No Surgery for Full-Thickness Rectal Prolapse: What Happens with Continence?

Background

Surgery is the only validated means of treating overt rectal prolapses, but both patients and physicians may decline or postpone the surgical approach. However, little is known on the functional outcome of nonoperated rectal prolapse. The aim of the present study was to highlight the natural history of overt rectal prolapse in patients for whom surgery was avoided or delayed.

Patients and methods

A total of 206 patients complaining of full-thickness rectal prolapse were referred to a single institution that provided anorectal physiology for functional anorectal disorders. Standardized questionnaires, anorectal manometry, endosonography, and evacuation proctography constituted a prospective database. Fecal incontinence was evaluated with the Cleveland Clinic score (CCIS), and constipation was evaluated with the Knowles Eccersley Scott Symptom score (KESS).

Results

Forty-two nonoperated patients (mean age: 61 ± 16 years) were compared to those of operated patients paired according to age and gender: the mean follow-up was 44 ± 26 months. The two groups had a similar past-history, follow-up, stool frequency, and main complaints, but lower quantified symptomatic scores and a better quality of life were reported in the nonsurgical group. At the end of follow-up, the nonsurgical group did not show any variation in CCI and KESS scores. By contrast, these two scores significantly improved in the rectopexy group. Sixteen nonoperated patients experienced a degradation of their continence status with an average increase of 5 ± 4.3 points of the CCIS. The patients with a CCIS <7 at referral were likely to deteriorate as compared to those having a higher score. Patients with a symptom history longer than 4 years never improved and in two-thirds continence deteriorated throughout the follow-up.

Conclusion

In the absence of the surgical option, patients with a 4-year duration of rectal prolapse and those with mild incontinence had no chance of improvement. These findings may be taken into account when surgery of rectal prolapse is not chosen.     

GLP-1 Response to a Mixed Meal: What Happens 10 Years after Roux-en-Y Gastric Bypass (RYGB)?

Background

Oral meal consumption increases glucagon-like peptide 1 (GLP-1) release which maintains euglycemia by increasing insulin secretion. This effect is exaggerated during short-term follow-up of Roux-en-y gastric bypass (RYGB). We examined the durability of this effect in patient with type 2 diabetes (T2DM) >10?years after RYGB.

Methods

GLP-1 response to a mixed meal in the 10-year post-RYGB group (n?=?5) was compared to lean (n?=?9), obese (n?=?6), and type 2 diabetic (n?=?10) controls using a cross-sectional study design. Analysis of variance (ANOVA) was used to evaluate GLP-1 response to mixed meal consumption from 0 to 300?min, 0?C20?min, 20?C60?min, and 60?C300?min, respectively. Weight, insulin resistance, and T2DM were also assessed.

Results

GLP-1 response 0?C300?min in the 10-year post-RYGB showed a statistically significant overall difference (p?=?0.01) compared to controls. Furthermore, GLP-1 response 0?C20?min in the 10-year post-RYGB group showed a very rapid statistically significant rise (p?=?0.035) to a peak of 40?pM. GLP-1 response between 20 and 60?min showed a rapid statistically significant (p?=?0.041) decline in GLP-1 response from ~40?pM to 10?pM. GLP-1 response in the 10-year post-RYGB group from 60 to 300?min showed no statistically significant difference from controls. BMI, HOMA, and fasting serum glucose before and >10?years after RYGB changed from 59.9????40.4, 8.7????0.88, and 155.2????87.6?mg/dl, respectively, and were statistically significant (p?Conclusions An exaggerated GLP-1 response was noted 10?years after RYGB, strongly suggesting a durability of this effect. This phenomenon may play a key role in maintaining type 2 diabetes remission and weight loss after RYGB.     

Lower Urinary Tract Reconstruction for Ectopic Ureterocele: What Happens in the Long-term Follow-up?

BackgroundWe aimed to analyze the long-term clinical and lower urinary tract function outcomes in children with duplex system ectopic ureterocele who underwent ureteroneocystostomy and ureterocelectomy.MethodsFifty-one patients (28 females, 23 males) who underwent a series of surgical interventions including lower urinary tract reconstruction in childhood for duplex system ectopic ureterocele in our center between 1998 and 2019, were retrospectively reviewed. The demographic and clinical data, surgical history, and the indication for ureterocelectomy were noted. Lower urinary tract dysfunction (LUTD) status was assessed through dysfunctional voiding symptom scores (DVSS) and uroflowmetry in all patients at the last follow-up. The clinical outcomes, and LUTD were evaluated.ResultsAt the last visit at a mean follow-up of 117.18 ± 57.87 months after ureterocelectomy, ipsilateral persistent lower pole VUR was detected in 5.6% (3/54 renal units, 2 females and 1 male) of the cases, who were treated using the subureteric injection. Abnormal DVSS (median 11, range 9–15) was detected in 27.4% (14/51 pts) of the patients. Out of these, 57.1% (8/14 pts) had storage symptoms, 35.7% (5/14 pts) had voiding symptoms, and 7.1% (1/14 pts) had both storage and voiding symptoms while 71.4%(10/14 pts) had abnormal uroflowmetry findings (plateau shaped flow curve in 2, staccato shaped curve with sustained EMG activity in 3, tower shaped curve in 2, interrupted shaped curve in 3 patients). Five patients had elevated residual volume. Anticholinergics were administered to six patients who had overactive bladder symptoms. In addition, two girls required open bladder neck reconstruction due to stress incontinence caused by bladder neck insufficiency.ConclusionsOur findings showed that clinical success was achieved using the lower urinary tract reconstruction with no need for re-operation in 90.2% of patients with duplex system ectopic ureterocele. However, LUTD was present in 27.4% of our patients in the long-term follow-up. Therefore, LUTD should be carefully assessed in the long-term follow-up of these patients.     

Twenty Years Trying to Protect the Brain: What Do We Know?

Thirty-five years ago at the Nixon Watergate hearings, a young attorney named Fred Thompson, current US presidential candidate, asked "What did the President know and when did he know it?" A couple of word changes and this question would be appropriate to ask any number of surgical specialties regarding negative neurologic outcomes. Even today, some specialties are in denial about impaired brain function after surgical intervention. Fortunately, the cardiac surgery community has been in the forefront in efforts to protect the brain.     

What Becomes of Patients One Year after the Intragastric Balloon has been Removed?

Background:The BioEnterics Intragastric Balloon (BIB) is a saline-filled balloon recommended to remain in the gastric cavity for a maximum of 6 months. Is this short period sufficient to change patients' lifestyle and eating practices to maintain weight reduction after BIB removal? Methods: 100 patients who received a BIB were included in this prospective study and followed for 1 year after BIB removal. The post-implantation follow-up visits took place monthly, during which the patient was seen by the surgeon, dietitian, and if necessary, psychologist. Results: At BIB removal, mean weight loss for the group was 12.0 kg. Mean percent excess weight loss (%EWL) was 39.8%. 12 months after removal of the BIB, mean weight loss was 8.6 kg and mean %EWL was 26.8% for the group as a whole. Conclusions: The results 1 year after removal of the BIB were encouraging. Because the BIB is a temporary non-surgical and non-pharmaceutical treatment for obesity that is reversible and repeatable, we recommend it to patients who have previously failed traditional methods of weight reduction. Careful patient follow-up is of primary importance in avoiding complications and supporting efficacy of the treatment. Although 1 year follow-up cannot be considered long term, these results are encouraging. Concurrent behavior modification is needed for durable weight loss.     

Examining Nutrition Knowledge of Bariatric Surgery Patients: What Happens to Dietary Knowledge over Time?

Background

Nutrition education is a standard of care in bariatric surgery clinical practice guidelines. Despite its known importance, no studies have documented the trajectory of nutrition knowledge over the course of the bariatric surgery process. Primary objectives included determining changes in bariatric surgery nutrition knowledge scores from the pre-surgical phase to 1-month post-surgical intervention and investigating the impact of time on nutrition education retention in bariatric patients. Secondary objectives focused on the relationship between patients’ pre-operative anxiety and depression on nutrition knowledge retention.

Methods

Prior to data collection, patients attended a nutrition education class and met with a registered dietitian. One hundred and nineteen consented patients eligible for bariatric surgery completed a nutrition knowledge questionnaire, Eating After Bariatric Surgery (EABS) prior to and 1 month following bariatric surgery.

Results

Analyses revealed (1) patients’ nutrition knowledge (measured by EABS) significantly increased from the pre-operative phase (M?=?46.9; SD?=?14.4) to the post-operative phase ((M?=?56.9; SD?=?14.1), t(118)?=??8.01, p?<?.001); (2) time between the nutrition education class and patients’ surgery significantly impacted knowledge retained; (3) patients with higher pre-operative levels of depression and anxiety had significantly lower post-operative nutrition knowledge; and (4) gender differences in terms of patients’ nutrition knowledge.

Conclusions

This study confirmed that dietary knowledge significantly improves following surgical intervention. Furthermore, increased time in between receiving nutrition knowledge and surgery resulted in less retained knowledge 1-month post-op. Future education interventions for bariatric surgery programs should focus on addressing these factors to optimize patient knowledge and information retention after surgery.

     

Twenty Years of Biliopancreatic Diversion: What is the Goal of the Surgery?

Background: Comparative evaluation of weight loss after bariatric surgery is difficult without definition of success and without a norm for presenting results. We explored the pertinence of defining success: a residual BMI <40 or <35 kg/m², and the need for reporting results with stratification by initial obesity and length of follow-up. Methods: Results of 1,271 consecutive biliopancreatic diversion (BPD) patients were compared when presented with or without stratification, and we searched for landmarks of success which would be shared by patients themselves. Results: Presented globally, after a mean follow-up of 7.9 ± 4.2 years, BMI decreased from 48.4 ± 9.4 to 31.3 ± 6.5, and only 10% and 26% of patients would have been considered failures with a residual BMI ≥ 40 or ≥ 35 respectively. Because heavier patients were losing less in terms of percentage ( P <0.0001) and regained weight faster ( P <0.0001), global and cumulative results failed to show a failure-rate doubling every 5 years and a very high failure-rate in heavier patients. The landmarks of BMI 40 and 35 were the same unconsciously used by patients to express their own perception of failure. For patients with an initial BMI <50, a residual BMI of 35 caused a significant drop in the degree of satisfaction from 90 to 40%. For super-obese, the same critical point was found at a BMI of 40 where satisfaction dropped from 91 to 57%. Conclusion: Landmarks of success at BMI 40 and 35 were realistic, reasonable and coincided with patients' own expectations. Since initial obesity and duration after surgery made so much difference in results, a comparison of different surgical approaches was useless without stratification for both factors together.     

What Happens to a Published Article if a Cited Article Is Corrected?

When one considers that as many as 2.5 million scientific articles are published each year, it is likely that more than a few contain errors. Probably, most go undetected. In theory, scientific literature is self-correcting, and the truth will eventually be revealed. However, to maintain the integrity of our literature, it is best to correct errors. Fortunately, when it comes to an errant citation, most scientific citations provide background, and errors in background citations should not change the conclusion of a study. However, for systematic reviews that quantitatively synthesize published research findings in a meta-analysis, an error in (or retraction of) an included citation will affect the study results. Such errors require correction, revision of the meta-analysis, and electronic attachment of the notation to the publication.     

Tumor Markers for Pancreatic Cancer: What Happens When Preoperative CA 19--9 is Undetectable?

Annals of Surgical Oncology -