Effect of bariatric surgery on in vitro fertilization in infertile men with obesity.

BACKGROUND: Obesity has previously been related to reduced female fertility, with prolonged waiting time to pregnancy among women with a body mass index (BMI) >35 kg/m2 but there are few studies investigating the relationship between high BMI, bariatric surgery, and male fertility. OBJECTIVES: The primary objective of this article was to investigate the effect of bariatric surgery on in vitro fertilization (IVF) outcomes in a cohort of men with morbid obesity who underwent sleeve gastrectomy (SG). SETTING: University hospital, bariatric surgery unit. METHODS: Pre- and postsurgery data on patient age, body mass index (BMI), and variables related to male fertility (semen volume, concentration, progressively motile sperm count, and sperm morphology) were collected; assisted reproductive technology outcomes before and after bariatric surgery were measured by the number of metaphase II oocytes; the number of top-quality oocytes and embryos; the number of fertilized oocytes; the number of transferred embryo; the implantation rate; the pregnancy rate; the live birth rate and the miscarriage rate. RESULTS: Thirty-five men with obesity and idiopathic infertility were included in this study. We found a significant increase, after bariatric surgery, in semen volume, total sperm concentration, progressively motile sperm count, and sperm morphology. Considering IVF outcomes, mean number of top-quality oocytes, mean number of fertilized oocytes, mean number of embryos obtained, and top-quality embryos were significantly increased after bariatric procedure. CONCLUSION: Bariatric surgery is confirmed to be safe and effective in increasing the outcomes of assisted reproductive technology treatment also in case of infertile men with obesity, both in terms of pregnancy and live birth rate.

Endoscopic Treatment of Pilonidal Sinus Disease: State of Art and Review of the Literature.

Background: Pilonidal sinus disease (PSD) is a chronic troublesome pathology of the natal cleft of the sacrococcygeal region, with an estimated incidence of 26 cases in every 100,000 inhabitants. The aim of this review is to give a snapshot of the current literature on the endoscopic approach to PSD. Methods: A search on endoscopic treatment of pilonidal disease was performed according to PRISMA guidelines, adopting the following search terms: (pilonidal OR sacrococcygeal) and (endoscopic OR VAAPS OR EPSiT OR minimally invasive OR video-assisted OR video assisted). Results: Thirty-four articles were included in the final analysis, among which 23 were on adults and 11 were on pediatric population. The endoscopic approach is associated with painless postoperative pain, good aesthetic results, short time off work, and high patient satisfaction. Despite these advantages in short-term outcomes, results on recurrence rate in a long-term follow up are needed to definitively confirm the importance of this technique. Conclusions: The endoscopic approach is associated with significant postoperative advantages over other standard surgical approaches, and it should be included in the surgical portfolio for the treatment of PSD. According to the Italian guidelines, this technique could be considered as the gold standard for limited PSD. However, the favorable short-term-outcomes and lack of reliable data on long-term follow-up must be a stimulus to perform further high-quality studies to give definitive conclusions on this technique.

Endoscopic Approach to Recurrent Pilonidal Sinus: A Retrospective Analysis.

Background: The aim of this study is to report short- and long-term results using video-assisted ablation of pilonidal sinus (PS) technique to treat recurrent PS. Methods: We included all consecutive patients with a recurrent PS disease operated on with endoscopic approach since 1st January 2014 to 31st December 2018. Analyzed outcomes were recurrence rate at 1, 3, and 5 years, time off work, time to sitting on toilet and to walk without pain, time to wound healing, rate of incomplete wound healing and postoperative infection, postoperative pain at 6 hours, 1 day, and 1 week, and patients' satisfaction after 1 month. Demographic and sinuses' data were recorded. To adjust for all the variables, multivariate analyses were performed with outcomes as dependent variables, and with patients' and sinuses' characteristics as independent variables. Results: Sixty-three patients were included in the analysis. Recurrence rate at 1-year follow-up was 4.7% (3 patients on 63), at 3-year follow-up was 11.7% (4 on 34), and at 5-year follow-up was 23.07% (3 on 13). A 3- and 5-year follow-up was completed by 34 and 13 patients, respectively. The mean time off work was 3.5 ± 1.5 days, time to sitting on toilet without pain was 1.5 ± 1.1 days, and time to walk without pain was 1.3 ± 0.9 days. The mean time to wound healing was 27.9 ± 10.3 days, with a rate of incomplete wound healing of 4.7%. Postoperative infection rate was 7.9%. The mean postoperative pain was 1 ± 0.9 at 6 hours after the procedure, 0.6 ± 0.6 at 1 day and 0.1 ± 0.3 at 1 week. Patients' satisfaction was good in 98.5% of patients. After the multivariate analysis, no parameters showed an influence on the postoperative outcomes. Conclusions: Our results encouraged to adopt an endoscopic approach even in case of recurrent PS.

Long-term results of a randomized clinical trial comparing endoscopic versus conventional treatment of pilonidal sinus.

BACKGROUND: In the new era of minimally invasive surgery, recent studies encouraged the adoption of endoscopic approaches as the most effective way to treat (pilonidal sinus disease) PSD but little is known about long-term results of minimally invasive procedures. MATERIALS AND METHODS: A total of 145 patients with chronic non recurrent pilonidal sinus were enrolled for this randomized controlled trial. The follow-up rate was 97% at 5 years for a total of 74 patients assigned to the minimally invasive treatment group and 67 patients assigned to the conventional Bascom cleft lift treatment group. We evaluated the following outcomes: long-term recurrence rate, patients' satisfaction, cosmetic outcome and cost-effectiveness results. RESULTS: Long-term data confirm that the recurrence rate was similar in both groups and, in minimally invasive patients, there were a higher satisfaction and better cosmetic results. Costs analysis revealed improved outcome in favour of VAAPS with a much lower mean global cost. CONCLUSION: Minimally invasive treatment has all the characteristics of an ideal approach to PSD with advantages including minimal patient inconveniences, high satisfaction and good aesthetics results. It was also more cost effective to carry out the treatment.

Association of human leukocyte antigen-G 14 bp polymorphism with recurrent pregnancy loss in European countries: a meta-analysis of literature studies.

OBJECTIVE: To study the controversial association between human leukocyte antigen-G (HLA-G) 14 bp polymorphism and recurrent pregnancy loss (RPL). We performed a meta-analysis of studies in the literature that enrolled only women of European countries who experienced RPL spontaneously or after undergoing IVF. DESIGN: Systematic meta-analysis of articles published before January 2019 pertaining the association of HLA-G genotype and RPL. The search was performed in electronic databases (PubMed, Web of Science, Scopus, EMBASE), without any language or publication year restriction. SETTING: Academic hospitals and private clinics. PATIENT(S): Women who experienced RPL spontaneously or after undergoing IVF. INTERVENTION(S): Genotyping of 14 bp polymorphism (insertion/insertion, insertion/deletion, deletion/deletion) in exon 8 of the HLA-G gene. MAIN OUTCOME MEASURE(S): Meta-analyses of the association between HLA-G 14 bp polymorphism in homozygosis (insertion/insertion) and heterozygosis (insertion/deletion) in women with RPL compared with pregnant controls with at least one live birth and no history of RPL. RESULT(S): Ten studies were analyzed comprising 1,091 women with RPL and 808 controls without RPL. Women with RPL showed significantly higher prevalence of HLA-G 14 bp insertion/insertion genotype compared with women without RPL (19.8% vs. 14.1%; odds ratio = 1.562; 95% confidence interval, 1.203-2.027), and this result was also confirmed when separately analyzing women with RPL during a spontaneous pregnancy (odds ratio, 1.562; 95% confidence interval, 1.203-2.027) and those undergoing IVF (odds ratio, 1.990; 95% confidence interval, 0.978-4.051). CONCLUSION(S): Women of European countries with the HLA-G 14 bp insertion/insertion genotype have a significantly higher prevalence of RPL.

Video-assisted ablation of pilonidal sinus (VAAPS) versus sinusectomy for treatment of chronic pilonidal sinus disease: a comparative study.

Since its first description in 1883, different treatments for pilonidal sinus disease have been proposed, but we are still far from the identification of an ideal approach. The objective of this study is to determine if video-assisted ablation of pilonidal sinus (VAAPS) could be considered superior/non-inferior to standard sinusectomy for treatment of pilonidal sinus disease. After applying propensity score analysis, data from 40 patients who underwent sinusectomy and 40 patients who underwent VAAPS, from March 2011 to August 2013, were collected. The two groups were similar in terms of sex, age, BMI, smoking status and complexity of sinus. The mean operative time was less for the sinusectomy group compared with the minimally invasive treatment group (30.38 ± 6.23 vs 44.39 ± 7.76; p = 0.001). On the other hand, the recurrence rate (7.5% vs 25%; p = 0.035) was significantly lower in the VAAPS group and the infection rate showed a trend toward reduction in the endoscopically treated patients (12.5% vs 30%; p = 0.057). No differences were found in terms of pain score at 1 week from surgery (3.71 ± 1.24 vs 3.76 ± 1.39; p = 0.883), satisfaction at 6 months (8.3 ± 1.2 vs 8.2 ± 1.3; p = 0.78) and time off work (2.01 ± 1.30 vs 2.08 ± 1.24; p = 0.620). The effectiveness of our new technique can be assessed again and the comparative analysis with the conventional sinusectomy shows the feasibility of VAAPS, suggesting that this procedure is the best way to perform a sinusectomy.

Minimally Invasive Pilonidal Sinus Treatment: A Narrative Review.

The management of chronic pilonidal disease remains controversial, but recently, new minimal invasive approaches have been proposed. Whereas in the conventional surgical treatment an elliptical wedge of skin and subcutaneous tissue is created to remove the sinus and its lateral tracks, the basis for our new treatment is to create a minimal elliptical wedge of the subcutaneous tissue, including all the inflamed tissue and debris while leaving the overlying skin intact. The mechanism of an endoscopic approach relies on use of the endoscope without cutaneous tissue damage. Advantages include shorter operative time and time to discharge, which impact resource management in both primary and secondary care: patients undergoing endoscopic technique have a high satisfaction rate, probably due to the low level of postoperative pain and early return to work and daily activities. However, it is mandatory that further studies would analyze surgical approaches to pilonidal sinus disease (PSD) with a consistent and adequate follow-up of at least 5 years. Both sinusectomy and endoscopic approach to PSD were found to be safe and effective compared with conventional techniques. Publishedresults of studies of newer approaches have demonstrated a low short-term complication rate, comparable to conventional surgery results.

Incidence of Successful Pregnancy After Weight Loss Interventions in Infertile Women: a Systematic Review and Meta-Analysis of the Literature.

Little is known about the impact of weight loss interventions on pregnancy rate. A systematic review with meta-analysis of literature has been performed to evaluate the incidence of successful pregnancy after bariatric interventions in infertile women. By pooling together data from 589 infertile obese women, we have been able to provide an aggregate estimation of successful pregnancy after weight loss interventions. Our results showed an impressive high incidence (58%) of infertile women who become spontaneously pregnant after surgery. Based on our results, bariatric interventions could be included in the treatment of obesity-related infertility. However, the results must be interpreted with caution owning to the quality of the data provided by included studies. Further ad hoc studies are needed to validate the effectiveness of bariatric interventions on reproductive function.

Role of colonoscopy in the diagnostic work-up of bowel endometriosis.

AIM: To evaluate the accuracy of colonoscopy for the prediction of intestinal involvement in deep pelvic endometriosis. METHODS: This prospective observational study was performed between September 2011 and July 2014. Only women with both a clinical and imaging diagnosis of deep pelvic endometriosis were included. The study was approved by the local ethics committee and written informed consent was obtained in all cases. Both colonoscopy and laparoscopy were performed by expert surgeons with a high level of expertise with these techniques. Laparoscopy was performed within 4 wk of colonoscopic examination. All hypothetical colonoscopy findings (eccentric wall thickening with or without surface nodularities and polypoid lesions with or without surface nodularities of endometriosis) were compared with laparoscopic and histological findings. We calculated the sensitivity, specificity, positive predictive value and negative predictive value for the presence of colonoscopic findings of intestinal endometriosis. RESULTS: A total of 174 consecutive women aged between 21-42 years with a diagnosis of deep pelvic endometriosis who underwent colonoscopy and surgical intervention were included in our analysis. In 76 of the women (43.6%), intestinal endometrial implants were found at surgery and histopathological examination. Specifically, 38 of the 76 lesions (50%) were characterized by the presence of serosal bowel nodules; 28 of the 76 lesions (36.8%) reached the muscularis layer; 8 of the 76 lesions (10.5%) reached the submucosa; and 2 of the 76 lesions (2.6%) reached the mucosa. Colonoscopic findings suggestive of intestinal endometriosis were detected in 7 of the 174 (4%) examinations. Colonoscopy failed to diagnose intestinal endometriosis in 70 of the 76 women (92.1%). A colonoscopic diagnosis of endometriosis was obtained in all cases of mucosal involvement, in 3 of 8 cases (37.5%) of submucosal involvement, in no cases of muscularis layer involvement and in 1 of 38 cases (2.6%) of serosa involvement. The sensitivity, specificity, positive predictive and negative predictive values of colonoscopy for the diagnosis of intestinal endometriosis were 7%, 98%, 85% and 58%, respectively. CONCLUSION: Being an invasive procedure, colonoscopy should not be routinely performed in the diagnostic work-up of bowel endometriosis.

Video-assisted ablation of pilonidal sinus: a new minimally invasive treatment--a pilot study.

BACKGROUND: We hypothesized that video-assisted ablation of pilonidal sinus could be an effective, minimally invasive treatment of pilonidal sinus. This new, minimally invasive treatment allows the identification of the sinus cavity with its lateral tracks, destruction and the removal of all infected tissue, and the removal of any hair. STUDY DESIGN: All consecutive patients with primary sacrococcygeal pilonidal sinus were screened for enrolment in our study. We analyzed time off work, time to walk without pain, time to sitting on the toilet without pain, recurrences, wound infections, and patient satisfaction (pain, health status, and aesthetic appearance). RESULTS: We analyzed 27 patients. All procedures were successful, with complete ablation of the sinus cavity. No infection and only 1 recurrence were recorded during the follow-up (1 year) with an immediate return to work and normal activities. In addition, patient satisfaction and aesthetic appearance were high. CONCLUSION: Our results are encouraging and suggest that this technique may offer a very effective way to treat pilonidal sinus. Further studies are necessary to validate its use in daily practice.

A vaginal drain of a pelvic abscess due to colonic diverticulitis.

Although well recognized for tubo-ovarian abscesses, we report, in our best knowledge, the first case of a vaginal drain of a pelvic abscess due to colonic diverticulitis. A 78-year-old patient presented with abdominal and pelvic pain, fever (39.3 °C) and an elevated white blood cell count (18500/mL). After abdominopelvic computed tomography the patient was presumed to have a pelvic abscess, which developed as a complication of the sigmoid diverticulitis. Due to the numerous intervening structures that create obstacles to safe percutaneous access, we planned a trans-vaginal drain. A rapid recovery was obtained within 2 d from the procedure and, at present, the follow-up was uneventful after 18 mo. We believe that transvaginal drain of pelvic abscess could be a useful alternative, when percutaneous approach is not feasible.

Diagnostic value of abdominal free air detection on a plain chest radiograph in the early postoperative period: a prospective study in 648 consecutive patients who have undergone abdominal surgery.

BACKGROUND: To the best of our knowledge, this is the first study to evaluate the predictive value of free air (on a plain radiograph) for bowel perforation in a large prospective cohort of surgical patients. METHODS: All consecutive patients undergoing abdominal surgery between January 2011 and June 2012 were screened for this study. We performed an upright chest radiograph on the second and third postoperative day. Thereafter, additional radiographic evaluations were performed every 2 days until the disappearance of abdominal free air. RESULTS: Of the 648 subjects enrolled in our study, free abdominal air was found in 65 subjects on the first radiographic evaluation (2 days after surgery), 51 on the second (3 days after surgery), three on the third (5 days after surgery), and none on the fourth (7 days after surgery). The presence of free abdominal air was associated with an increased risk of gastrointestinal perforation. The presence of free air was associated with a hazard ratio (HR) of 21.54 (95% CI 9.66-48.01, p<0.001) and a HR of 23.87 (95% CI 10.68-53.34, p<0.001) at 2 and 3 days after surgery, respectively. Sensitivity, specificity, positive predictive value, and negative predictive value were 70, 93, 33, and 98%, respectively, at 2 days after surgery, and similar results were confirmed at 3 days after surgery. CONCLUSION: We believe that the presence of free air at 3 days after surgery should not be considered a common finding. Here, we demonstrate that the detection of free air has a remarkable predictive value for gastrointestinal perforation, which has been overestimated in previous experience.

Effect of bariatric surgery on obesity-related infertility.

BACKGROUND: There is a strong association between obesity and infertility, and weight loss can increase fecundity in obese women. In an attempt to determine the effect of bariatric surgery on obesity-related infertility, we reviewed the fertility outcomes after intragastric balloon placement, adjustable gastric banding, sleeve gastrectomy, and gastric bypass in childbearing women with a diagnosis of infertility at a university hospital in Italy. METHODS: This was a retrospective study of 110 obese infertile women. We evaluated the effectiveness of bariatric surgery in improving fertility, assessing the influence of age, surgical technique, co-morbidities (hypertension and diabetes), weight loss, and body mass index before and after surgery. RESULTS: Of these 110 women who had tried unsuccessfully to become pregnant before weight loss, 69 became pregnant afterward. The pregnancies proceeded without complications and ended with a live birth. Only the weight loss (odds ratio 20.2, P = .001) and the achieved body mass index (P = .001) after surgery were the predictors of pregnancy. CONCLUSION: Bariatric surgery might be effective in young infertile obese women who wish to become pregnant. Weight loss appears to be independent from the surgical technique in determining the increase in the pregnancy rate as well as the body mass index achieved at pregnancy.

Review of new office-based hysteroscopic procedures 2003-2009.

Office operative hysteroscopy is a recent technique that enables treatment of uterine pathologic disorders in the ambulatory setting using miniaturized hysteroscopes with mechanical or electric instruments. The available international literature from 1990 to 2002 has clearly demonstrated that such technique enables performance of hysteroscopically directed endometrial biopsy and treatment of uterine adhesions, anatomic disorders, polyps, and small myomas safely and successfully without cervical dilation and the need for anesthesia. This review provides a comprehensive survey of further advancements of office operative hysteroscopy in the treatment of other gynecologic pathologic conditions that have not been included in the schema of treatment indications for office procedures proposed in 2002. A search of MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews identified articles published from 2003 to 2009. Eighteen articles were identified: 9 on hysteroscopic sterilization; 1 on office-based metroplasty, 8 on office-based treatment of some uncommon gynecologic pathologic conditions (e.g., hematometra, diagnosis and treatment of vaginal lesions, treatment of uterine cystic neoformations, bleeding from the cervical stump, diagnosis and treatment of endocervical ossification, and removal of uterovaginal packing). All performed procedures were carried out safely and successfully in the office setting, with high patient tolerance and minimal discomfort. The success of the procedures has been confirmed by resolution of symptoms and at follow-up ultrasonographic and hysteroscopic examinations. Currently, as a result of technologic advancements and increased operator experience, an increasing number of gynecologic pathologic conditions traditionally treated in the operating room may be treated safely and effectively using office operative hysteroscopy.