to large numbers of sperm over the next few weeks. The overall proportion of men with presumed early recanalization was 13% (95% CI 12%–15%). The risk was highest with ligation and excision without FI (25%) and lowest for thermal cautery with FI (0%). The highest proportion of presumed early recanalization was observed among men classified as vasectomy failures.

Conclusion

Early recanalization, occurring within the first weeks after vasectomy, is more common than generally recognized. Its frequency depends on the occlusion technique performed.     

A Retrospective Review of Factors Associated with Vasovasostomies in United States Military Members

Background

Men seeking a vasectomy should receive counseling prior to the procedure that includes discussion of later seeking a reversal. We sought to determine demographic factors that may predispose patients to possibly later seek a vasectomy reversal.

Methods

All U.S. Military electronic health records were searched between 2000 and 2009 for either a vasectomy or vasovasostomy procedure code. Aggregate demographic information was collected and statistical analysis performed.

Result

A total of 82,945 patients had a vasectomy of which 4,485 had a vasovasostomy resulting in a vasovasostomy-to-vasectomy rate of 5.04%. The average age at vasovasostomy was 34.9±5.0, with an average interval of 4.1±2.2 years. Men undergoing a vasectomy at a younger age were more likely to have a vasovasostomy. Various religions did have statistically significant differences. Within ethnic groups, only Native Americans [OR=1.39 (95% CI 1.198-1.614)] and Asians [OR=0.501 (95% CI 0.364-0.690)] had statistically significant differences when compared to Caucasians. Men with more children at the time of vasectomy were more likely to have a vasovasostomy.

Conclusion

Younger men, Native Americans, and men with more children at vasectomy were more likely to undergo a vasovasostomy. The reason for these differences is unknown, but this information may assist during pre-vasectomy counseling.Key Words: Vasovasostomy, Vasectomy counseling, Demographics, Infertility     

The association between fecal incontinence and sexual activity and function in women attending a tertiary referral center

Introduction and hypothesis

To determine whether fecal incontinence (FI) is associated with sexual activity and to compare sexual function in women with and without FI.

Methods

We conducted a retrospective chart review of all new patients seen in an academic urogynecology clinic. Women who reported fecal incontinence, as defined by loss of fecal material on the Wexner scale, were compared with those without fecal incontinence. We compared sexual activity and Pelvic Organ Prolapse Incontinence Sexual Questionnaire-12 (PISQ-12) scores between groups.

Results

In our population of women with pelvic floor disorder, 588 women reported FI compared with 527 who did not. On multivariate analysis, FI was not associated with sexual activity status, but was associated with worsened PISQ-12 scores (p?<?0.001). PISQ-12 item analysis found that women with FI reported more dyspareunia, fear, and avoidance of sexual activity with greater partner problems (all p <0.05) than women without FI.

Conclusions

Women with FI were as likely to engage in sexual relations as women without FI; however, sexually active women with FI had poorer sexual function than those without FI.     

Image changes of paraspinal muscles and clinical correlations in patients with unilateral lumbar spinal stenosis

Study design

This is a retrospective study.

Purpose

To compare the morphometric parameters of the psoas major and lumbar multifidus muscles in lumbar spinal stenosis (LSS) patients exhibiting different functional performance.

Summary of background data

LSS refers to symptoms related to size reduction of the lumbar spinal canal; however, the degree of stenosis is poorly related to symptom severity and functional impairments. Morphometric changes in the paraspinal muscles have been correlated with chronic lower back pain in previous studies. However, correlations between the functional performance of LSS patients and the morphometric changes in paraspinal muscles have seldom been reported.

Methods

Sixty-six LSS patients without mechanical back pain or segmental instability were enrolled in the study. A review of their medical records and MRI images was performed. Morphometric parameters, including the fatty infiltration (FI) of the lumbar multifidus muscle as well as the relative cross-sectional area (RCSA) of the psoas major and lumbar multifidus muscles, were measured. Subjects were divided into high and low functional performance groups according to their Japanese Orthopedic Association (JOA) scores.

Results

The male LSS patients exhibited a larger psoas RCSA than the female patients, whereas the older patients exhibited a smaller psoas RCSA and higher multifidus FI than the younger patients. LSS patients in the high functional performance group exhibited a significantly larger psoas RCSA and lower multifidus FI.

Conclusion

The psoas RCSA and multifidus FI can be used as predictive factors for functional performance in LSS patients.     

Vasectomy reversal with ultrasonography‐guided spermatic cord block

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Vasectomy reversal is often performed in general or neuraxial anaesthesia. Even though the site of vasectomy reversal is easily amenable to regional/local anaesthesia, spermatic cord blocks are rarely applied because of their risk of vascular damage within the spermatic cord. Recently, we described the technique of ultrasonography (US)‐guided spermatic cord block for scrotal surgery, which, thanks to the US guidance, at the same time avoids the risk of vascular damage of blindly performed injections and the risks of general and neuraxial anaesthesia. Vasectomy reversal can easily be done in regional anaesthesia with the newly described technique of US‐guided spermatic cord block without the risks of vascular damage by a blindly performed injection and the risks of standard general and neuraxial anaesthesia. In addition, this technique grants long‐lasting postoperative pain relief and patients recover more quickly. Microsurgical conditions are excellent and patient satisfaction is high. Thanks to these advantages, more patients undergoing vasectomy reversal might avoid general or neuraxial anaesthesia.

OBJECTIVE

• ? To assess the success rate, microsurgical conditions, postoperative recovery, complications and patient satisfaction of ultrasonography (US)‐guided spermatic cord block in patients undergoing microscopic vasectomy reversal and to compare them to a control group with general or neuraxial anaesthesia.

PATIENTS AND METHODS

• ? The present study comprised a prospective series of 10 consecutive patients undergoing US‐guided spermatic cord block for microscopic vasectomy reversal.
• ? The cohort was compared with 10 patients in a historical control group with general or neuraxial anaesthesia.

RESULTS

• ? Nineteen of 20 (95%) blocks were successful, defined as no pain >3 on the Visual Analogue Scale (VAS), no additional analgesics and/or no conversion to general anaesthesia. Median pain was 0 on the VAS (range 0–5). Additional analgesics were requested in one (5%) block, and there was no conversion to general anaesthesia.
• ? Microsurgical conditions were excellent.
• ? In the spermatic cord block vs general/neuraxial anaesthesia groups, median times (range) between surgery and first postoperative analgesics, alimentation, mobilization and hospital discharge were 12 (2–14) vs 3 (1–6), 1 (0.25–3) vs 4 (3–6), 2 (1–3) vs 6 (3–10), and 4 (3–11) vs 8.5 (6–22) h, respectively.
• ? No complications were reported after the spermatic cord block.
• ? Patient satisfaction was excellent.

CONCLUSIONS

• ? US‐guided spermatic cord block for microscopic vasectomy reversal is highly successful and provides long‐lasting perioperative analgesia.
• ? Times to alimentation, mobilization and hospital discharge are shorter under US‐guided spermatic cord block than under general/neuraxial anaesthesia.
• ? Additional anaesthetic pain management might, however, be required unexpectedly with US‐guided spermatic cord block.

     

Advances in Male Reproductive Surgery: Robotic-Assisted Vasovasostomy

It is estimated that 3–6% of all vasectomised men request vasectomy reversal for different reasons. Microsurgical vasovasostomy is the gold standard technique of vasectomy reversal. However, the microsurgical technique is time-consuming and challenging to most urological surgeons. Therefore, alternative methods of vasal anastomosis have been studied including robotic-assisted vasovasostomy. This review discusses the feasibility and practice of robotic-assisted vasovasostomy. Based on the available studies robotic-assisted vasovasostomy is feasible. The reported rate of vasal patency associated with this new technique is similar to that of microsurgical vasovasostomy. There is no clear difference between the 2 approaches in terms of operating time. Robotic-assisted vasovasostomy does not appear to afford significant advantages in the era of vasectomy reversal.Key Words: Robotic surgery, Vasectomy reversal, Vasovasostomy     

Nomograms for Predicting the Risk of Arm Lymphedema after Axillary Dissection in Breast Cancer

Background

Lymphedema (LE) after axillary lymph node dissection (ALND) is a multifactorial, chronic, and disabling condition that currently affects an estimated 4 million people worldwide. Although several risk factors have been described, it is difficult to estimate the risk in individual patients. We therefore developed nomograms based on a large data set.

Methods

Clinicopathologic features were collected from a prospective cohort comprising 1,054 women with unilateral breast cancer undergoing ALND as part of their surgical treatment from August 2001 to November 2002. LE was defined as a volume difference of at least 200?ml between arms at 6?months or more after surgery. The cumulative incidence of LE was ascertained by the Kaplan?CMeier method, and Cox proportional hazard models were used to predict the risk of developing LE on the basis of the available data at each time point: model 1, preoperatively; model 2, within 6?months from surgery; and model 3, at 6?months or later after surgery.

Results

The 5?year cumulative incidence of LE was 30.3%. Independent risk factors for LE were age, body mass index, ipsilateral arm chemotherapy infusions, level of ALND, location of radiotherapy field, development of postoperative seroma, infection, and early edema. When applied to the validation set, the concordance indices were 0.706, 0.729, and 0.736 for models 1, 2, and 3, respectively.

Conclusions

The proposed nomograms can help physicians and patients predict the 5?year probability of LE after ALND for breast cancer. Free online versions of the nomograms are available at http://www.lymphedemarisk.com/.     

Written versus oral disclosure of fecal and urinary incontinence in women with dual incontinence

Introduction and hypothesis

To compare fecal incontinence (FI) and urinary incontinence (UI) disclosure in women with dual incontinence (DI), and to assess UI disclosure in DI subjects compared with women with UI alone. We hypothesized that women with DI would be less likely to disclose FI in comparison to UI and as likely to disclose UI as women with UI alone.

Methods

We performed a retrospective chart review of new patient visits to an academic urogynecology clinic from 2007 to 2011. Clinical records were reviewed; demographic data and responses to the Incontinence Severity Index (ISI) and Wexner scales were recorded. Patients’ written responses to the ISI and Wexner were compared with the diagnoses obtained from the oral history by the physician.

Results

Of 1,899 women in the database, 557 women were diagnosed with DI and 447 women were diagnosed with UI alone. Women with DI were less likely to orally disclose FI than UI (135 out of 557 [23 %], vs 485 out of 557 [87 %], p?p?=?0.66). In the multivariate analysis, DI subjects had greater odds of disclosing FI to their physicians if they had private insurance (OR 1.9, 95 %CI 1.2, 3.0) or Wexner score >7 (OR 9.0, 95 % CI 5.4,14.8) and lower ISI score (OR 1.5, CI 1.4, 1.6).

Conclusions

Women with DI were less likely to report FI in comparison to UI. Patients were more likely to orally report FI when the symptoms were severe.     

Long-term Outcome of Local Excision after Complete Pathological Response to Neoadjuvant Chemoradiation Therapy for Rectal Cancer

Background

Neoadjuvant chemoradiotion therapy (CRT) for advanced rectal cancer has improved local disease. Complete rectal wall tumor regression may be associated with the absence of viable cancer cells in the mesorectum, and thus local excision (LE) of such lesions as an alternative to radical surgery has recently gained interest. We report the long-term outcome of LE in patients with a mural pathological complete response (ypT0) after CRT.

Methods

A retrospective review of patients with rectal cancer treated by CRT and followed by LE with pathological complete response in the specimen between 1998 and 2009 was performed.

Results

A total of 174 patients had neoadjuvant CRT, and 68 (39?%) showed complete clinical response (cCR). Thirty-one of the cCR patients underwent LE; 23 of them resulted in ypT0 and 8 had residual disease. The ypT0 group included 12 men and 11 women with a median age of 66. The pretreatment stage was T3N1 in 4 (17?%) patients, T3N0 in 11 (48?%), T2N1 in 3 (13?%), and T2N0 in 5 (22?%). The median tumor distance from the anal verge was 6?cm. Sixteen patients (70?%) underwent transanal excision, and 7 (30?%) were treated by transanal-endoscopic microsurgery. Three patients died: one of pneumonia, one of melanoma of the rectum, and one of lung carcinoma. No local or distant recurrences were detected in the remaining 20 patients. The median follow-up was 87?months.

Conclusions

Although radical rectal resection is the treatment of choice, LE of complete rectal tumor regression could be a safe alternative with an acceptable result in selected patients.     

Development of breast cancer-related lymphedema: is it dependent on the patient, the tumor or the treating physicians?

Introduction

Breast cancer-related lymphedema (LE) is relatively common. The aim of this study was to identify the risk factors involved in the development of this complication.

Methodology

This was a cross-sectional study of breast cancer patients treated at our Center between 2004 and 2009. A total of 515 patients were included. Lymphedema was defined as a mid-arm or forearm circumference difference between both limbs of 2 cm or more.

Results

The incidence of LE in this population was 21.4 %. Patients with a BMI of 25 or higher had a significantly higher risk of LE (p = 0.002). The presence of lymphovascular invasion (LVI) (p = 0.05) and the number of positive lymph nodes (LN) (p = 0.001) were both associated with LE. Patients who underwent axillary dissection (AD) had a significantly higher incidence of LE than patients who had a sentinel LN biopsy (25 vs. 4.5 %). Adjuvant radiotherapy was also a significant risk factor in patients who had a mastectomy (p = 0.003).

Conclusion

There are multiple risk factors for LE. Most of those factors can be influenced by early tumor detection. Early tumors are smaller with no LVI or axillary LN metastasis. They do not usually require AD or axillary radiotherapy, which are the strongest factors associated with the development of LE.     

Robotically-enhanced surgical anatomy enables surgeons to perform distal gastrectomy for gastric cancer using electric cautery devices alone

Background

Despite recent advances in robotic urological surgery, the feasibility and clinical merit of robotic gastric surgery have not yet been fully documented. Therefore, we designed a prospective, non-randomized study to determine the feasibility and safety of robot-assisted distal gastrectomy (RADG) for gastric cancer using electric cautery devices, which are more familiar to open surgery.

Methods

Between April 2010 and December 2012, 181 patients treated by distal gastrectomy for gastric carcinoma were eligible for this study. According to their intent to undergo uninsured robotic surgery, 21 patients were treated with RADG (RADG group) while 160 patients were treated by conventional laparoscopic distal gastrectomy (LDG group). Under a basic working hypothesis that the superior visualization and unique movement of the robotic arms during dissection would be closely associated with reduced amount of blood loss, even though an equivalent extension of lymph node dissection was carried out, we prospectively collected data from patients in the RADG and LDG groups.

Results

All patients were successfully treated without conversion except for one patient in the RADG group who underwent conversion to laparoscopic total gastrectomy. In comparison with the patient groups, the estimated blood loss in patients in the RADG group treated with electric cautery devices only was smaller, but not significantly, than patients in the LDG group treated with ultrasonic-activated devices, although the same extent of lymph node dissection was achieved. In contrast, there were four patients (2.5 %) in the LDG group who developed a pancreas fistula or intra-abdominal abscess, while no patients treated with RADG developed such complications.

Conclusions

RADG using electric cautery instruments without ultrasonic-activated devices is feasible and safe. The robot enables particular surgical views, called robotically-enhanced surgical anatomy, and may contribute to reducing blood loss despite the fact that only electric cautery was used.     

The treatment of patellar tendinopathy

Background

Patellar tendinopathy (PT) presents a challenge to orthopaedic surgeons. The purpose of this review is to revise strategies for treatment of PT

Materials and methods

A PubMed (MEDLINE) search of the years 2002–2012 was performed using "patellar tendinopathy" and "treatment" as keywords. The twenty-two articles addressing the treatment of PT with a higher level of evidence were selected.

Results

Conservative treatment includes therapeutic exercises (eccentric training), extracorporeal shock wave therapy (ESWT), and different injection treatments (platelet-rich plasma, sclerosing polidocanol, steroids, aprotinin, autologous skin-derived tendon-like cells, and bone marrow mononuclear cells). Surgical treatment may be indicated in motivated patients if carefully followed conservative treatment is unsuccessful after more than 3–6 months. Open surgical treatment includes longitudinal splitting of the tendon, excision of abnormal tissue (tendonectomy), resection and drilling of the inferior pole of the patella, closure of the paratenon. Postoperative inmobilisation and aggressive postoperative rehabilitation are also paramount. Arthroscopic techniques include shaving of the dorsal side of the proximal tendon, removal of the hypertrophic synovitis around the inferior patellar pole with a bipolar cautery system, and arthroscopic tendon debridement with excision of the distal pole of the patella.

Conclusion

Physical training, and particularly eccentric training, appears to be the treatment of choice. The literature does not clarify which surgical technique is more effective in recalcitrant cases. Therefore, both open surgical techniques and arthroscopic techniques can be used.     

Faecal incontinence 20 years after one birth: a comparison between vaginal delivery and caesarean section

Introduction and hypothesis

The aetiology of bowel incontinence in middle-aged women is multifactorial and the contribution of birth-related factors later in life is still poorly defined. The aim was to assess prevalence, risk factors and severity of faecal (FI, defined as the involuntary loss of faeces—solid or liquid) and anal incontinence (AI, includes FI as well as the involuntary loss of flatus) 20 years after one vaginal (VD) or one caesarean section (CS).

Methods

This was a registry-based national cohort study of primiparae giving birth in 1985–1988 and having no further births (n?=?5,236). Data from the Swedish Medical Birth Register were linked to information from a pelvic floor disorder questionnaire in 2008 (response rate 65.2 %). Analysis of variance and multivariate analysis were used to obtain adjusted prevalence and odds ratios (adj-OR).

Results

Overall prevalences of FI and AI were 13.6 and 47.0 %. FI prevalence was higher after VD compared with CS [14.5 versus 10.6 %, adj-OR 1.43, 95 % confidence interval (CI) 1.16–1.77] but was not increased after acute versus elective CS. Perineal tear (≥second degree) increased the prevalence and risk of FI compared with no tear (22.8 versus 13.9 %, adj-OR 1.95, 95 % CI 1.33–2.85). The prevalence of FI was lower after VD with an episiotomy (11.1 %) and similar to that after CS (10.6 %). With each unit increase of current body mass index the odds of FI increased by 6 % (OR 1.06, 95 % CI 1.04–1.08).

Conclusions

Late FI and AI prevalences were higher after VD compared with CS. Perineal tear (≥second degree) versus no tear doubled the prevalence of FI. FI prevalence was similar after a CS and a VD combined with episiotomy.     

A Comparison of Indocyanine Green Fluorescence Imaging Plus Blue Dye and Blue Dye Alone for Sentinel Node Navigation Surgery in Breast Cancer Patients

Purpose

To evaluate two methods of sentinel node navigation surgery (SNNS) using blue dye with and without indocyanine green (ICG) fluorescence imaging (FI) to determine the usefulness of combined ICG and blue dye.

Methods

Between 2005 and 2010, a total of 501 patients underwent SNNS in our hospital. Detection of sentinel lymph node (SLN) was performed with sulfan blue (SB) alone until 2008 and with a combination of SB and ICG-FI since 2009. ICG 5?mg and SB 15?mg were injected in the subareolar region, and FI was obtained by a fluorescence imaging device.

Results

We attempted to identify SLNs in 393 patients by SB alone and in 108 patients by a combination of SB and FI. The mean number of SLNs detected was 1.6 (0?C5) for SB alone and 2.2 (1?C6) for the combination method. The SLN identification rate was 95.7?% for SB alone and 100?% for the combination method so that the combination was significantly superior to SB in terms of the identification rate (p?=?0.0037). In patients who received the combination method, detection of SLN was made through only SB in 1 patient, only ICG in 8 patients, and both in 99 patients. Lymph node metastasis was found in 56 patients with SB alone and in 16 patients with the combination method. Recurrence of an axillary node was observed in 3 patients (0.8?%) with SB alone and in no patients with the combination method.

Conclusions

ICG-FI is a useful method and is especially recommended in cases where no radiotracers are available.     

Responsiveness and interpretability of incontinence severity scores and FIQL in patients with fecal incontinence: a secondary analysis from a randomized controlled trial

Introduction and hypothesis

This study aims to assess the responsiveness and interpretability of the Vaizey score, Wexner score, and the Fecal Incontinence Quality of Life Scale (FIQL) for use in the evaluation of patients with fecal incontinence (FI).

Methods

Eighty patients with FI with a mean age of 59.3 (SD?±?11.9) were enrolled in a randomized controlled trial. The patient-reported outcomes were tested for internal and external responsiveness, longitudinal construct validity, and interpretability.

Results

All total scores proved to have both adequate to excellent responsiveness and longitudinal construct validity, and changes were in agreement with subjective improvement. Due to variability in minimally important change estimates (Vaizey score ?5 to ?3, Wexner score ?3 to ?2, FIQL 1.1 to 1.2), they should be used as indicators. All patient-reported outcomes showed psychometric or practical limitations.

Conclusions

The instruments available to date to evaluate severity and quality of life in FI do not yet attain the highest levels of psychometric soundness. As the focus of patients may differ from that of physicians, it is recommended that several measures should be included for evaluation. So far, there are suggestions that the Wexner score is most suitable for severity assessment and the FIQL for evaluating quality of life.     

Surgical Needs of Nepal: Pilot Study of Population Based Survey in Pokhara,Nepal

Background

The Surgeons OverSeas assessment of surgical need (SOSAS) tool, a population-based survey on surgical conditions in low- and middle-income countries (LMICs), was performed in Sierra Leone and Rwanda. This pilot study in Nepal is the initial implementation of the SOSAS survey in South Asia.

Methods

A pilot study of SOSAS, modified for Nepal’s needs and reprogrammed using mobile data collection software, was undertaken in Pokhara in January 2014. Cluster randomized sampling was utilized to interview 100 individuals in 50 households within two wards of Pokhara, one rural and one urban. The first portion of the survey retrieved demographic data, including household members and time to nearest health facilities. The second portion interviewed two randomly selected individuals from each household, inquiring about surgical conditions covering six anatomical regions.

Results

The pilot SOSAS in Nepal was easily completed over 3 days, including training of 18 Nepali interns over 2 days. The response rate was 100 %. A total of 13 respondents had a current surgical need (face 4, chest 1, back 1, abdomen 1, groin 3, extremity 3), although eight reported there was no need for surgical care. Five respondents (5 %) had a current unmet surgical need.

Conclusion

The SOSAS pilot study in Nepal was successfully conducted, demonstrating the feasibility of performing SOSAS in South Asia. The estimated 5 % current unmet surgical need will be used for sample size calculation for the full country survey. Utilizing and improving on the SOSAS tool to measure the prevalence of surgical conditions in Nepal will help enumerate the global surgical burden of disease.     

The effect of obesity on fecal incontinence symptom distress, quality of life, and diagnostic testing measures in women

Introduction and hypothesis

Weight-loss has been demonstrated to result in an improvement in fecal incontinence (FI) severity; however, there is a paucity of data addressing the differential impact of FI on the quality of life (QOL) and results of diagnostic testing across BMI categories. We wished to evaluate symptom distress, QOL, and diagnostic testing parameters among normal, overweight, and obese women with fecal incontinence.

Methods

Women undergoing evaluation for FI between 2003 and 2012 were identified. Participants completed validated, symptom-specific distress, impact, and general QOL measures including the Modified Manchester Questionnaire (MMHQ), which includes the Fecal Incontinence Severity Index (FISI), and the mental and physical component summary scores, MCS and PCS, respectively, of the Short Form-12. Anorectal manometry measures were also included. Multivariate regression analyses were performed.

Results

Participants included 407 women with a mean age ± SD of 56?±?13. Multivariate analyses revealed no differences in symptom-specific distress and impact as measured by MMHQ, MCS, and PCS across BMI groups; however, obese women had increased resting and squeeze pressures compared with normal and overweight BMI women (p?<?0.0001 and p?<?0.0001; p?=?0.007 and p?=?0.004 respectively).

Conclusions

Obese women with FI did not have more general impact and symptom-specific distress and impact on quality of life compared with normal and overweight women. Obese women with FI had higher baseline anal resting and squeeze pressures suggesting a lower threshold to leakage with pressure increases.     

Vitamin D deficiency is associated with increased fecal incontinence symptoms

Introduction and hypothesis

Vitamin D is an important micronutrient in muscle function. We hypothesize that vitamin D deficiency may contribute to fecal incontinence (FI) symptoms by affecting the anal continence mechanism. Our goal was to characterize the association of vitamin D deficiency as a variable affecting FI symptoms and its impact on health-related quality of life (HR-QoL).

Methods

This case–control study assessed women seen at a tertiary-care referral center. Participants were identified as having had a serum vitamin D level obtained within a year of their visit: cases were women presenting for care for FI symptoms; controls were women without any pelvic floor symptoms presenting to the same clinical site for general gynecologic care. Cases completed the Modified Manchester Health Questionnaire (MMHQ) and the Fecal Incontinence Severity Index to measure symptom severity and burden on QoL.

Results

Among the 31 cases and 81 controls, no demographic or medical differences existed. Women with FI had lower vitamin D levels (mean 29.2?±?12.3 cases vs. 35?±?14.1 ng/ml controls p?=?0.04). The odds of vitamin D deficiency were higher in women with FI compared with controls [odds ratio (OR) 2.77, 95 % confidence interval (CI) 1.08–7.09]. Among cases, women with vitamin D deficiency (35 %) had higher MMHQ scores, indicating greater FI symptom burden [51.3?±?29.3 (vitamin D deficient) vs. 30?±?19.5 (vitamin D sufficiency), p?=?0.02]. No differences were noted for FI severity, p?=?0.07.

Conclusions

Vitamin D deficiency is prevalent in women with fecal incontinence and may contribute to patient symptom burden.     

Endoscopic piecemeal resection of large colorectal polyps with long-term followup

Background

Colonoscopic removal of large colorectal polyps is challenging and requires advanced endoscopic technique. Successful endoscopic management not only avoids the morbidity of surgery but also risks perforation, hemorrhage, and recurrence.

Methods

This study is a retrospective review of a prospectively maintained database of all patients undergoing cautery snare piecemeal polypectomy for large colorectal polyps by a single operator over 20 years with long-term followup.

Results

231 patients underwent 269 piecemeal polypectomies over a 20 year period. The complication rate was 4.3 %. Malignancy was identified in 25 (10.8 %) of patients. Local recurrences occurred in 24 % of patients with benign adenomas. The vast majority of these were managed with repeat endoscopy. Overall, benign large polyps were managed successfully endoscopically in 94.4 % of patients.

Conclusions

Piecemeal polypectomy is effective and safe for the management of large colorectal polyps. With long-term followup, the recurrence rate is appreciable, but most recurrences can be successfully managed with further endoscopic intervention. More complex techniques such as endoscopic submucosal dissection are usually unnecessary.