Outpatient hysteroscopy is effective for uterine cavity evaluation following failed office-based endometrial biopsy.

BACKGROUND: Failure to obtain an office-based endometrial biopsy for abnormal uterine bleeding is not uncommon. Although operating room-based procedures are traditionally considered the gold standard assessment tool in these circumstances, outpatient hysteroscopy is a less invasive, more cost-effective, and safer alternative. However, there is no contemporary Canadian literature on the effectiveness of an outpatient approach for this specific population. OBJECTIVE: We aim to evaluate the effectiveness and outcomes of outpatient hysteroscopy for uterine cavity evaluation for patients who have failed an in-office endometrial biopsy attempt. METHODS: We conducted a retrospective cohort study of all patients referred to an academic outpatient hysteroscopy unit between January 2015 and January 2018, who underwent an outpatient hysteroscopy following failed endometrial biopsy. Data were collected from electronic medical records. RESULTS: Of the 407 consecutive patients who underwent an outpatient hysteroscopic procedure, 68 met inclusion criteria. Postmenopausal bleeding was the most common indication for initial biopsy, and most failures were attributed to cervical stenosis. Outpatient hysteroscopies were successfully completed in 96% of cases (n = 65/68). Failure resulted from either anxiety and discomfort (n = 2), or severe intrauterine adhesions (n = 1). Overall, 10% of patients subsequently required an operating room-based hysteroscopy, either to complete a myomectomy or polypectomy, or to allow general anesthesia. Outpatient hysteroscopy identified endometrial hyperplasia and cancer in 4.5% and 3% of patients, respectively. CONCLUSION: Outpatient hysteroscopy following unsuccessful office endometrial biopsy attempts appears to be a feasible, safe, and cost-effective investigation strategy that may prevent the need for an operating room-based procedure in 90% of cases.

Enhanced Recovery After Surgery in Older Adults Undergoing Colorectal Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

BACKGROUND: Enhanced recovery after surgery is increasingly applied in older adults undergoing colorectal surgery. OBJECTIVE: This systematic review and meta-analysis evaluated the impact of enhanced recovery protocols on clinical outcomes including hospital-acquired geriatric syndromes in older adults undergoing colorectal surgery. DATA SOURCES: This review was conducted according to PRISMA guidelines. Ovid MEDLINE, Embase, PsycINFO, Scopus, Cochrane Central Register of Controlled Trials, CINAHL, and trial registry databases were searched (January 1980 to April 2020). STUDY SELECTION: Two researchers independently screened all articles for eligibility. Randomized controlled trials evaluating enhanced recovery protocols in older adults undergoing colorectal surgery were included. INTERVENTION: The enhanced recovery protocol was utilized. MAIN OUTCOME MEASURES: Primary outcomes of interest were functional decline and delirium. Other outcomes studied were length of stay, complications, readmission, mortality, gut function, mobilization, pain, reoperation, quality of life, and psychological status. RESULTS: Seven randomized trials (n = 1277 participants) were included. In terms of hospital-acquired geriatric syndromes, functional decline was reported in 1 study with benefits reported in enhanced recovery after surgery participants, and meta-analyses showed reduced incidence of delirium (risk ratio, 0.45; 95% CI, 0.21-0.98). Meta-analyses also showed reduction in urinary tract infections (risk ratio, 0.53; 95% CI, 0.31-0.90), time to first flatus (standardized mean differences, -1.00; 95% CI, -1.98 to -0.02), time to first stool (standardized mean differences, -0.59; 95% CI, -0.76 to -0.42), time to mobilize postoperatively (standardized mean differences, -0.92; 95% CI, -1.27 to -0.58), time to achieve pain control (standardized mean differences, -0.59; 95% CI, -0.90 to -0.28), and hospital stay (mean differences, -2.20; 95% CI, -3.46 to -0.94). LIMITATIONS: The small number of randomized trials in older adults is a limitation of this study. CONCLUSIONS: Enhanced recovery protocols in older adults undergoing colorectal surgery appear to reduce the incidence of delirium and functional decline, 2 important hospital-acquired geriatric syndromes, as well as to improve other clinical outcomes. Future research should measure these geriatric syndromes and focus on high-risk older adults including those with frailty.

Recurrence and colon cancer-specific death in patients with large bowel obstruction requiring urgent operation: a competing risks analysis.

AIM: Clinical presentation with large bowel obstruction has been proposed as a predictor of poor long-term oncological outcomes after resection for colorectal cancer. This study examines the association between obstruction and recurrence and cancer-specific death after resection for colon cancer. METHOD: Consecutive patients who underwent resection for colon cancer between 1995 and 2014 were drawn from a prospectively recorded hospital database with all surviving patients followed for at least 5 years. The outcomes of tumour recurrence and colon cancer-specific death were assessed by competing risks multivariable techniques with adjustment for potential clinical and pathological confounding variables. RESULTS: Recurrence occurred in 271 of 1485 patients who had a potentially curative resection. In bivariate analysis, obstruction was significantly associated with recurrence [hazard ratio (HR) 2.23, CI 1.52-3.26, p < 0.001] but this association became nonsignificant after adjustment for confounders (HR 1.53, CI 0.95-2.46, p = 0.080). Colon cancer-specific death occurred in 238 of 295 patients who had a noncurative resection. Obstruction was not significantly associated with cancer-specific death (HR 1.02, CI 0.72-1.45, p = 0.903). In patients who had a noncurative resection, the competing risks incidence of colon cancer-specific death was not significantly greater in obstructed than in unobstructed patients (HR 1.02, CI 0.72-1.45, p = 0.903). CONCLUSION: Whilst the immediate clinical challenge of an individual patient presenting with large bowel obstruction must be addressed by the surgeon, the patient's long-term oncological outcomes are unrelated to obstruction per se.

Evaluating the Prevalence of Regret With the Decision to Proceed With a Hysterectomy in Women Younger than Age 35.

OBJECTIVE: This study sought to evaluate prevalence of regret with the decision to undergo a hysterectomy at a young age. METHODS: A retrospective cohort study was performed at two centres and included patients who underwent an elective hysterectomy for benign indications under age 35, between January 1, 2008 and December 31, 2015. Eligible patients were contacted and completed a validated decision regret survey and patient health questionnaire. RESULTS: A total of 189 patients met the study criteria. Of the 95 patients who could be contacted, 71 consented to participate (response rate, 75%). The most common indications for surgery were menorrhagia (35.2%), uterine fibroids (22.5%), endometriosis (19.7%), and pain (15.5%). Overall, 91.5% of patients agreed that having this surgery was the right decision for them, and 90% said that they would make the same choice in the future. A total of 2.8% regretted the choice that they made, and 14% responded that this caused them harm. Over 95% of patients reported that the decision was either mostly patient driven or shared with the physician. CONCLUSION: This is the first evaluation of regret after hysterectomy specifically examining a younger patient population. The study results suggest that patients who are appropriately counselled do not regret their decision to proceed with hysterectomy.

Global Prevalence of Helicobacter pylori Infection: Systematic Review and Meta-Analysis.

BACKGROUND & AIMS: The epidemiology of Helicobacter pylori infection has changed with improvements in sanitation and methods of eradication. We performed a systematic review and meta-analysis to evaluate changes in the global prevalence of H pylori infection. METHODS: We performed a systematic search of the MEDLINE and EMBASE databases for studies of the prevalence of H pylori infection published from January 1, 1970 through January 1, 2016. We analyzed data based on United Nations geoscheme regions and individual countries. We used a random effects model to calculate pooled prevalence estimates with 95% confidence intervals (CIs), weighted by study size. We extrapolated 2015 prevalence estimates to obtain the estimated number of individuals with H pylori infection. RESULTS: Among 14,006 reports screened, we identified 263 full-text articles on the prevalence of H pylori infection; 184 were included in the final analysis, comprising data from 62 countries. Africa had the highest pooled prevalence of H pylori infection (70.1%; 95% CI, 62.6-77.7), whereas Oceania had the lowest prevalence (24.4%; 95% CI, 18.5-30.4). Among individual countries, the prevalence of H pylori infection varied from as low as 18.9% in Switzerland (95% CI, 13.1-24.7) to 87.7% in Nigeria (95% CI, 83.1-92.2). Based on regional prevalence estimates, there were approximately 4.4 billion individuals with H pylori infection worldwide in 2015. CONCLUSIONS: In a systematic review and meta-analysis to assess the prevalence of H pylori infection worldwide, we observed large amounts of variation among regions-more than half the world's population is infected. These data can be used in development of customized strategies for the global eradication.

Oral and upper gastrointestinal Crohn's disease.

Crohn's disease is a heterogeneous, inflammatory condition that can affect any location of the gastrointestinal tract. Proximal gastrointestinal involvement occurs in 0.5-16% of patients, and it is usually diagnosed after recognition of intestinal disease. Symptoms are often mild and nonspecific; however, upper gastrointestinal disease predicts a more severe Crohn's phenotype with a greater frequency of complications such as obstruction and perforation. Gastroscopy and biopsy is the most sensitive diagnostic investigation. There is a paucity of data examining the treatment of this condition. Management principles are similar to those for intestinal disease, commencing with topical therapy where appropriate, progressing to systemic therapy such as glucocorticoids, 5-aminosalicylic acid, immunomodulators, and biologics. Acid suppression therapy has symptomatic but no anti-inflammatory benefit for gastroduodenal and esophageal involvement. Surgical intervention with bypass, strictureplasty, or less frequently, endoscopic balloon dilation may be required for complications or failed medical therapy.

Normal Values and Clinical Use of Bedside Sonographic Assessment of Postoperative Gastric Emptying: A Prospective Cohort Study.

BACKGROUND: GI dysfunction is common after abdominal surgery. However, assessment and diagnosis currently lack objective measurement. OBJECTIVE: The purpose of this study was to evaluate the feasibility and clinical use of bedside sonographic assessment of gastric emptying by measuring the time to complete emptying of a standard volume of ingested water in patients after colorectal surgery. DESIGN: This was a prospective cohort study. SETTINGS: The study was conducted at a single tertiary institution in Sydney. PATIENTS: Healthy volunteers (n = 30) were studied to establish a reference range. Gastric emptying was then measured in patients (n = 39) before and after colorectal surgery. INTERVENTION: Assessment of gastric emptying was performed on days 1 to 4 by measuring antral cross-sectional area every 10 minutes after ingestion of 250 mL of water. MAIN OUTCOME MEASURES: The time to complete emptying of water was used as a surrogate measure of gastric emptying. Information concerning postoperative outcomes, GI symptoms, and recovery was also recorded. RESULTS: The median time to complete emptying of water for healthy volunteers was 20 minutes (range, 10-40 minutes). The study protocol was completed in 30 of 39 patients. The time to complete emptying of water on day 2 had the best discriminatory power to identify patients with ileus (sensitivity, 85.71%; specificity, 82.61%). Gastric emptying was normal in 20 of 30 (67%) patients, with only 1 case of ileus (false negative). These patients had less nausea (p = 0.0003), earlier intake of solid diet (p = 0.001), and shorter hospital stay (p = 0.040) compared with patients with abnormal gastric emptying. LIMITATIONS: Ultrasound is operator dependent with a learning curve. CONCLUSIONS: Bedside sonographic assessment of gastric emptying is feasible and reliable. Assessment of antral contents with a single ultrasound 40 minutes after ingestion of water enables classification of patients into those with normal and abnormal gastric emptying. When performed on postoperative day 2, it has good sensitivity/specificity for discriminating patients with ileus.

Young-onset colorectal cancer in New South Wales: a population-based study.

OBJECTIVE: Australia has the highest incidence of colorectal cancer (CRC) in the world. The incidence of young-onset CRC (yCRC) is increasing in developed nations. Our aim was to determine the incidence of yCRC in New South Wales, the demographic and clinico-pathological characteristics of these patients, and their survival. DESIGN, SETTING, PARTICIPANTS: A population-based cohort study of all cases of CRC diagnosed in NSW during 2001-2008. Data on newly diagnosed cases of CRC were obtained from the NSW Central Cancer Registry; mortality data were obtained from the NSW Registry of Births Deaths and Marriages (to 2012). The characteristics and tumour-related factors of patients under 50 years of age (yCRC) were compared with those for patients aged 50 years or more. MAIN OUTCOME MEASURES: Current incidence of yCRC and trends in incidence; 5-year cancer-specific survival rates and risks of death compared with older patients. RESULTS: 32 178 patients were diagnosed with CRC, including 2001 (6.2%) with yCRC. The incidence of yCRC was unchanged across the study period (2001, 13.7 cases per 100 000 population; 2008, 11.8 per 100 000; P = 0.26). Rectal cancer was more frequent in yCRC than in older patients (34.4% v 26.0%), as was distant disease (21.2% v 15.3%). However, 5-year cancer-specific survival was greater for patients with yCRC (68.8%; 95% CI, 66.2-71.2%) than for older patients (66.3%; 95% CI, 65.6-67.0%; P < 0.001). CONCLUSIONS: The incidence of yCRC did not increase in NSW during 2001-2008. Despite more advanced disease at presentation, cancer-specific survival was better than for older patients with CRC.

Prevalence of Uterine Myomas Among Women with 2 or More Recurrent Pregnancy Losses: A Systematic Review.

Recurrent pregnancy loss (RPL), defined as 2 or more failed clinical pregnancies, affects approximately 5% of reproductive women. Several etiologies for RPL have been studied including uterine myomas. However, the effect of uterine myomas on pregnancy outcomes in this patient population remains unclear. The purpose of this systematic review was to critically appraise the evidence associating uterine myomas with RPL and quantify the prevalence of uterine myomas in this patient population. The inclusion criteria included women of reproductive age with at least 2 or more recurrent, failed clinical pregnancies found to have a submucosal and/or intramural myoma distorting the uterine cavity on a hysterosalpingogram, a saline infusion sonogram, and/or hysteroscopy. Studies with biochemical pregnancies; molar, ectopic, and pregnancies of unknown location; pregnancies conceived with assisted-reproductive technologies; therapeutic abortions; subserosal myomas and intramural myomas not distorting the uterine cavity; studies using only 2-dimensional pelvic ultrasound; or studies in which no additional workup for RPL was initiated or in which multiple etiologies were included were omitted from this review. Risk of bias and quality assessment were conducted using the Quality Assessment Tool for Observational Cohort and Cross-sectional studies published by the National Institutes of Health. The electronic search yielded 934 citations. After title, abstract, and full-text screening, 3 studies had met the pre-established inclusion/exclusion criteria and were included in the review. The prevalence of submucosal and cavity-distorting myomas in women with 2 or more pregnancy losses was found to be 4.08% (29/711). The prevalence of uterine myomas was highest in women with 3 or more RPLs (5.91% [28/473]). No studies with a proper control group were identified. In summary, the association between uterine myomas and RPL remains unclear. High-quality studies are required to assert the impact of uterine myomas on pregnancy outcomes in this patient population. Patients with RPL and uterine myomas should be properly counseled regarding the existing evidence before surgical consideration.

Lymphatic injury at sacrocolpopexy: an unusual complication.

BACKGROUND: Lymphorrhea is a rare condition with a paucity of reports in the gynaecologic literature. The most frequent causes are invasive procedures and surgical interventions. CASE: A multiparous woman underwent a total abdominal hysterectomy with prophylactic bilateral salpingectomy and abdominal sacrocolpopexy for pelvic organ prolapse. During retroperitoneal dissection, clear fluid discharge was encountered. Ureteric injury was subsequently ruled out. A sample of the fluid was taken to confirm lymphatic injury. Ligation suture and closing the peritoneum slowed fluid drainage. CONCLUSION: To our knowledge, this is the first reported lymphatic injury in association with a urogynaecologic procedure. Gynaecologists should be aware of this potential complication and should have an approach to diagnosis and management. This case highlights the importance of intraoperative consultation.

Contexte : La lymphorrhée est un trouble rare n'ayant fait l'objet que de très peu de signalements au sein de la littérature gynécologique. Les interventions effractives et les interventions chirurgicales en constituent les causes les plus fréquentes. Cas : Une femme multipare a subi une hystérectomie abdominale totale (s'accompagnant d'une salpingectomie bilatérale prophylactique) et une sacrocolpopexie abdominale (pour contrer le prolapsus des organes pelviens). Au cours de la dissection rétropéritonéale, un écoulement de liquide transparent a été constaté. La présence d'une lésion urétérale a par la suite été écartée. Un échantillon de ce liquide a été prélevé afin de confirmer la présence d'une lésion lymphatique. La mise en place de ligatures et la fermeture du péritoine ont ralenti le drainage du liquide. Conclusion : À notre connaissance, il s'agit du premier signalement d'une lésion lymphatique associée à une intervention urogynécologique. Les gynécologues devraient être à l'affût de cette complication potentielle et disposer d'une approche envers son diagnostic et sa prise en charge. Ce cas souligne l'importance de la consultation peropératoire.

Long lasting effect on testes following methylene blue injection in laparoscopic lymphatic sparing varicocelectomy.

OBJECTIVE: Injection of methylene blue to testis has been shown to have adverse effect in animal studies but it is still being used frequently as lymphatic mapping agent during lymphatic sparing varicocelectomy in adolescent varicoceles. We aim to report postoperative ultrasound changes after subaortic injection of methylene blue in human testes. STUDY DESIGN: A retrospective observational study of consecutive patients under 18 years old undergoing laparoscopic varicocelectomy from August 2017 to August 2021 was performed. Demographics such as age, symptoms, pre-operative testicular volume was collected. Primary outcome was change on testicular ultrasound at 3, 6, 12 months after the operation. Secondary outcome was testicular volume difference between affected and unaffected testes, and growth rate of affected testis at 1 year after the operation. RESULTS: Fifty-eight patients were included, with median age of 15 years old (IQR 11-18 years). Thirty-one patients had non-lymphatic sparing varicocelectomy (Group A) and 27 patients had lymphatic sparing varicocelectomy (Group B). There was no statistical difference between the mean testicular volume difference between the two groups, but hydrocele rate was significantly higher in Group A (16% vs 0%, p = 0.03). In group B, 6 patients (22.2%, p = 0.005) developed testicular change detectable by ultrasound. No statistical difference could be demonstrated for median testicular size difference (between affected and unaffected testes) at 1 year between group with and without ultrasound change (-23% vs 0%, p = 0.36). Median follow up time was 20.4 months (IQR 5-32 months). DISCUSSION: Varicocele treatments improve testicular volume and increase total sperm concentration and lymphatic sparing surgery significantly decreased post-operative hydrocele rates [2]. Different agents have been used to delineate lymphatic vessels and one commonly used agent is methylene blue [10,15-16]. However it has been shown in other animal studies that intraparenchymal injection of methylene blue to rat testis result in degenerative changes [18]. Our study is the first to describe post-operative changes of human testes on imaging after lymphatic sparing varicocelectomy with subdartoic injection of methylene blue. Six patients (22.2%) demonstrated new onset testicular changes on post-operative ultrasound. Although no statistically significant testicular volume reduction was seen in the group with change on imaging, these observations may serve as a surrogate marker for testicular injury or reduced testicular function. It will be desirable for future studies if we can investigate it further with hormonal markers or semen analysis after puberty has been reached. CONCLUSION: Lymphatic sparing procedure reduced post-operative hydrocele in adolescent varicocele, however long-lasting effect on testis is evident with subdartoic injection of methylene blue. This agent must be used with caution and long term follow up of these patients are needed.

Prehabilitation Before Gastrointestinal Cancer Surgery: Protocol for an Implementation Study.

BACKGROUND: Surgery remains the standard curative treatment for early-stage colorectal and upper gastrointestinal cancer. Reduced preoperative functional capacity, nutritional status, and psychological well-being are associated with poor postoperative outcomes. Prehabilitation aims to improve preoperative functional reserves through physical, nutritional, and psychological interventions. Yet, how it transitions from a trial setting to being integrated into a real-world health setting is unknown. OBJECTIVE: The primary aim is to evaluate the implementation of a multimodal (supervised exercise, nutrition, and nursing support) prehabilitation program into standard care for patients with gastrointestinal cancer (colorectal and upper gastrointestinal cancer) scheduled for curative intent surgery. The secondary aim is to determine the impact of a multimodal prehabilitation program on functional capacity, nutritional and psychological status, and surgical outcomes. METHODS: This is an implementation study that will investigate a multimodal prehabilitation intervention, in a nonblinded, nonrandomized, single-group, pre-post design. Patients diagnosed with colorectal and upper gastrointestinal cancer scheduled for potentially curative intent surgery at Concord Repatriation General Hospital, with ≥14 intervention days prior to surgery and are medically cleared to exercise will be eligible. The study will be evaluated using the Reach, Effectiveness, Adoption, Implementation, and Maintenance Evaluation Framework. RESULTS: The protocol was approved in December 2019 by the Concord Repatriation General Hospital Human Research Ethics Committee (reference number 2019/PID13679). Recruitment commenced in January 2020. In response to the COVID-19 pandemic, recruitment was paused in March 2020 and reopened in August 2020 with remote or telehealth intervention adaptations. Recruitment ended on December 31, 2021. Over the 16-month recruitment period, a total of 77 participants were recruited. CONCLUSIONS: Prehabilitation represents an opportunity to maximize functional capacity and improve surgical outcomes. The study will provide guidance and contribute to the evidence on the integration of prehabilitation into standard care using adaptive models of health care delivery including telehealth. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry ACTR 12620000409976; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378974&isReview=true. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/41101.

Short-term multimodal prehabilitation improves functional capacity for colorectal cancer patients prior to surgery.

AIM: Evaluate feasibility and outcomes of a multimodal prehabiliation program in patients with stage I-III colorectal cancer (CRC) awaiting surgery. METHODS: Patients scheduled for elective CRC resection at Concord Repatriation General Hospital were recruited from pre-admission clinic between January and November 2018. Participants received a 2-4 week prehabilitation program consisting of supervised exercise sessions, nurse-led phone support, and written nutritional information. Participants were assessed at baseline, pre-surgery, and 4 weeks post-surgery. RESULTS: Twenty-two patients participated in the program: 55% male; median age 73 (56-86) years. Six (28%) required an interpreter. At baseline, 19 of 22 (86%) had at least one comorbidity. Median intervention length was 11.5 days (range 7-29). Participants attended 79% of scheduled exercise sessions (range 33-100%, mean 3.5 sessions) and 66% of nurse support calls (range 0-100%, mean 2.6 sessions). Between baseline and pre-surgery, participants reported increasing mean unsupervised moderate-intensity aerobic exercise from 17 (range 0-210) to 73 minutes/week (range 0-276) and mean vigorous-intensity aerobic exercise from 0 to 24 minutes/week (range 0-300). Resistance exercise sessions increased from 0.6 to 2.6 times/week. Mean 6-minute walk test distance increased by 48 meters (435-483 m) and 30-second "sit to stand" by 1.6 repetitions. Small improvements were seen in global quality of life and fatigue. Nutritional status and body composition remained unchanged. All participants were satisfied/strongly satisfied with the program and would recommend it to others. CONCLUSION: Our multimodal prehabilitation program was feasible in CRC patients inclusive of those from non-English speaking backgrounds, with improvement in functional capacity before CRC surgery.