Colonoscopic findings in patients with pelvic floor dysfunction.

BACKGROUNDY: Colonoscopy is often performed in the initial workup of pelvic floor dysfunction, even in the absence of red flag symptoms. Current guidelines suggest colonoscopy is only required in the presence of rectal bleeding, diarrhoea or change in bowel habit. The aim of this study was to evaluate the prevalence of significant pathology found at colonoscopy in patients with pelvic floor dysfunction. METHODS: Retrospective chart review was performed on all patients presenting to a functional colorectal outpatient clinic between May 2018 and August 2019. Information was collected on presenting symptoms, whether colonoscopy had been performed within 5 years, quality of bowel preparation, withdrawal time, number of polyps detected, histology, presence of diverticular disease, colorectal malignancy, inflammatory bowel disease, solitary rectal ulcer or rectal prolapse. RESULTS: There were 260 patients seen within the study period, of which 67% had undergone recent colonoscopy within the last 5 years. The mean age was 53 and 219 (84%) patients were female. Average withdrawal time was 13 min. Polyps were found in 48.7% and adenomas in 32.4% of all colonoscopies. The adenoma detection rate was 32.7%. None of the colonoscopies found evidence of malignancy. A new diagnosis of inflammatory bowel disease was discovered in two patients. CONCLUSION: There was low rates of serious pathology such as malignancy or inflammatory bowel disease in patients referred to a functional clinic. However, colonoscopy is still useful in workup of pelvic floor dysfunction, as many patients have erratic bowel habits or vague symptoms, and will have adenomas found.

Body mass index and surgical outcomes in laparoscopic liver resections: a systematic review.

BACKGROUND: Laparoscopic liver resection is gaining momentum; however, there is limited evidence on its efficacy and safety in obese patients. The aim of this study was to examine the relationship between BMI and outcomes after laparoscopic liver resection (LLR) using a systematic review of the existing literature. METHODS: A systematic search of Medline (Ovid 1946-present), PubMed (NCBI), Embase (Ovid 1966-present) and Cochrane Library was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement for parameters of LLR and BMI. Operative, post-operative and oncological outcomes were recorded. RESULTS: Of 1460 abstracts, seven retrospective studies were analysed, published between 2015 and 2017 (study periods 1998-2017). Total patient cohort were classified as 481 obese and 1180 non-obese with a median age range of 42.5-69.4 years. Variations existed in definitions of obesity (Asia BMI >25 kg/m2 , Western BMI >30 kg/m2 ). Rates of conversion were examined in four studies (0-31%) with one reporting BMI >28 kg/m2 as an independent risk factor. Estimated blood loss and transfusion rates were similar. Operative time was increased in obese patients in one study (P = 0.02). Mortality rates ranged from 0% to 4.3% with no difference between BMI classes. No difference in major morbidity was demonstrated. Bile leak rates were increased in obese groups in one study (0-3.44%, P < 0.05). Wound infections were reported in five studies, with higher rates in obese patients (0-5.8% versus 0-1.9%). Tumour size was comparable in both groups. Completeness of resection was analysed in four studies with one study reporting increased R0 rates in obese patients (P = 0.012). CONCLUSION: This systematic review highlights that current evidence shows LLR in obese patients is safe, however, further studies are required.

Perforation of gastric volvulus within a giant hiatus hernia secondary to alendronate: A rare complication of bisphosphonate use.

INTRODUCTION: Bisphosphonates are commonly used in the treatment of metabolic bone disease. However, they are associated with gastrointestinal side effects including acid reflux, mucosal erosion, and oesophageal stricture. We present a rare case of alendronate causing perforated gastric volvulus in a patient with giant hiatus hernia. PRESENTATION OF CASE: An 82-year-old woman presented to our hospital with central chest pain, palpitations and new onset atrial fibrillation on the background of 2 weeks of vomiting. Computed tomography (CT) imaging revealed a perforated, mixed type organoaxial/mesoenteroaxial gastric volvulus within a giant hiatus hernia, with partial gastric outlet obstruction. The patient underwent laparoscopic reduction of hiatus hernia and gastric volvulus, conversion to laparotomy, and distal gastrectomy with Bilroth II reconstruction. An alendronate tablet was found in the right mediastinum. The patient had a prolonged post-operative course and was discharged home after completing extensive physical rehabilitation. DISCUSSION: Bisphosphonates are widely used to treat metabolic bone disease, however can have devastating adverse effects on the gastrointestinal tract. There are a number of mechanisms postulated for how these medications cause injury to the gastric and oesophageal mucosa. CONCLUSION: This case illustrates the importance of considering the gastrointestinal effects associated with bisphosphonates when prescribing them to patients, especially those with functional or anatomical disorders of the gastrointestinal tract. The presence of a large hiatus hernia should be a contraindication to prescribing alendronate.

Laparoscopic paraduodenal hernia repair with bioabsorbable mesh: A case of a novel technique for a rare cause of bowel obstruction.

INTRODUCTION: Paraduodenal hernias are the most common type of internal hernia but a rare cause of bowel obstruction. Given the high risk of incarceration, obstruction and associated mortality, surgical repair is recommended. PRESENTATION OF CASE: We present a novel technique for laparoscopic repair of paraduodenal hernia using biosynthetic mesh to reinforce suture closure of the hernia defect. An 18-year-old healthy female presented with symptoms of recurrent subacute small bowel obstruction and right paraduodenal hernia was diagnosed on computed tomography (CT). Laparoscopic repair was performed with reinforcement of suture repair with GORE® BIO-A® Hiatal Tissue Reinforcement to decrease the risk of recurrence. The patient had an uneventful recovery and was discharged on the second post-operative day. Subsequent follow-up revealed complete resolution of symptoms. DISCUSSION: Biosynthetic tissue reinforcement carries a lower theoretical risk of erosion than permanent mesh. A hiatal-shaped prosthesis represents a suitable shape for paraduodenal hernia repair. CONCLUSION: We present the first reported use of bioabsorbable mesh to repair paraduodenal hernia. This technique may minimise risk of mesh erosion and can be considered a safe and effective approach where suture repair is inadequate due to large defect size.

Coronary CT radiation dose reduction strategies at an Australian Tertiary Care Center - improvements in radiation exposure through an evidence-based approach.

INTRODUCTION: Coronary CT Angiography (CCTA) is a rapidly increasing technique for coronary imaging; however, it exposes patients to ionising radiation. We examined the impact of dose reduction techniques using ECG-triggering, kVp/mAs reduction and high-pitch modes on radiation exposure in a large Australian tertiary CCTA service. METHODS: Data on acquisition modes and dose exposure were prospectively collected on all CCTA scans from November 2009 to March 2014 at an Australian tertiary care centre. A dose reduction algorithm was developed using published techniques and implemented with education of medical staff, radiographers and referrers. Associations of CCTA acquisition to radiation over time were analysed with multivariate regression. Specificity in positive CCTA was assessed by correlation with invasive coronary angiography. RESULTS: 3333 CCTAs were analysed. Mean radiation dose decreased from 8.4 mSv to 5.3, 4.4, 3.7, 2.9 and 2.8 mSv (P < 0.001) per year. Patient characteristics were unchanged. Dose reduction strategies using ECG-triggering, kVp/mAs reduction accounted for 91% of the decrease. High-pitch scanning reduced dose by an additional 9%. Lower dose was independently related to lower kVp, heart rate, tube current modulation, BMI, prospective triggering and high-pitch mode (P < 0.01). CCTA specificity remained unchanged despite dose reduction. CONCLUSION: Implementation of evidence-based CCTA dose reduction algorithm and staff education programme resulted in a 67% reduction in radiation exposure, while maintaining diagnostic specificity. This approach is widely applicable to clinical practice for the performance of CCTA.