Tandem vaginoscopy with colonoscopy: a diagnostic technique for the assessment of colovaginal fistula.

AIM: Colovaginal fistula (CVF) has a negative impact on quality of life. Identifying the fistula track is a critical step in its management. In a subset of patients, localizing the fistula preoperatively can be difficult. The purpose of this report is to describe the technique and results of tandem vaginoscopy with colonoscopy (TVC). METHOD: A retrospective analysis was conducted of all patients referred to a tertiary centre with symptoms suggestive of CVF but no prior successful localization of a fistula. TVC was performed by one colorectal surgeon in the endoscopy suite under intravenous sedation. RESULTS: Between 2003 and 2013, 18 patients (median age 58 years) underwent TVC. CVF was ruled out in three patients. In the remaining 15 patients, TVC documented the fistula in 13. In eight cases a wire was passed through the fistulous track from the vagina to the colon, in three the track was large enough to be traversed with the endoscope and in two a fistulous opening was noted on the vaginal side but passage of a wire to localize the opening on the colonic side was not possible due to extensive scarring. No TVC-related complications were recorded. The sensitivity, specificity, positive predictive value and negative predictive value for TVC in detecting CVF were 86.7%, 100%, 100% and 60%, respectively. CONCLUSION: TVC is a useful technique that can localize the fistulous track in most patients with CVF.

A single dose of prophylactic antibiotic may be sufficient to prevent postprocedural infection in upper endosonography guided fiducial marker placement.

AIM: Prophylactic antibiotic after endosonographic ultrasound (EUS) guided fiducial marker placement is common practice to prevent infection. Duration of using prophylaxis antibiotic is unknown. The aim of this paper was to assess whether one time intraprocedural administration of a prophylactic antibiotic is sufficient to prevent infection after EUS guided fiducial marker placement. METHODS: Retrospective study was performed included all adult patients who underwent EUS guided fiducial markers over 18 month period. Procedure related infection was defined as any infection not directly attributable to any other cause within 30 days of the procedure. The patients followed up with the Gastroenterology clinic in one week and with Radiation Oncology clinic weekly after undergoing EUS guided fiducial marker placement. RESULTS: A total of 35 upper EUS-guided fiducial markers were placed during 20 procedures on 18 patients. The average age of patients was 59 years. There were 10 females and 8 males.. All patients received one dose of cephalosporin, amoxicillin, clindamycin or levoflocaxin. The fiducial markers were deployed in different organs. None of the patients developed any infections due to the procedure. CONCLUSION: This study suggests that one dose of intravenous antibiotic administered intraprocedurally is sufficient to prevent infection related to upper EUS guided fiducial marker placement.

Effect of fluoroscopy utilization monitoring on fluoroscopy times during ERCP.

AIM: The aim of the present study was to find whether informing endoscopists that their FT is being tracked would result in decreasing their overall fluoroscopy utilization as measured by FT. METHODS: We reviewed the medical charts of patients underwent ERCP from April 2011 to May 2012. On December 15, 2011, the endoscopists were informed about their mean FT during ERCP, were encouraged to decrease FT and were informed their FT would be monitored. We compared the mean FT of the endoscopists individually and as a group before and after December 15, 2011. RESULTS: The study included 293 patients and 3 endoscopists. Before informing the endoscopists that their FT was being tracked, utilization of fluoroscopy was significantly variable among endoscopists. The mean FT for all endoscopists was 9.04 minutes and for each endoscopist was 6.06, 11.43, and 7.67 minutes, respectively (P<0.02). After informing the endoscopists that their FT will be followed, there was a trend toward a decrease in FT among the group (9.04 vs. 7.4 minutes, P=0.06). However, the changes in FT among endoscopists individually were variable. The FT for first, second and third endoscopists changed from 6.06 min to 3.39 min, p<0.02, 11,43 min to 8.8 min, P=0.14 and 7.67 to 11.47 minutes, P=0.06, respectively. CONCLUSION: Fluoroscopic utilization during ERCP among endoscopists is variable. Endoscopists' knowledge that their FT during ERCP is being tracked leads to variable results among endoscopists. Nonetheless, overall it leads to a trend in reducing fluoroscopy utilization.

Sirolimus-induced intractable chronic diarrhea: a case report.

Sirolimus is a macrolide that is extensively used in transplant clinics. The most common side effects of sirolimus are hypertriglyceridemia, hypercholesterolemia, hypertension, rash, and well-tolerated diarrhea. Herein I have reported a case of intractable, disabling, chronic diarrhea secondary to sirolimus in a renal transplant recipient. The sirolimus dose had been recently increased from 2 mg to 5 mg 1 month before the patient began to complain of severe diarrhea. In addition to the case presentation, the literature is reviewed as well as possible mechanisms of sirolimus-induced diarrhea are discussed. In conclusion, clinicians should consider sirolimus as a potential etiology for severe chronic diarrhea among patients who are treated with sirolimus.