Defecation Scores Research Articles

Surgical and Functional Outcome of Laparoscopic Vaginal Suspension Combined with Suture Rectopexy for Management of Pelvic Organ Prolapse

Abstract Purpose Laparoscopic techniques to treat pelvic organ prolapse are gaining popularity around the globe due to their low recurrence rates and better functional results compared to perineal techniques. However, the optimum surgical procedures are not yet determined. In the current research, we suggest a novel surgical approach, laparoscopic vaginal suspension with suture rectopexy, to treat multiorgan pelvic prolapse. Methods This prospective cohort trial was conducted from March 2018 to March 2022 and comprised 35 females with multiorgan pelvic organ prolapse with obstructed defecation symptoms. A residual rectal prolapse was still present despite the manual reduction of uterine prolapse. Patients' conditions before and after the operation were monitored regarding the obstructed defecation score, sexual function, need for laxatives, anorectal manometry pressures, anorectal sensations, and recurrence. The mean follow-up duration was one year. Results Modified Longo score for obstructed defecation significantly decreased at six and twelve months after surgery. Additionally, a significant reduction was reported in the number of patients who needed laxatives at six and twelve months after surgery. Anorectal manometry pre- and post-surgery showed a significant elevation in the mean squeeze pressure and a decline in all rectal sensations. All parameters of the female sexual function scoring system increased postoperatively. No recurrence was reported during follow-up. Conclusion For multiorgan pelvic prolapse, laparoscopic vaginal suspension combined with suture rectopexy has excellent functional outcomes, minimal morbidity, and low cost.

Clinical outcomes and prognostic factors in the surgical treatment of spinal dural arteriovenous fistulas: a retrospective study of 118 patients

Spinal dural arteriovenous fistulas (SDAVFs) are the most common type of spinal vascular malformations (AVMs), constituting approximately 70% of all spinal AVMs. The impact of various clinical and radiologic features on the outcomes in patients with SDAVFs is still controversial. The purpose of the study is to investigate the clinical outcomes and prognostic factors in patients with surgically treated SDAVFs in a single center. A retrospective review was performed for all patients with SDAVFs from January 2013 to September 2021 who underwent surgery at our institution. Medical records and pre- and postoperative imaging data were analyzed. Neurological function status was evaluated by modified Aminoff-Logue Scale (mALS). Student’s t-test, Wilcoxon rank sum test, χ2 test and logistic regression were used to find significant prognostic factors. P values < 0.05 were considered significant. One hundred and eighteen patients were ultimately included in the study. By comparing preoperative and postoperative mALS, 69 (58.5%) patients experienced improvement, and 49 (41.5%) patients showed no improvement (worse or unchanged). Wilcoxon rank sum test showed that there was a difference between the improvement group and the no improvement group in preoperative mALS Micturition score and preoperative mALS Defecation score. The logistic regression revealed that preoperative mALS Gait score was associated with clinical improvement after surgery in patients with SDAVFs. Surgical treatment of SDAVFs is a safe and effective procedure and can lead to symptom improvement or stabilization in most patients. Preoperative neurological function status was the only factor associated with clinical prognosis.

Change over time in the postoperative defecation function in female patients with anovestibular fistula at a single institution: focus on the comparison of anal transposition with anterior sagittal anorectoplasty.

Anovestibular fistula (AVF) is the most common type of ARM in female patients. The present study investigated changes over time in the postoperative defecation function of female patients with AVF. Patient data were collected from 1984 to 2021. Eighty-eight female patients with AVF were enrolled. Patients' characteristics and the long-term outcome of defecation function were reviewed and analyzed retrospectively. The bowel function was evaluated according to the Japan Society of ARM Study Group evacuation score (ES). Thirty-eight patients underwent anal transposition (AT), and 8 underwent anterior sagittal anorectoplasty (ASARP). The total evacuation score (ES) in AVF patients reached "excellent" at nine years old, regardless of the operative procedure. The constipation scores with AT showed better improvement than those with ASARP, but soiling scores in the ASARP group showed better improvement than those in the AT group. The postoperative complications did not affect the postoperative bowel function in AVF patients. Most patients with AVF eventually achieved a satisfactory total ES. Given the difference in defecation score transition depending on the operative procedure or postoperative complications, it may be important to perform long-term defecation management via surgical procedures.

The Effect of Transvaginal Prolapse Surgery on Anorectal Function

AbstractObjective Pelvic floor dysfunction can manifest as a spectrum including anorectal dysfunction, vaginal prolapse, and urinary incontinence. Sacrospinous fixation is a procedure performed by gynecologists to treat vaginal prolapse. The present study aims to evaluate the impact of transvaginal prolapse surgery on anorectal function.Materials and Methods We conducted a retrospective review of patients undergoing sacrospinous fixation surgery for vaginal prolapse between 2014 to 2020. Those with anorectal dysfunction who had also been evaluated by the colorectal service preoperatively and postoperatively were included for analysis. These patients were assessed with symptom-specific validated questionnaires. The effect of surgery on constipation and fecal incontinence symptoms was analyzed.Results A total of 22 patients were included for analysis. All patients underwent transvaginal sacrospinous fixation, and 95.4% also had posterior colporrhaphy for vaginal prolapse. There were a statistically significant improvements in the Fecal Incontinence Severity Index (FISI), the St. Mark's Incontinence Score (Vaizey), the embarrassment and lifestyle components of the Fecal Incontinence Quality of Life Score, the Constipation Scoring System, the Obstructed Defecation Score, and components of the Patient Assessment of Constipation Quality of Life score.Conclusion Transvaginal prolapse surgery leads to a favorable effect on anorectal function, with improvements in both obstructed defecation and fecal incontinence scores in this small series.

Biofeedback pelvic floor muscle training versus posterior tibial nerve electrostimulation in treatment of functional obstructed defecation: a prospective randomized clinical trial

BackgroundFunctional obstructed defecation is a common anorectal problem among adult population. The objective was to compare the short-term efficacy of biofeedback pelvic floor muscle training versus transcutaneous posterior tibial nerve electrostimulation in treatment of patients with functional obstructed defecation.ResultsThere were 41 patients completed the study. There were no statistical significant differences between biofeedback pelvic floor muscle training group and transcutaneous posterior tibial nerve electrostimulation group regarding different clinical characteristics, as well as, electrophysiological findings. There was statistically significant reduction in all outcome measures after intervention in both groups. The primary outcome measure was Modified obstructed defecation score. Secondary outcome measures were Patient Assessment of Constipation-Quality of Life questionnaire, time of toileting, and maximum anal pressure during straining to evacuate. No significant differences were present between both groups regarding different outcome measures in the pretreatment and post-treatment assessments. Successful outcome was reported in 81% of patients in biofeedback pelvic floor muscle training group in comparison to 40% of patients in the posterior tibial nerve electrostimulation group according to the Modified obstructed defecation score which was the primary outcome measure.ConclusionsBoth biofeedback pelvic floor muscle training and posterior tibial nerve electrostimulation are considered effective methods in the treatment of functional obstructed defecation. However, biofeedback pelvic floor muscle training seems to be more effective and superior in comparison to posterior tibial nerve electrostimulation. Posterior tibial nerve electrostimulation could be combined with biofeedback pelvic floor muscle training or considered as a second line therapy after failure of biofeedback pelvic floor muscle training.Trial registrationPan African Clinical Trials Registry, PACTR202009762113535. Registered 2 September 2020—retrospectively registered, https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=12321.

Bowel frequency (night) and urgent defecation are improved by budesonide foam in patients with ulcerative colitis: a retrospective observational study

IntroductionPatients with ulcerative colitis (UC) are known to have a significantly poor quality of life due to bowel frequency (night) and urgent defecation. Budesonide foam is a topical medication that was approved in Japan in 2017 for the treatment of UC. However, its efficacy in the treatment of bowel frequency (night) or urgent defecation is unknown. This study aimed to explore the efficacy of budesonide foam for the alleviation of these symptoms.MethodsUC patients who received budesonide foam between December 2017 and January 2020 at the Jikei University School of Medicine in Tokyo were enrolled. The simple clinical colitis activity index (SCCAI) was evaluated at the start of budesonide foam treatment and 2 and 6 weeks later in patients who initially scored ≥ 1 for bowel frequency (night) and urgent defecation, respectively. We also studied the effect of budesonide foam on remaining symptoms in patients who had used 5-aminosalicylic acid (5-ASA) topical treatment, those with SCCAI ≥ 3, and those in remission with residual symptoms (SCCAI 1 or 2).ResultsOf the 233 enrolled patients, 102 were eligible for the study. In 36 patients with bowel frequency (night) treated with budesonide foam were significantly effective, score in SCCAI decreased from 1.17 ± 0.45 at baseline to 0.53 ± 0.61 at week 2 (p < 0.0001) and 0.17 ± 0.38 at week 6 (p < 0.0001). In 45 patients with urgent defecation score in SCCAI decreased significantly from 1.33 ± 0.52 at baseline to 0.44 ± 0.59 at week 2 (p < 0.0001) and 0.22 ± 0.40 at week 6 (p < 0.0001). Of 22 patients who switched from topical 5-ASA administration to budesonide foam, nine at week 2 (41%) and 11 (50%) at week 6 were improved with no symptoms, and there were no cases of worsened symptoms. No severe side effects associated with budesonide foam were observed.ConclusionBudesonide foam administration significantly improves both bowel frequency (night) and urgent defecation-related UC activity and is also effective for the patients who were refractory to topical 5-ASA administration.

Complete endoscopic healing is associated with lower disability than partial endoscopic healing in Crohn's disease: A prospective multicenter study

IntroductionCrohn's disease (CD) has a significant impact on health status and quality of life, affecting physical and emotional well-being and impairing social and functional abilities. In the era of the treat-to-target concept, endoscopic healing has emerged as the goal to achieve to prevent intestinal damage and disability. It is not clear what level of endoscopic healing is associated with lower disability. We therefore aimed to compare disability associated with complete endoscopic healing to disability with partial endoscopic healing in patients with CD. MethodsWe conducted a multicenter prospective study, between September 2019 and November 2020, in one university hospital, one general hospital, and one private practice center. Consecutive patients with CD in clinical remission were included, having either complete endoscopic healing (CDEIS = 0) or partial endoscopic healing (CDEIS >0 and <4). The 10-item IBD-Disk self-assessment questionnaire was used to assess disability. Moderate to severe disability was defined as an overall IBD-Disk score ≥40. ResultsA total of 82 patients were included. Forty-four (53%) were women, the median age and disease duration were respectively 35.3 years (interquartile range [IQR], 28.6–45.2) and 8.0 years (IQR, 3.0–17.0). The median overall IBD-Disk score was 26.5 (IQR, 9 -45.0), and 30 (36.6%) patients had moderate to severe disability. Complete endoscopic healing was observed in 48 patients (57.3%). The median IBD-Disk score was respectively 24 (IQR, 9.0–40.5) and 34 (IQR, 9.5–51.5) for patients with complete and partial endoscopic healing (p = 0.068). Respectively, 13/48 (27%) and 17/34 (50%) of patients with complete and partial endoscopic healing had moderate to severe disability (p = 0.039). In multivariate analysis, partial endoscopic healing (OR=5.82, 95% CI [1.65, 24.69], p = 0.0009), female gender (OR=4.0, 95%CI [1.13, 16.58], p = 0.04), and smoking (OR=8.33, 95% CI [1.96, 50.0] p = 0.006) were significantly associated with moderate to severe disability. Among the IBD-Disk sub scores, the defecation score (median, IQR) (0.0 [0.0–3.0] vs 4.0 [0.0–7.5], p = 0.028) and energy score (4.0 [0.0–6.0] vs 6.0 [2.5–8.0], p = 0.023) were significantly lower with complete endoscopic healing. ConclusionsOne-third of patient with endoscopic healing reported moderate to severe disability. Complete endoscopic healing (CDEIS = 0) was associated with lower disability than partial endoscopic healing (CDEIS >0 and <4). Deeper endoscopic healing may be needed to reduce the risk of disability in CD.

Relation between pelvic floor neurophysiological abnormalities and erectile dysfunction in patients with obstructed defecation

BackgroundObstructed defecation is a common pelvic floor medical problem among adult population. Pelvic floor disorders were reported to be associated with sexual dysfunction including erectile dysfunction among male patients. The aim was to determine the relation between pelvic floor neurophysiological abnormalities and erectile dysfunction in male patients with obstructed defecation.MethodsThis cross-sectional study included 65 married male patients with obstructed defecation and a control group consisted of 15 apparently healthy married males. Assessment of obstructed defecation severity was done by using modified obstructed defecation score, time of toileting and Patient Assessment of Constipation-Quality of Life questionnaire. Assessment of erectile functions was done using erectile function domain of International Index of Erectile Function questionnaire and Erectile Dysfunction-Effect on Quality of Life Questionnaire. Anal manometry and dynamic pelvis magnetic resonance imaging were done. Electrophysiological studies included pudendal nerve motor conduction study and needle electromyography of external anal sphincter, puborectalis and bulbocavernosus muscles.ResultsThere were 32 patients (49.2%) who had erectile dysfunction. The maximum straining anal pressure was significantly higher among patients with erectile dysfunction. Pudendal nerve terminal motor latency was significantly delayed and the percentage of bilateral pudendal neuropathy was significantly higher among patients with erectile dysfunction. The percentage of electromyography evidence of denervation with chronic reinnervation in the external anal sphincter and bulbocavernosus muscles were significantly higher among patients with erectile dysfunction. Regression analysis detected three co-variables to be associated with significantly increasing the likelihood of development of erectile dysfunction. These were maximum straining anal pressure (odd ratio = 1.122), right pudendal nerve terminal motor latency (odd ratio = 3.755) and left pudendal nerve terminal motor latency (odd ratio = 3.770).ConclusionsErectile dysfunction is prevalent among patients with obstructed defecation. It is associated with characteristic pelvic floor electrophysiological abnormalities. Pelvic floor neurophysiological changes vary from minimal to severe neuromuscular abnormalities that usually accompanying erectile dysfunction. Pudendal neuropathy and increased maximum straining anal pressure are essential risk factors for increasing the likelihood of development of erectile dysfunction in patients with obstructed defecation.

Cannabidiol reduces lesion volume and restores vestibulomotor and cognitive function following moderately severe traumatic brain injury

Despite the high incidence of traumatic brain injury (TBI), there is no universal treatment to safely treat patients. Blunt brain injuries destroy primary neural tissue that results in impaired perfusion, excessive release of glutamate, inflammation, excitotoxicity, and progressive secondary neuronal cell death. We hypothesized that administration of cannabidiol (CBD) directly to a brain contusion site, will optimize delivery to the injured tissue which will reduce local neural excitation and inflammation to spare neural tissue and improve neurological outcome following TBI. CBD was infused into a gelfoam matrix forming an implant (CBDi), then applied over the dura at the contusion site as well as delivered systemically by injection (CBD.IP). Post-injury administration of CBDi+IP greatly reduced defecation scores, lesion volume, the loss of neurons in the ipsilateral hippocampus, the number of injured neurons of the contralateral hippocampus, and reversed TBI-induced glial fibrillary acidic protein (GFAP) upregulation which was superior to either CBD.IP or CBDi treatment alone. Vestibulomotor performance on the beam-balance test was restored by 12 days post-TBI and sustained through 28 days. CBDi+IP treated rats exhibited preinjury levels of spontaneous alternation on the spontaneous alternation T-maze. In the object recognition test, they had greater mobility and exploration of novel objects compared to contusion or implant alone consistent with reduced anxiety and restored cognitive function. These results suggest that dual therapy by targeting the site of injury internally with a CBD-infused medical carrier followed by systemic supplementation may offer a more effective countermeasure than systemic or implant treatment alone for the deleterious effects of penetrating head wounds.

P175 Complete endoscopic healing is associated with lower disability than partial mucosal healing in Crohn’s disease: a prospective multicentric study

Abstract Background Crohn’s disease (CD) has a significant impact on health status and quality of life, by affecting physical and emotional well-being and by impairment of social and functional abilities. In the era of treat to target concept, endoscopic healing has emerged to be the goal to achieve to prevent intestinal damage and disability. It is not clear what level of endoscopic healing is associated with CD disability. We, therefore, aimed to compare disability associated to complete endoscopic healing or partial endoscopic healing in patients with CD. Methods We conducted a multicentric prospective study, between September 2019 and November 2020, in one University Hospital, one general hospital and one private practice center including consecutive patients with CD in clinical remission and either complete mucosal healing (CDEIS =0) or partial mucosal healing (CDEIS &amp;gt; 0 and ≤ 4). The 10-item self-questionnaire IBD-disk was used to assess disability. Moderate-to-severe disability was defined as an overall IBD-disk score ≥ 40. Results A total of 82 patients were included. Forty-four (53%) were women, the median age and disease duration were respectively 35.3 years (Interquartile range (IQR 28.6–45.2) and 8.0 years (IQR, 3.0–17.0). The median overall IBD-disk score was 26.5 (IQR, 9 -45.0) and 30 (36.6%) had moderate-to-severe disability. Complete endoscopic healing was observed in 48 patients (57.3%). Median IBD-Disk score was respectively 24 (IQR, 9.0–40.5) and 34 (IQR, 9.5–51.5) for patients with complete and partial endoscopic healing (p=0.068). Respectively, 13/48 (27%) and 17/34 (50%) of patients with complete and partial endoscopic healing had moderate-to-severe disability (p=0.039). In multivariate analysis, partial mucosal healing (OR=3.04, CI95% [1.11, 8.94], p=0.03), female gender (OR=3.93, CI95% [1.43, 11.94], p=0.008) and smoking (OR= CI95% 5.88 [1.72, 25.0] p=0.039) were significantly associated with moderate-to-severe disability. Among the IBD-disk subscores, defecation score (median, IQR) (0.0 [0.0–3.0] vs 4.0 [0.0–7.5], p=0.028) and energy score (4.0 [0.0–6.0] vs 6.0 [2.5–8.0], p=0.023) were significantly lower in complete endoscopic healing. Conclusion One-third of patient with endoscopic healing reported moderate-to-severe disability. Complete endoscopic healing (CDEIS = 0) was associated with lower disability than partial endoscopic healing (CDEIS &amp;gt; 0 and ≤ 4) in CD. Deeper endoscopic healing may be needed to reduce the risk of disability in CD.

Preliminary Report From the Pelvic Floor Disorders Consortium: Large-Scale Data Collection Through Quality Improvement Initiatives to Provide Data on Functional Outcomes After Rectal Prolapse Repair.

The surgical management of rectal prolapse is constantly evolving, yet numerous clinical trials and meta-analyses studying operative approaches have failed to make meaningful conclusions. The purpose of this study was to report on preliminary data captured during a large-scale quality improvement initiative to measure and improve function in patients undergoing rectal prolapse repair. This was a retrospective analysis of prospectively collected surgical quality improvement data. This study was conducted at 14 tertiary centers specializing in pelvic floor disorders from 2017 to 2019. A total of 181 consecutive patients undergoing external rectal prolapse repair were included. Preoperative and 3-month postoperative Wexner incontinence score and Altomare obstructed defecation score were measured. The cohort included 112 patients undergoing abdominal surgery (71 suture rectopexy/56% minimally invasive, 41 ventral rectopexy/93% minimally invasive). Those offered perineal approaches (n = 68) were older (median age, 75 vs 62 y; p < 0.01) and had more comorbidities (ASA 3-4: 51% vs 24%; p < 0.01) but also reported higher preintervention rates of fecal incontinence (Wexner 11.4 ± 6.4 vs 8.6 ± 5.8; p < 0.01). Patients undergoing perineal procedures had similar incremental improvements in function after surgery as patients undergoing abdominal repair (change in Wexner, -2.6 ± 6.4 vs -3.1 ± 5.6, p = 0.6; change in Altomare, -2.9 ± 4.6 vs -2.7 ± 4.9, p = 0.8). Similarly, patients undergoing posterior suture rectopexy and ventral mesh rectopexy had similar incremental improvements in overall scores; however, patients undergoing ventral mesh rectopexy had a higher decrease in the need to use pads after surgery. The study was limited by its retrospective data analysis and 3-month follow-up. Functional outcomes improved in all of the patients undergoing prolapse surgery. Larger cohorts are necessary to show superiority among surgical procedures. Quality improvement methods may allow for systematic yet practical acquisition of information and data analysis. We call for the creation of a robust database to benefit this patient population. See Video Abstract at http://links.lww.com/DCR/B581. ANTECEDENTES:El tratamiento quirúrgico del prolapso rectal está evolucionando constantemente, sin embargo, numerosos estudios clínicos y metaanálisis que evalúan los tratamientos quirúrgicos no han logrado demostrar conclusiones significativas.OBJETIVO:Reportar datos preliminares obtenidos a gran escala durante una iniciativa de mejoramiento de la calidad para medir y mejorar la función en pacientes sometidos a reparación de prolapso rectal.DISEÑO:Análisis retrospectivo de datos recolectados prospectivamente de mejoramiento de la calidad quirúrgica.ENTORNO CLINICO:Este estudio se realizó en 14 centros terciarios especializados en trastornos del piso pélvico del 2017 al 2019.PACIENTES:Un total de 181 pacientes consecutivos sometidos a reparación de prolapso rectal externo.PRINCIPALES MEDIDAS DE VALORACION:Escala de incontinencia de Wexner y de defecación obstruida de Altomare preoperatoria y tres meses postoperatoria.RESULTADOS:El cohorte incluyó 112 pacientes sometidos a cirugía abdominal (71 rectopexia con sutura / 56% minimally invasive, 41 rectopexia ventral / 93% minimally invasive). Aquellos a los que se les realizaron abordajes perineales (n = 68) eran mayores (edad media de 75 vs. 62, p <0,01) y tenían mayorcomorbilidades (ASA 3-4: 51% vs. 24%, p <0,01), además reportaron una mayor tasa de incontinencia fecal previo a la intervención (Wexner 11,4 ± 6,4 vs. 8,6 +/- 5,8, p <0,01). Posterior a la cirugía, los pacientes sometidos a procedimientos perineales tuvieron mejoría progresiva en la función similar que los pacientes sometidos a reparación abdominal (cambio en Wexner -2,6 ± 6,4 vs. -3,1 ± 5,6, p = 0,6; cambio en Altomare -2,9 ± 4,6 vs. -2,7 ± 4,9, p = 0,8). De manera similar, los pacientes con rectopexia posterior con sutura y rectopexia ventral con malla tuvieron mejoría progresiva similares en las escalas generales; no obstante, pacientes con rectopexia ventral con malla tuvieron una mayor disminución en la necesidad de usar paños protectores después de la cirugía.LIMITACIONES:Análisis de datos retrospectivo y seguimiento de tres meses.CONCLUSIONES:Los resultados funcionales mejoraron en todos los pacientes sometidos a cirugía de prolapso. Se necesitan cohortes más grandes para demostrar superioridad entre los procedimientos quirúrgicos. Métodos de mejoramiento de la calidad pueden permitir la adquisición sistemática, pero práctica de información y análisis de datos. Hacemos un llamado para la creación de una base de datos sólida para beneficiar a esta población de pacientes. Consulte Video Resumen en http://links.lww.com/DCR/B581. (Traducción- Dr Francisco M. Abarca-Rendon).

Functional and sexual outcome of laparoscopic ventral mesh rectopexy vs transperineal mesh repair in the treatment of rectocele: a retrospective analysis

This study aimed to compare functional outcomes and quality of life, between transperineal mesh repair (TPMR) and laparoscopic ventral mesh rectopexy (LVMR) in the treatment of rectocele. Consecutive women with symptomatic rectocele without associated internal rectal prolapse or enterocele who underwent TPMR (n = 15) or LVMR (n = 20) from January 2013 to February 2019 were included. This study was a retrospective review of a prospectively maintained database. Patient demographics and postoperative complications were evaluated. Altomare’s obstructed defecation (OD) and Cleveland Clinic Incontinence Scores (CCIS), Patient Assessment of Constipation Quality of Life (PAC-QoL), Short-Form 36 Health Survey (SF-36) and Female Sexual Function Index (FSFI) were compared before, 3 months, and 12 months after surgery. The median follow-up was 49 (range 13–65) and 28 (range 13–60) months in the TPMR (mean age 47.8 ± 11.7, years) and LVMR (mean age of 52.4 ± 9.9 years) cohort, respectively. Incontinence, OD, and PAC-QoL scores significantly improved at 3 and 12 months after surgery in both groups. FSFI did not deteriorate 3 and 12 months after LVMR. FSFI scores significantly improved 3 months after TPMR, but a significant deterioration was observed 12 months after TPMR. A gradual increase observed for SF-36 3 months after surgery in both groups, and six of the eight subscale scores improved at 12 months, but social functioning in both groups and vitality in the TPMR group returned to baseline scores. TPMR and LVMR improved defecation. Sexual function was not worsened after LVMR, and some individual domains of FSFI worsened after TPMR.

Prevalence and predictors of laxatives use in clozapine-related constipation: an observational study

Clozapine-induced constipation is a frequently overlooked side effect that can prove fatal. This study aimed to investigate the prevalence of constipation and the breakdown of laxatives, and to identify whether use of laxative may be predicted by demographics or baseline metabolic markers in 53 Japanese treatment-resistant schizophrenia inpatients switched to clozapine. Differences of present age, onset age and duration of illness, previous antipsychotic dose using the chlorpromazine equivalent, and 10-items of metabolic markers, including fasting plasma glucose and ratio of triglyceride to high-density lipoprotein cholesterol levels were compared between the laxative and nonlaxative user groups. Sequential changes of defecation scores using Bristol stool form scale, and clozapine dosage at 1, 2 and 3 months were evaluated within each group. Multiple linear stepwise regression analysis was performed to assess the predicting use of laxatives. Half of subjects required treatment with laxative, were significantly older and had longer durations of illness than nonlaxative users. Magnesium oxide and lubiprostone were mainly used singly or in combination. Longer disease duration, and lower levels of fasting blood glucose and insulin resistance were predicting the use of laxatives. Screening and preventive strategies for minimizing clozapine-related constipation should be established in future study.

Three years prospective clinical and radiologic follow-up of laparoscopic sacrocolpoperineopexy.

When Rectocele is part of a complex pelvic organ prolapse, a full repair is recommended. The aim of this study was to evaluate the clinical and radiological results after laparoscopic surgery in patients with symptomatic rectocele and III/IV stage vaginal vault prolapse METHODS: This is a prospective cohort study of women with symptomatic rectoceles and middle compartment prolapse operated on between 2013 and 2015, who underwent a laparoscopic sacrocolpoperineopexy with synthetic Y mesh attached to puborectalis muscles, the anterior and posterior vagina wall and the sacrum. The clinical outcomes measured were symptoms of prolapse, obstructive defecation syndrome and quality of life. Radiological outcomes were distance of the vaginal vault below pubococcigeal line and depth of rectovaginal wall protrusion in dynamic pelvic resonance. 33 patients were included. 32 of them remained asymptomatic after a three years follow-up. Significant differences were shown in the obstructed defecation score and quality of life after 6, 12 and 36months compared to preoperatively. No differences were identified when the postoperative results were compared. Significant differences were shown in preoperative vaginal vault prolapse (3.2cms ± 0.8 SD below the pubococcigeal Line) and rectocele size, compared with 1 and 3years after surgery. There were no significant differences in vaginal vault prolapse when compared after 1 and 3years. When rectocele size after 1 and 3years was compared, significant differences were shown, but only one clinical recurrence (3%) was identified after a mean follow-up of 47months. Laparoscopic sacrocolpoperineopexy in patients with symptomatic rectocele and III/IV vaginal vault prolapse solves the constipation and obstructed defecation with an excellent quality of life and low clinical recurrences. Radiological deterioration, especially in rectocele size, was identified in the mid-term follow-up without clinical significance.

Diagnosis and treatment of superior mesenteric artery compression syndrome secondary to chronic constipation (Lee's triad syndrome)

Objective: To summarize the experience of diagnosis and treatment of superior mesenteric artery compression syndrome (SMACS) secondary to chronic constipation according to the concept of Lee's triad syndrome. Methods: The concept of Lee's triad syndrome: (1) clinical symptoms: triad of constipation, malnutrition, upper gastrointestinal obstruction (vomiting, difficulty in eating); (2) anatomical manifestations: with triple anatomy anomaly of transverse colon sagging, elevated spleen flexure, and mesentery arterial compression; (3) treatment: with triple treatment of enteral nutrition support, chest-knee posture and fecal microbiota transplantation. A descriptive cohort study was performed. According to Lee's triad syndrome criteria, clinical data of 78 patients with superior mesenteric artery compression syndrome secondary to chronic constipation in the Tenth People's Hospital of Tongji University and General Hospital of Eastern Theater Command from June 2004 to November 2018 were prospectively collected, including basic information, symptoms and signs, imaging findings, nutritional indicators, gastrointestinal quality of life index (GIQLI) and Wexner defecation score. The above parameters based on Lee's triad syndrome criteria were followed up and recorded at 1, 3, 6, 12 months after comprehensive treatment. Results: All the patients had Lee's triple symptoms of constipation, malnutrition, upper gastrointestinal obstruction (vomiting, eating difficulties), and triple anatomy anomaly of transverse colon sagging, elevated spleen curvature, and mesentery arterial compression before treatment. After triple treatment of enteral nutrition support, chest-knee posture, and fecal microbiota transplantation, 69 (88.5%) patients had a significant improvement of symptoms, and 9 patients had no significant improvement of symptoms and then eventually received surgery. The 69 cases without operation received follow-up for 12 months. All the patients eventually returned to normal eating, and upper gastrointestinal angiography and superior mesenteric artery imaging showed duodenal compression disappeared. After 1 month, the constipation-related indexes were improved. After 12 months, the number of autonomous defecation per week increased from 1.0±0.8 to 5.0±1.6 (P<0.001). The GIQLI score increased from 52.7±8.5 to 93.2±7.5 (P<0.001), and the Wexner score decreased from 19.1±2.5 to 6.2±2.1 (P<0.001). After 1 month, nutritional indexes were improved gradually. After 12 months, the BMI increased from (17.9±1.8) kg/m(2) to (21.0±1.3) kg/m(2), total protein increased from (65.2±5.7) g/L to (68.3±4.2) g/L, albumin increased from (32.1±5.1) g/L to (40.4±3.0) g/L, prealbumin increased from (163.2±53.7) mg/L to (259.1±45.6) mg/L, fibrinogen increased from (1.9±0.5) g/L to (2.4±0.5) g/L, whose differences were statistically significant (all P<0.001). Upper gastrointestinal angiography and superior mesenteric artery imaging showed duodenal compression were relieved. The angle between superior mesenteric artery and abdominal aorta increased from (17.4±3.8)° to (37.8±5.8)° (t=-22.26, P<0.001). Conclusion: When patients with SMACS secondary to chronic constipation have Lee's triple symptoms and triple anatomy anomaly, the triple combination treatment of enteral nutrition support, chest-knee posture and fecal microbiota transplantation should be applied.

Mirogabalin prevents repeated restraint stress-induced dysfunction in mice

Gabapentinoids, which are the common analgesics, are also thought to be an effective treatment for anxiety disorder, which is one of several psychiatric disorders triggered and exacerbated by stress. The aim of the present study was to investigate whether mirogabalin, a recently launched gabapentinoid, protects multiple brain functions against repeated restraint stress. Adult male ddY mice were restrained for 7 days (repeated restraint stress: 2 h/day) or for 30 min (single restraint stress). Mirogabalin (intraperitoneal, intracerebroventricular or intrahippocampal injection) was administered prior to the restraint stress. Y-maze, elevated-plus maze and c-Fos immunohistochemistry were performed to evaluate learning function, anxiety levels and hippocampal neuronal activities, respectively, after the 7th day of the repeated restraint stress. Intestinal function was evaluated in terms of defecation, which was scored after the 5th day of repeated restraint stress and by the number of fecal pellets excreted after a single session of restraint stress.Repeated restraint stress induced memory dysfunction, anxiety-like behavior, an abnormal defecation score and increased hippocampal c-Fos expression. These changes were prevented by systemic administration of mirogabalin. Abnormal defecation was also induced by single restraint stress, and was inhibited by both systemic and central administration of mirogabalin, suggesting that the effect on the intestinal function was also mediated via the central nervous system. Enhancement of c-Fos expression by repeated stress was decreased by intrahippocampal injection of mirogabalin. Together, these observations suggest that mirogabalin protects multiple brain functions from repeated stress, which may be mediated by inhibition of hippocampal neuron hyperactivation.

Lifestyle Habits Associated with Poor Defecation Habit among Pupils in Japan.

PurposeNot enough attention has been paid to defecation habits in Japan. This study aimed to emphasize the importance of defecation habits on health and function in Japanese pupils.MethodsUsing multiple regression analysis, 2,722 questionnaires obtained from pupils in grades 5 to 12 were analyzed to determine lifestyle habits associated with defecation frequency.ResultsSignificant regression formulae for defecation scores were obtained for all school types: elementary school (ES) (adjusted R2=0.08, p<0.001), junior high school (JHS) (0.09, p<0.001), and senior high school (SHS) (0.15, p<0.001). The following factors were associated with poorer defecation scores, according to school type: female gender (all 3 school types), breakfast skipping (elementary and JHSs), lower physical activity (JHSs and SHSs), and longer school-day screen time (elementary and SHSs). In addition, poorer self-reported academic performance scores in ES, less standardized body mass index (BMI) in JHS, and shorter non-school- day screen time scores in SHS, were associated with poorer defecation scores.ConclusionPoor defecation frequency showed significant associations with various lifestyle habits, such as breakfast skipping, physical activity, and screen time, among pupils. Academic performance and standardized BMI were also associated with defecation frequency. More attention should be paid to defecation frequency to sustain health and function in pupils.

Efficacy of "Pinggan Formula" in Controlling Acute Type B Aortic Dissection Perioperative Blood Pressure: A Randomized Controlled Clinical Trial.

Objective To explore a new treatment that can proceed from the whole, control blood pressure smoothly and coordinate the treatment of multiple factors causing blood pressure fluctuations. Method We conducted a single-center, double-blinded, and randomized controlled clinical trial. 48 patients with acute Type B aortic dissection were randomly assigned into two groups: the experimental group, who received pinggan formula treatment, and the control group, who received placebo treatment. The drug was taken orally after meals three times a day. Only when the patients' blood pressure fluctuated, conventional antihypertensive drugs were given to maintain the blood pressure within the target range and the dosage was recorded to convert the DDD value. Meanwhile, the international standardized score was used to evaluate the defecation, sleep, pain, anxiety, and depression of patients in the two groups during the hospitalization. Result Univariate analysis was conducted on variables that might affect the assessment results, and it was found that grouping factors had a significant impact on the outcome variables, that is, after the intervention, the mean value of DDDs used in the perioperative period in the control group was 2.19 (0.38, 4.00). (P=0.0219), defecation score (2.13 (1.59, 2.67); P < 0.0001), sleep score (0.95 (0.40, 1.50); P=0.0014), pain score (1.77 (0.61, 2.93); P=0.0045), depression score (4.04 (2.95, 5.12); and P < 0.0001) were significantly higher than that of the experimental group, and the difference was statistically significant. Conclusion Pinggan formula has a clear therapeutic regulation effect on the overall hemodynamics of acute Stanford type B aortic dissection during the perioperative period and can be recommended as an auxiliary drug for conventional antihypertensive drugs at the current stage.

Effects of chewing gum on gastrointestinal function in patients with intraspinal tumors after surgery

Objective To explore the effects of chewing gum on recovery of gastrointestinal function in patients with intraspinal tumors after surgery. Methods Totally 214 patients with intraspinal tumors treated in the Neurosurgical Ward of Spinal Cord and Spine of Beijing Tiantan Hospital, Capital Medical University from May 2018 to May 2019 were selected and divided into control (n=107) and observation (n=107) groups. Patients in the control group received conventional anti-constipation care, including postoperative dietary guidance, abdominal massage guidance and rehabilitation training, while patients in the observation group chewed 2 pieces of gum four times a day, each time for 10-15 min after awaking from anesthesia on the basis of conventional nursing care. Both groups received interventions for 7 d. The incidence of constipation and abdominal distension, time of first defecation and oral comfort scores after 7 d postoperatively. Results The incidence rate of constipation and abdominal distension was 7.48% and 15.89% in the observation group, lower than 25.23% and 37.38% in the control group, and there were statistically significant differences between the two groups (χ2=12.331, 12.650; P<0.05) . The time of first defecation was (19.22±5.64) h in the observation group, earlier than (27.08±6.61) in the control group, and there was statistically significant difference between the two groups (t=-9.366, P<0.05) . The oral comfort score after 7 d postoperatively was (8.59±1.13) in the observation group, higher than (5.12±2.66) in the control group, and there was statistically significant difference between the two groups (t=-12.420, P<0.05) . Conclusions Chewing gum can accelerate the recovery of gastrointestinal function in patients with intraspinal tumors after surgery and improve their oral comfort. Key words: Intraspinal neoplasms; Perioperative nursing; Fast track surgery; Gastrointestinal function; Gum

Ventral rectopexy with biological mesh for recurrent disorders of the posterior pelvic organ compartment

Recurrent prolapse of the posterior pelvic organ compartment presents a management challenge, with the best surgical procedure remaining unclear. We present functional outcome and patient satisfaction after laparoscopic and robotic ventral mesh rectopexy (VMR) with biological mesh in patients with recurrence. We analyzed data from 30 patients with recurrent posterior pelvic organ prolapse who underwent VMR with biological mesh from August 2012 to January 2018. Data included patient demographics and intra- and postoperative findings; functional outcome as assessed by Cleveland Clinic Constipation Score (CCCS), Obstructed Defecation Score Longo (ODS), and Cleveland Clinic Incontinence Score (CCIS); and patient satisfaction. CCCS, CCIS, and ODS were significantly improved at 6-12months postoperatively and at last follow-up. Patient satisfaction (visual analog scale [VAS] 6.7 [0 to 10]), subjective symptoms (+ 3.4 [scale - 5 to + 5]), and quality of life improvement (+ 3.0 [scale from - 5 to + 5]) were high at last follow-up. The rates of morbidity and major complications were 13% and 3%, respectively. There were no mesh-related complications or deaths. Difference in type of previous surgery (abdominal or transanal/perineal) had no significant effect on results. VMR with biological mesh is a safe and effective option for patients with recurrent posterior pelvic organ prolapse. It reduces functional symptoms, has a low complication rate, and promotes patient satisfaction.