Risk factors for complications following sacral neuromodulation for faecal incontinence: Long-term follow-up.

AIM: Sacral neuromodulation (SNM) has become a standard surgical treatment for faecal incontinence (FI). Prior studies have reported various adverse events of SNM, including suboptimal therapeutic response, infection, pain, haematoma, and potential need for redo SNM. The aim of this study was to identify the risk factors associated with long-term complications of SNM. METHOD: This retrospective cohort reviewed patients who underwent two-stage SNM for FI at our institution between 2011-2021. Preoperative baseline characteristics and follow-up were obtained from the medical record and/or by telephone interview. Management and outcome of each postoperative event were evaluated by univariate and multivariate regression analyses. RESULTS: A total of 291 patients (85.2% female) were included in this study. Postoperative complications were recorded in 219 (75.2%) patients and 154 (52.9%) patients required surgical intervention to treat complications. The most common postoperative event was loss of efficacy (46.4%). Other common adverse events were problems at the implant site (pain, infection, etc.) in 16.5% and pain during stimulation in 11.7%. Previous vaginal delivery (OR 2.74, p = 0.003) and anal surgery (OR = 2.46, p = 0.039) were independent predictors for complications. Previous colorectal (OR = 2.04, p = 0.026) and anal (OR = 1.98, p = 0.022) surgery and history of irritable bowel syndrome (IBS) (OR = 3.49, p = 0.003) were independent predictors for loss of efficacy. CONCLUSION: Postoperative adverse events are frequently recorded after SNM. Loss of efficacy is the most common. Previous colorectal or anal surgery, vaginal delivery, and IBS are independent risk factors for complications.

Recovery of Proteases and Protease Inhibitors from Ganoderma spp. Cultivated in Amazonian Lignocellulose Wastes.

BACKGROUND: Ganoderma spp. are a great source of bioactive molecules. The production and recovery of bioactive molecules vary according to strain, growth substrate, and extraction solution. Variations in protease and their inhibitors in basidiomata from a commercial strain (G. lingzhi) and an Amazonian isolate (Ganoderma sp.) cultivated in Amazonian lignocellulosic wastes and extracted with different solutions are plausible and were investigated in our study. METHODS: Basidiomata from cultivation in substrates based on açaí seed, guaruba-cedro sawdust and three lots of marupá sawdust were submitted to extraction in water, Tris-HCl, and sodium phosphate. Protein content, proteases, and protease inhibitors were estimated through different assays. The samples were characterized by sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) and Fourier transform infrared spectroscopy with attenuated total reflectance (FTIR-ATR). RESULTS: Tris-HCl provided higher protein extraction from Ganoderma sp. and higher caseinolytic, gelatinolytic, and fibrinolytic activity for G. lingzhi cultivated in açaí. Water extracts of Ganoderma sp., in general, exhibited higher trypsin and papain inhibitor activities compared to G. lingzhi. Extracts in Tris-HCl and sodium phosphate showed more intense protein bands in SDS-- PAGE, highlighting bands of molecular weights around 100, 50, and 30 kDa. FTIR spectra showed patterns for proteins in all extracts, with variation in transmittance according to substrate and extractor. CONCLUSION: Water extract from Amazonian Ganoderma sp. cultivated in marupá wastes are promising as a source of protease inhibitors, while the Tris-HCL extract of G. lingzhi from açaí cultivation stands out as a source of proteases with fibrinolytic, caseinolytic, and gelatinolytic activities.

Ketamine versus electroconvulsive therapy for major depressive episode: An updated systematic review and non-inferiority meta-analysis.

We conducted a systematic review and meta-analysis to investigate the comparative effectiveness of ketamine versus electroconvulsive therapy (ECT) for the treatment of major depressive episodes (MDEs). PubMed, EMBASE and Cochrane Library databases were systematically searched for randomized controlled trials (RCTs) comparing ketamine and ECT for MDE. The primary outcome was response rate, for which we prespecified a non-inferiority margin of -0.1, based on the largest and most recent RCT. Response was defined as a reduction of at least 50 % in the depression scale score. Six RCTs met the inclusion criteria, comprising 655 patients. In the overall population, ketamine was not non-inferior to ECT in response rate (RD -0.10; 95 % CI -0.26 to 0.05; p = 0.198; I2 = 72 %). The ECT group had a higher reduction in depression scores, but without difference in remission and relapse rates. Regarding safety outcomes, ketamine had better posttreatment cognition scores and reduced muscle pain rate compared with ECT, albeit with an increased rate of dissociative symptoms. In a subanalysis with only inpatients, ketamine was inferior to ECT in response rate (RD -0.15; 95 % CI -0.27 to -0.03; p = 0.014; I2 = 25 %), remission, and change in depression scores. These findings support the use of ECT over ketamine for inpatients. Further RCTs are warranted to clarify the comparative effect of these treatments for outpatients.

Effect of neoadjuvant therapy regimens on lymph nodes yield in rectal cancer.

BACKGROUND AND OBJECTIVES: Pathological nodal staging is relevant to postoperative decision-making and a prognostic marker of cancer survival. This study aimed to assess the effect of different total neoadjuvant therapy (TNT) regimens on lymph node status following total mesorectal excision (TME) for locally advanced rectal cancer (LARC). METHODS: A retrospective cohort study of patients treated for node-positive clinical stage 3 LARC with TNT between January 2015 and August 2022. Patients were stratified into induction therapy and consolidation therapy groups. Variables collated included patient demographics, clinical and radiological characteristics of the tumor, and pathology of the resected specimen. Primary outcome was total harvested lymph nodes. RESULTS: Ninety-seven patients were included (57 [58.8%] males; mean age of 58.5 ± 11.4 years). The induction therapy group included 85 (87.6%) patients while 12 (12.4%) patients received consolidation therapy. A median interquartile range value of 22.00 (5.00-72.00) harvested lymph nodes was recorded for the induction therapy group in comparison to 16.00 (16.00-47.00) in the consolidation therapy arm (p = 0.487). Overall pathological complete response rate was 34%. CONCLUSION: Total harvested nodes from resected specimens were marginally lower in the consolidation therapy group. Induction therapy may be preferrable to optimize postoperative specimen staging.

Impact of social distancing from the COVID-19 pandemic on the immuno-inflammatory response of older adults.

BACKGROUND: Older adults, as the population considered at increased risk for severe COVID-19, were the most impacted by social isolation. Thus, this study aimed to assess the salivary immune/inflammatory response of older adults before and during the COVID-19 pandemic. METHODS: A cohort of 11 older adults (mean age 66.8 ± 6.1) was followed at three different time points: before (S1) and after 6 (S2) and 20 months (S3) of the beginning of the COVID-19 pandemic in Brazil. Unstimulated saliva samples were obtained to assess the levels of antibodies (secretory IgA, IgG and IgM) by ELISA and cytokines (IL-2, IL-5, IL-6, IL-8 and IL-10, TSLP, IFN-γ, TNF-α) by multiplex analysis. Significant differences were evaluated using the Kruskal-Wallis test with Dunn's post-test. RESULTS: None volunteer presented periodontal disease or caries. All volunteers received at least two doses of the COVID-19 vaccines after S2 and before S3. A tendency to increase salivary levels of SIgA and IgM at S2 and of IgG at S3 were observed compared to the values found at S1 and S2. Significantly decreased levels of IL-2 and IL-5 were found at S2 and S3 (p < 0.001) time points. Lower levels of IFN-γ were found at S2 as compared to the values observed at S1 (p < 0.01). A significant decrease in the IFN-γ/IL-10 ratio was found at S2 (p < 0.01). When assessing the Th1/Th2 ratios, a significant decrease was found in the IFN-γ/TSLP ratio at S2 (p < 0.001) and S3 (p < 0.001) when compared to the values at S1. In addition, a significant increase was observed in the TNF-α/IL-5 ratio at S2 (p < 0.001) and S3 (p < 0.001) in comparison to the values at S1. In a similar way, an increase in the TNF-α/IL-6 ratio (Fig. 5E) was observed at S3 (p < 0.001) when compared to the values at S1. CONCLUSIONS: Overall, this study provides valuable insights into the impact of COVID-19-induced social isolation on immune/inflammatory responses in the upper airway mucosa, particularly those present in oral cavity, of older adults. It demonstrates that a controlled shift in Th1 and Th2 immune responses, both during infection and post-vaccination, can create favorable conditions to combat viral infections without exacerbating the immune response or worsening the pathology.

The SAGES MASTERS program presents: the top 10 seminal articles for laparoscopic left and sigmoid colectomy pathway for uncomplicated disease.

BACKGROUND: As one of the 8 Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Masters Program clinical pathways, the Colorectal Pathway aims to deliver educational content for the general surgeon organized along 3 levels of performance (competency, proficiency and mastery) each represented by an anchoring procedure. In this article, the SAGES Colorectal Task Force presents focused summaries of the top 10 seminal articles selected for laparoscopic left/sigmoid colectomy for uncomplicated disease. METHODS: Using a systematic literature search of Web of Science, the most cited articles on laparoscopic left and sigmoid colectomy were identified, reviewed, and ranked by members of the SAGES Colorectal Task Force. Additional articles not identified in the literature search were included if deemed impactful by expert consensus. The top 10 ranked articles were then summarized, including their findings, strengths and limitations with emphasis on relevance and impact in the field. RESULTS: The top 10 articles selected focus on variations in minimally invasive surgical techniques, video demonstrations, stratified approaches for benign and malignant disease as well as assessments of the learning curve. CONCLUSIONS: The selected top 10 seminal articles for laparoscopic left and sigmoid colectomy in uncomplicated disease are considered by the SAGES colorectal task force to be fundamental to the knowledge base of minimally invasive surgeons as they progress to mastery in these procedures.

Efficacy and Safety of a Nonanimal Stabilized Hyaluronic Acid/Dextranomer in Improving Fecal Incontinence: A Prospective, Single-Arm, Multicenter, Clinical Study With 36-Month Follow-up.

BACKGROUND: Fecal incontinence affects 7% to 12% of the US adult population, causing social, financial, and quality of life burdens. OBJECTIVE: The primary aim of this study was to evaluate the efficacy and safety of nonanimal stabilized hyaluronic acid/dextranomer through 36 months as a condition of postmarket approval application. DESIGN: This was a prospective, single-arm, multicenter, observational Food and Drug Administration-mandated postapproval clinical study. SETTINGS: This study was designed and executed by participating centers in 18 hospitals and colorectal health clinics in coordination with the Food and Drug Administration and the study sponsor. PATIENTS: A total of 283 subjects who previously failed conservative therapy were enrolled across 18 US sites. INTERVENTIONS: Participants received 1 to 2 nonanimal stabilized hyaluronic acid/dextranomer treatments. The first treatment occurred within 30 days of baseline, and a second treatment was administered 1 to 3 months after initial treatment if determined necessary by the physician. Subjects were followed through 7 visits over 36 months after last treatment. MAIN OUTCOME MEASURES: Efficacy (as specified by the Food and Drug Administration) was measured as a fecal incontinence reintervention rate of <50% at 36 months. Reintervention included nonanimal stabilized hyaluronic acid/dextranomer re-treatment, surgical interventions, and physical therapy. Safety was measured by device-related adverse events. Secondary end points included Fecal Incontinence Quality of Life Scale and Cleveland Clinic Florida Fecal Incontinence Score. RESULTS: Using a Bayesian estimate, the reintervention rate of the intention-to-treat population (n = 283) was 18.9% (95% CI, 14.0-24.4) at 36 months. At 36 months, the reintervention rate for subjects with complete data (n = 192) was 20.8% (95% CI, 15.1-26.6). Significant improvement ( p < 0.0001) was noted across the Cleveland Clinic Florida Fecal Incontinence Score and Fecal Incontinence Quality of Life subscales at 36 months. Ninety-two device-related adverse events were reported by 15.2% of enrolled patients; most were GI disorders and resolved quickly. There were no serious adverse events. LIMITATIONS: Limitations of the study included a 32% attrition rate and homogeneous patient population (91.8% white; 85.5% female), possibly limiting generalizability. CONCLUSIONS: Nonanimal stabilized hyaluronic acid/dextranomer demonstrated clinically significant, sustained improvement in symptoms and quality of life for fecal incontinence patients without the occurrence of any serious adverse events. See Video Abstract at http://links.lww.com/DCR/B890 . REGISTRATION: ClinicalTrials.gov ; Unique identifier: NCT01647906. EFICACIA Y SEGURIDAD DE UN CIDO HIALURNICO/ DEXTRANMERO ESTABILIZADO DE ORGEN NO ANIMAL PARA MEJORAR LA INCONTINENCIA FECAL UN ESTUDIO CLNICO PROSPECTIVO, MULTICNTRICO Y DE UN SOLO BRAZO CON SEGUIMIENTO DE MESES: ANTECEDENTES:La incontinencia fecal afecta entre el 7 y el 12% de la población adulta de los EE. UU. Y genera cargas sociales, económicas y de calidad de vida.OBJETIVO:Los objetivos principales de este estudio fueron evaluar la eficacia y seguridad del ácido hialurónico/ dextranómero estabilizado de origen no animal durante 36 meses como condición para la solicitud de aprobación posterior a la comercialización.DISEÑO:Este fue un estudio clínico prospectivo, observacional, de un solo brazo, multicéntrico, ordenado por la FDA después de la aprobación.AJUSTES:Este estudio fue diseñado por los investigadores participantes, la FDA y el patrocinador del estudio que gestionó la recopilación de datos.PACIENTES:Un total de 283 sujetos en quienes previamente falló la terapia conservadora se inscribieron en el estudio prospectivo de un solo brazo en 18 sedes de EE. UU. (NCT01647906).INTERVENCIONES:Los participantes recibieron 1-2 tratamientos con ácido hialurónico/ dextranómero estabilizado no animal. El primer tratamiento se dio dentro de los 30 días posteriores al inicio, mientras que un segundo tratamiento se administró 1-3 meses después del tratamiento inicial si el médico lo determinaba necesario. Los sujetos fueron seguidos durante 7 visitas durante 36 meses después del último tratamiento.PRINCIPALES MEDIDAS DE RESULTADO:La eficacia (según especificado por la FDA) se midió como una tasa de reintervención de incontinencia fecal de <50% a los 36 meses. La reintervención incluyó retratamiento con ácido hialurónico/ dextranómero estabilizado no animal, intervenciones quirúrgicas y fisioterapia. La seguridad se midió mediante los eventos adversos relacionados con tratamiento. Los criterios de valoración secundarios incluyeron la escala de calidad de vida de incontinencia fecal y la puntuación de incontinencia fecal de Cleveland Clinic Florida.RESULTADOS:Utilizando una estimación bayesiana, la tasa de reintervención de la población por intención de tratar (n = 283) fue del 18.9% (IC del 95%: 14.0%, 24.4%) a los 36 meses. A los 36 meses, la tasa de reintervención para los sujetos con datos completos (n = 192) fue del 20.8% (IC del 95%: 15.1%, 26.6%). Se observó una mejora significativa (p <0.0001) en las subescalas de la puntuación de incontinencia fecal de la Cleveland Clinic Florida y de la calidad de vida de la incontinencia fecal a los 36 meses. El 15.2% de los pacientes inscritos informaron 92 eventos adversos relacionados con el tratmiento; la mayoría eran trastornos gastrointestinales y se resolvieron rápidamente. No hubo eventos adversos graves.LIMITACIONES:Las limitaciones incluyen una tasa de deserción del 32% y una población de pacientes homogénea (91.8% blancos, 85.5% mujeres), lo que posiblemente limite la generalización.CONCLUSIÓNES:El ácido hialurónico/ dextranómero estabilizado de origen no animal demostró una mejora sostenida y clínicamente significativa de los síntomas y la calidad de vida de los pacientes con incontinencia fecal, sin que se produjeran efectos adversos graves. Consulte el Video Resumen en http://links.lww.com/DCR/B890 . ( Traducción-Dr. Jorge Silva Velazco )Registro: ClinicalTrials.gov número NCT01647906.

Clinical Factors Contributing to Anastomotic Leak After Mid-to-High Colorectal Anastomosis.

BACKGROUND: Low colorectal anastomoses carry a high anastomotic leak (AL) rate (up to 20%) and thus are commonly diverted. Much less is known about mid-to-high colorectal anastomosis, which carries a leak rate of 2-4%. The objective of this study was to determine our AL rate after mid-to-high colorectal anastomosis and associated risk factors. METHODS: A single center retrospective cohort study of patients undergoing left colonic resections with mid-to-high colorectal anastomosis (≥7 cm from the anal verge) from January 2008 to October 2017 was utilized. Main outcome, AL, defined as clinical suspicion supported by radiological or intraoperative findings, was calculated and risk factors assessed using multivariable logistic regression analysis. RESULTS: 977 patients were included; 487 (49.9%) were male, with a mean age of 59.8 (+/-12.1) years. Mean BMI was 27.5 (+/-5.5) kg/m2. Diverticular disease (67.5%), malignancy (17.4%), and inflammatory bowel disease (2.2%) were the main indications for resection. Mean length of stay was 6.7 (+/-4.5) days. 455 (46.8%) colonic resections were performed by laparoscopy, 283 (29.1%) by hand assisted surgery, 219 (22.5%) by laparotomy, and 16 (1.6%) by robotics. Majority of patients had complete donuts (99.6%) and a negative air leak test (97.7%). 149 patients (15.3%) underwent construction of a diverting stoma. The overall AL rate was 2.1% (n = 20). Increased BMI (>30 kg/m2), P = .02, was an independent risk factor for AL and a trend observed for positive air leak tests (P = .05), with other factors failing to achieve statistical significance. CONCLUSIONS: Patients with mid-to-high colorectal anastomosis have a 2% AL risk. Increased BMI was a risk factor for AL.

The Characterization and Outcomes of Colorectal Malignancy in Patients ≤40 Years of Age: A Single-Center Experience.

BACKGROUND: Implementation of screening modalities has led to a decreased incidence of colorectal malignancies. Unfortunately, overall incidence has remained unchanged as cases have increased in patients below the suggested screening age. Therefore, we evaluated characteristics and oncological outcomes of malignancies in patients ≤40 years of age. METHODS: Single-center retrospective analysis of prospectively collected data of malignancies in patients ≤40 years evaluated in our institution between 2010 and 2016. Basic descriptors for demographic, clinical, histologic, and genetic data were collected. Disease-free survival (DFS) and 5-year overall survival (OS) were compared for patients between 30-40 years and <30 years. RESULTS: Fifty-six patients ≤40 years were identified, 44 of whom (96.5%) had adenocarcinomas. Most common malignancy location was the rectum (64.3%). Despite aggressive tumor characteristics such as moderate/poor differentiation (88.6%), lymphovascular invasion (26.8%), perineural invasion (21.4%), and advanced tumor stage T3/T4 (60.7%), OS rate was 94.6%. Both age groups had similar oncologic characteristics. There was a trend toward worse OS (2/11 and 1/45, P = .06) but not for DFS (7/11 and 15/43, P = .18) in patients <30 years of age compared to 30-40 years. There were no differences in OS (3/44 vs 0/88, P = .44) or DFS (17/42 vs 3/8, P = .80) between sporadic vs non-sporadic malignancies, respectively. CONCLUSIONS: Patients ≤40 years of age with malignancy have advanced tumor stages and aggressive tumor characteristics at diagnosis. Although there is higher OS risk for patients <30 compared to those aged 30-40 years, no differences were found for DFS between these two groups.

Obstructive sleep apnea and orofacial myofunctional aspects in obesity.

PURPOSE: This study aimed to evaluate the quality of sleep, presence of obstructive sleep apnea (OSA), and its relationship with the presence of snoring, cephalometric characteristics, degree of collapse of the upper airways, and orofacial myofunctional profile in obese and overweight individuals. METHODS: All participants completed polysomnography, as well as sleep and snoring questionnaires. We further performed orofacial, otorhinolaryngological, and anthropometric evaluations on all participants. RESULTS: A total of 102 adults, comprising 29 obese, 21 overweight, and 52 eutrophic individuals of both sexes participated in this study. We observed a high prevalence of snoring in both obese and overweight (100%), and in 65% of eutrophic individuals. Among the obese subjects 58% had a severe degree of OSA, whereas 4% of eutrophic subjects presented a risk for OSA development. Sleep quality was related to body mass index (BMI) and cervical and abdominal circumference. All obese and overweight individuals presented with orofacial myofunctional alterations such as facial asymmetry, alteration of the maxilla-jaw relationship, inadequate tongue posture, changes in masticatory pattern and swallowing, and inadequate general orofacial myofunctional condition. Airway obstructions at the retropalatal and retrolingual levels > 75% were observed in at least 48% of the individuals. CONCLUSION: Obese and overweight individuals presented a higher risk for the development of OSA compared with eutrophic patients, and obese individuals presented a greater severity of OSA. The higher the BMI and greater the cervical and abdominal circumferences, the higher the prevalence of OSA, worse the quality of sleep, and more serious orofacial myofunctional characteristics in this population.

'Bumps down under:' hemorrhoids, skin tags and all things perianal.

PURPOSE OF REVIEW: There continues to be a concentrated effort to improve treatment options readily available for some of the most common perianal diseases: hemorrhoids, anal fissure and anal fistula. The emphasis remains on therapies that definitively address the underlying pathology yet minimize pain and risk of incontinence, have a short recovery period, and are cost-effective. In this analysis, recent developments in the literature are reviewed. RECENT FINDINGS: Treatment of early stage hemorrhoidal disease remains the same. For grades II-IV disease, hemorrhoidal vessel ligation/obliteration with laser or bipolar energy are reported. For more advanced diseases, modifying the technique for hemorrhoidectomy to improve postoperative complications and pain is described. For anal fissure, a stepwise method continues to be the mainstay of treatment (initiating with vasodilators, followed by botox, and ultimately sphincterotomy), which decreases the risk of incontinence with proper patient selection and technique. Management of anal fistula continues to be challenging, balancing cure vs. risk of harm. Recent developments include modifications to ligation of intersphincteric fistula tract procedure and use of laser to obliterate the tract. SUMMARY: Advancements in managing benign anorectal disease are ongoing. Several reports are novel, whereas others involve enhancing well-established treatment options by either operative technique or patient selection.

Recent advances in managing fecal incontinence.

Fecal incontinence (FI) is the uncontrolled passage of feces or gas in an individual who previously had control. The prevalence of the problem varies but can be as high as 50% of institutionalized individuals. The severity varies among individuals, but the negative impact on self-esteem and quality of life can have devastating effects. The goals of treatment are to decrease the frequency and severity of episodes as well as to improve quality of life. At present, several therapies, ranging from medical management to more invasive surgical interventions, are offered for the management of FI. In this article, we review the most recent advances in the management of FI.

Does laparoscopic ileal pouch-anal anastomosis reduce infertility compared with open approach?

BACKGROUND: The aim of this study was to assess the association of the mode of surgery on female fertility after restorative proctocolectomy with ileal pouch-anal anastomosis. METHODS: All female patients aged 18 to 44 years who underwent restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis, familial adenomatous polyposis, or Crohn's disease at the Cleveland Clinic Ohio or the Cleveland Clinic Florida from 1983 to 2012 were sent a standardized fertility questionnaire. Infertility was defined as lack of pregnancy after 1 year of unprotected sexual intercourse. Patients who had attempted to conceive after restorative proctocolectomy with ileal pouch-anal anastomosis were compared based on the surgical approach: laparoscopic ileal pouch-anal anastomosis versus open ileal pouch-anal anastomosis. RESULTS: A total of 890 female patients were surveyed, of which 519 (58.3%) responded. Of these, 161 (31%) had attempted pregnancy after surgery: 18 (12%) had laparoscopic ileal pouch-anal anastomosis and 143 (88%) had open ileal pouch-anal anastomosis. There were no significant differences regarding demographics between groups. There was no difference in reported infertility rates (61.1% vs 65%, respectively, P = 0.69) between the laparoscopic ileal pouch-anal anastomosis and open ileal pouch-anal anastomosis groups. The median time to pregnancy (3.5 months vs 9 months, respectively, log-rank P = 0.01) was reduced in patients who underwent laparoscopic ileal pouch-anal anastomosis compared with those who underwent open ileal pouch-anal anastomosis. CONCLUSION: Postoperative infertility rates were higher after ileal pouch-anal anastomosis regardless of mode of surgery. However, laparoscopy was associated with a significantly reduced time to conceive compared with the open approach.

The case of the missing appendix: a case report of appendiceal intussusception at the site of colonic mullerianosis.

Right lower quadrant pain is a symptom with an exceptionally broad differential diagnosis. Intussusception of the appendix is a very uncommon condition with many manifestations. Additionally, the pathologic finding of ectopic presence of a mixture of at least two mullerian-derived tissue components is rare. This report presents the case of a 49-year-old woman who presented twice with acute right lower abdominal pain. Diagnosis of appendiceal inversion was made surgically. Pathologic examination of the specimen identified extensive endometriosis, endosalpingiosis and endocervicosis of the colon wall. Appendiceal intussusception and colonic mullerianosis, present together, are discussed, and recommendations for the diagnosis and treatment of appendiceal intussusception are discussed.

Management of Complex Perineal Fistula Disease.

Management of complex perineal fistulas such as high perianal, rectovaginal, pouch-vaginal, rectourethral, or pouch-urethral fistulas requires a systematic approach. The first step is to control any sepsis with drainage of abscess and/or seton placement. Patients with large, recurrent, irradiated fistulas benefit from stoma diversion. In patients with Crohn's disease, it is essential to induce remission prior to any repair. There are different approaches to repair complex fistulas, from local repairs to transperineal and transabdominal approaches. Simpler fistulas are amenable to local repair. More complex fistulas, such as those secondary to irradiation, require interposition of healthy, well-vascularized tissue. The most common flap used for this treatment is the gracilis muscle with good outcomes reported. Once healing is confirmed by imaging and endoscopy, the stoma is reversed.

Pro-inflammatory cytokines and psychotherapy in depression: Results from a randomized clinical trial.

Depression is a serious condition that is associated with great psychic suffering and major impairments on the patient's general health, quality of life, and social and occupational activities. In some cases, it may lead to suicide. Regardless of the innumerous research works that have already addressed depression in wide and specific facets, there is still a lot to grasp in order to effectively help preventing and treating depression. This work presents data from a randomized clinical trial that sought to evaluate the effectiveness of two brief psychotherapeutic for Depression: Cognitive Behavioral Therapy (CBT) and Supportive-Expressive Dynamic Psychotherapy (SEDP). This was a convenience sample composed of 46 individuals that were evaluated using a structured diagnostic interview and then randomly allocated to the SEDP group. We examined baseline and post-intervention serum levels of the Interleukin-6 (IL-6) and the Tumor Necrosis Factor (TNF-α) in addition to the severity of depressive symptoms according to the Outcome Questionnaire - 45.2 (OQ-45.2) and the Beck Depression Inventory (BDI). Results show that serum IL-6 and TNF-α levels, as well as the scores from the OQ-45.2 and the BDI significantly decreased after 16 sessions of SEDP (p < 0.001), except for the Interpersonal Relationship domain from the OQ-45. Despite the reduction of serum cytokines levels and OQ-45 and BDI scores, they were only significantly correlated regarding the social role domain from the OQ-45. Nonetheless, our data suggests an effective role of brief psychodynamic psychotherapy in the reduction of depressive symptoms and serum inflammatory levels that are associated with depression.

Electrothermal bipolar vessel ligation improves operative time during laparoscopic total proctocolectomy: a large single-center experience.

BACKGROUND: Laparoscopic total proctocolectomy (TPC) with or without ileoanal pouch is a major operation for which the traditional benefits of laparoscopy were not immediately apparent, in part due to the longer operating times. The use of energy devices has been shown to improve operative outcomes for patients who undergo laparoscopic segmental colectomies, but there are limited data for laparoscopic TPC (LTPC). METHODS: All patients who underwent LTPC between January 2002 and July 2011 were identified from a prospectively maintained institutional-review-board-approved database. Univariate and multiple linear regression analyses were performed to assess the impact of electrothermal bipolar vessel sealers (EBVS) for vessel ligation on operative time. Secondary outcomes included vessel ligation failures, estimated blood loss, and other intra- and postoperative outcomes. RESULTS: One hundred and forty-five patients underwent LTPC, including 126 restorative ileoanal pouch and diverting ileostomy operations and 19 TPC and end ileostomy procedures. Fifteen percent of LTPCs were totally laparoscopic, 45 % were laparoscopic-assisted, 32 % were hand-assisted, and 8 % were laparoscopic-converted cases. Laparoscopic vessel ligation was performed using EBVS (76 %), endoscopic staplers (12 %), or hybrid techniques (12 %). Vessel ligation groups were similar in demographics, body mass index, surgical indication, immunosuppression, and prior surgery. EBVS were associated with shorter median operative times (247 vs. 290 vs. 300 min, p = 0.018) and fewer vessel ligation failures (1 vs. 11 vs. 12 %, p = 0.027) compared with endoscopic staplers and hybrid techniques, respectively. There were no differences in estimated blood loss and intra-operative complications among the three groups. Length of stay, 30-day morbidity, and 30-day re-operation rates were also similar. On multiple linear regression analysis, EBVS were a significant predictor of operative time (p = 0.019). CONCLUSIONS: Routine use of electrothermal bipolar vessel ligation for LTPC is associated with shorter operative time and fewer vessel ligation failures without higher risk of complications than other vessel control methods.

Brief psychoeducation for bipolar disorder: impact on quality of life in young adults in a 6-month follow-up of a randomized controlled trial.

There are scarce follow-up studies evaluating the role of psychoeducation in the treatment of bipolar disorder, especially in a young sample, with a recent diagnosis and that probably received a few previous interventions. This was a randomized clinical trial with young adults aged 18-29 years, who had been diagnosed with bipolar disorder through the Structured Clinical Interview for DSM (SCID). The evaluation of quality of life was carried out using the Medical Outcomes Survey 36-Item Short-Form Health Survey (MOS SF-36). All participants were randomized into two groups: combined intervention (psychoeducation plus medication) and treatment-as-usual (medication). The sample consisted of 61 patients divided in two groups (29 usual treatment; 32 combined intervention). The quality of life domains did not reveal statistically significant differences when comparing baseline, post-intervention and 6-month follow-up evaluations, which indicates that there is no difference between combined intervention and usual intervention regarding quality of life improvement. Both groups presented improvements in quality of life domains, except General Health and Bodily Pain, at post-intervention. Moreover, this improvement persisted at 6-month follow-up, except for the Role Physical Health domain, which remained reduced. Combined Psychoeducation plus pharmacological intervention is so effective in improving quality of life perception as it is pharmacological only intervention.

Childhood trauma and suicide risk in a sample of young individuals aged 14-35 years in southern Brazil.

Suicide is among the main causes of death of people aged between 15 and 44 years old. Childhood trauma is an important risk factor for suicide. Hence, the objective of this study was to verify the relationship between childhood trauma and current suicide risk (suicidal behavior and ideation) in individuals aged 14-35 years, in the city of Pelotas, Brazil. This is a cross-sectional, population-based study. Sample selection was performed by clusters. Suicide risk was evaluated using the Mini International Neuropsychiatric Interview (MINI) and Childhood trauma was assessed with the Childhood Trauma Questionnaire (CTQ). Moreover, the participants responded to a questionnaire concerning socioeconomic status, work, and substance use. The sample was composed of 1,380 individuals. The prevalence of suicide risk was 11.5%. The prevalence figures of childhood trauma were 15.2% (emotional neglect), 13.5% (physical neglect), 7.6% (sexual abuse), 10.1% (physical abuse), and 13.8% (emotional abuse). Suicide risk was associated (p<.001) with gender, work, alcohol abuse, tobacco use, and all types of childhood trauma. The odds of suicide risk were higher in women (OR=1.8), people who were not currently working (OR=2.3), individuals who presented alcohol abuse (OR=2.6), and among tobacco smokers (OR=3.4). Moreover, suicide risk was increased in all types of trauma: emotional neglect (OR=3.7), physical neglect (OR=2.8), sexual abuse (OR=3.4), physical abuse (OR=3.1), and emotional abuse (OR=6.6). Thus, preventing early trauma may reduce suicide risk in young individuals.

Burden and related factors in caregivers of young adults presenting bipolar and unipolar mood disorder.

BACKGROUND: Caregiver burden has been associated with caregivers' mental disorders and need for support and information. However, the lack of quantitative studies and formal interventions aiming to lower burden levels in this population reflect the current negligence regarding this important issue. AIM: To identify burden levels and associated factors in caregivers of young adults with bipolar and unipolar mood disorder. METHOD: This is a cross-sectional study nested within a population-based cross-sectional study with young adults. Caregiver burden was assessed through the Burden Interview. Information about caregiver mental disorders (Axis I) and alcohol abuse were obtained through the Mini International Neuropsychiatric Interview (MINI) and the Cut-Down, Annoyed, Guilty and Eye-Opener (CAGE) questionnaire, respectively. RESULTS: Caregiver burden was associated to caregiver's mood and anxiety disorders, suicide risk and being the caregiver of young adults with depression disorder and bipolar disorder. Also, burden was higher among caregivers of bipolar individuals. When excluding the control group from the analysis, only mood and anxiety disorders remained associated to caregiver burden. CONCLUSIONS: Caregivers are affected by the young adult's disorder even before a diagnosis has been given, with serious impairments in their lives. Thus, this is a subject in need of designing relevant strategies aiming to provide them with care.