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Study Design Systematic review. Clinical Questions (1) Is autologous local bone (LB) graft as safe and effective as iliac crest bone graft (ICBG) in lumbar spine fusion? (2) In lumbar fusion using ICBG, does a single-incision midline approach reduce postoperative iliac crest pain compared with a two-incision traditional approach? Methods Electronic databases and reference lists of key articles were searched up to October 2014 to identify studies reporting the comparative efficacy and safety of ICBG versus LB graft or comparing ICBG harvest site for use in lumbar spine surgery. Studies including allograft, synthetic bone, or growth factors in addition to ICBG and those with less than 80% of patients with degenerative disease in the lumbar spine were excluded. Two independent reviewers assessed the level of the evidence quality using the Grades of Recommendation Assessment, Development and Evaluation criteria, and disagreements were resolved by consensus. Results Seven studies were identified as using ICBG fusion for degenerative disease in the lumbar spine. There were no differences in the fusion, leg pain, low back pain, or functional outcomes between patients receiving LB versus ICBG. There was a higher incidence of donor site pain and sensory loss in patients receiving ICBG, with no donor site complications attributed to LB. Compared with patients with the graft harvested through the two-incision traditional approach, patients with the graft harvested through the single-incision midline approach had lower mean pain scores over the iliac crest, with a higher proportion reporting no iliac crest tenderness. In patients with ICBG harvested through the single-incision midline approach on either the right or the left side of the ilium, only 36% of the patients were able to correctly identify the side when asked whether they knew which iliac crest was harvested. Only 19% of the patients with ICBG harvested through the single-incision midline approach on either the right or the left side of the ilium reported pain that was concordant with the side that was actually harvested. Conclusions LB is as safe and efficacious as ICBG for instrumented fusion in the lumbar spine to treat degenerative disease. When ICBG is used, graft harvest through the single-incision midline approach reduces postoperative iliac crest pain compared with a two-incision approach.

Based on our data, first-year medical students with additional training can use the ROUTE to identify complications in pregnancy using ultrasound in rural Panama. Additional studies are required to determine the optimal amount of training required for proficiency.

Background Laser fistulectomy is a minimally invasive, sphincter-sparing procedure for treatment of anal fistula. In several studies, this method has been shown to be safe and effective, with reported success rates ranging from 40 to 88%. We hypothesized that with longer follow-up, these rates would decrease.Methods A retrospective case analysis assessing the effectiveness of laser fistulectomy in curing fistula-in-ano tracts within a cohort of patients at a single academic institution was conducted. All patients having laser ablation between March 2016 and July 2018 were analyzed. Cure of the fistula was determined by history and postoperative physical exam, and was defined as complete closure of fistula tract with resolution of symptoms. Secondary symptoms of fecal incontinence, infection, and pain were evaluated. ResultsEighteen patients (10 males, mean age 41 ± 13 years) were analyzed. Transphincteric fistula was the most common type (67%, N = 12). The mean number of previous fistula procedures was 1.33 ± 1.64. There was a 22% (N = 4) success rate at an average postoperative follow-up period of 29 ± 8 months (range 18-46 months). Of those who failed, 64% (N = 9) had a subsequent fistula procedure. There were no cases of fecal incontinence, but 3 cases (17%) of postoperative infection were reported and 8 patients (44%) had a subjective increase in pain at first follow-up appointment.Conclusions Our data showed a much higher failure rate of laser fistulectomy compared to those reported in the literature. However, the small sample size, a large amount of heterogeneity in our patient population with a mixture of fistula types present, and various laser techniques applied decreased the power of this study.

BACKGROUND: Dehydration and its associated symptoms are among the most common chief complaints of children in rural Panama. Previous studies have shown that intravascular volume correlates to the ratio of the diameters of the inferior vena cava (IVC) to the aorta (Ao). Our study aims to determine if medical students can detect pediatric dehydration using ultrasound on patients in rural Panama.METHODS: This was a prospective, observational study conducted in the Bocas del Toro region of rural Panama. Children between the ages of 1 to 15 years presenting with diarrhea, vomiting, or parasitic infection were enrolled in the study. Ultrasound measurements of the diameters of the IVC and abdominal aorta were taken to assess for dehydration.RESULTS: A total of 59 patients were enrolled in this study. Twenty-four patients were clinically diagnosed with dehydration and 35 were classified to have normal hydration status. Of the 24 patients with dehydration, half (n=12) of these patients had an IVC/Ao ratio below the American threshold of 0.8. Of the remaining asymptomatic subjects, about half (n=18) of these subjects also had an IVC/Ao ratio below the American threshold of 0.8. CONCLUSION:Our study did not support previous literature showing that the IVC/Ao ratio is lower in children with dehydration. It is possible that the American standard for evaluating clinical dehydration is not compatible with the rural pediatric populations of Panama.

It is estimated that more than 30 million women in the United States are affected by pelvic floor disorders. Of these, 3 million experience pelvic organ prolapse. A robust surgical option for treatment of vaginal vault prolapse is sacrocolpopexy (SC).A rare but life-threatening possible sequela of SC is bowel obstruction. There are only limited data on its prevention, prevalence, detection, and management.Previous studies reported rates of bowel obstruction after SC ranging from 1.9% to 2.5%. A comprehensive review found that bowel obstruction after SC was managed surgically in 0.6%-8.6% of cases. Few studies have described the diagnosis, therapeutic options, and long-term consequences of bowel obstruction. Although early detection and treatment can prevent patient morbidity and mortality from adverse events of obstruction such as bowel incarceration and ischemia, presenting symptoms can be mistakenly attributed to other diagnoses. Especially in the immediate postoperative period, common symptoms of bowel obstruction are often indistinguishable from those of ileus. Bowel obstruction can occur from 5 days to 14 years after surgery, further challenging its diagnosis.The aim of this study was to identify clinical and surgical factors associated with occurrence of bowel obstruction after SC and to describe its presentation, management strategies (medical vs surgical), and long-term sequelae. The authors obtained data from a retrospective case series of patients who underwent open, laparoscopic, or robotic SC between January 1, 2009 and December 31, 2019 at hospitals within a large health maintenance organization and a single academic medical center in Southern California.Of 3231 patients, 32 (1.0%) who underwent SC experienced a subsequent bowel obstruction. Thirteen (40.6%) of the 32 patients underwent SC using an open abdominal approach, and 19 (59.4%) via laparoscopic or robotic approach. Among the 32 patients experiencing bowel obstruction, medical management was undertaken in 19 (59.4%). Of the 13 patients managed surgically, 8 (61.5%) had severe bowel obstruction requiring bowel resection, and 3 (23.1%) had partial mesh excision. Two (10.5%) of the medically managed, and 2 (15.4%) of the surgically managed cases had recurrent obstruction.Findings in this small case series suggest that the type of hysterectomy may not be a risk factor for bowel obstruction. The timing of occurrence of this complication spans from days to nearly a decade after SC, which emphasizes the need for surveillance in the immediate postoperative period as well as long-term. Conservative management may be effective long-term as shown by similar rates of recurrence between medically and surgically managed patients. The data provide information to guide surgeons in patient selection, informed counseling, surgical planning before SC, and may aid in diagnosis and management of bowel obstruction after SC. The study is limited by its small sample size secondary to the low prevalence of bowel obstruction.

It is estimated that more than 30 million women in the United States are affected by pelvic floor disorders. Of these, 3 million experience pelvic organ prolapse. A robust surgical option for treatment of vaginal vault prolapse is sacrocolpopexy (SC).A rare but life-threatening possible sequela of SC is bowel obstruction. There are only limited data on its prevention, prevalence, detection, and management.Previous studies reported rates of bowel obstruction after SC ranging from 1.9% to 2.5%. A comprehensive review found that bowel obstruction after SC was managed surgically in 0.6%-8.6% of cases. Few studies have described the diagnosis, therapeutic options, and long-term consequences of bowel obstruction. Although early detection and treatment can prevent patient morbidity and mortality from adverse events of obstruction such as bowel incarceration and ischemia, presenting symptoms can be mistakenly attributed to other diagnoses. Especially in the immediate postoperative period, common symptoms of bowel obstruction are often indistinguishable from those of ileus. Bowel obstruction can occur from 5 days to 14 years after surgery, further challenging its diagnosis.The aim of this study was to identify clinical and surgical factors associated with occurrence of bowel obstruction after SC and to describe its presentation, management strategies (medical vs surgical), and long-term sequelae. The authors obtained data from a retrospective case series of patients who underwent open, laparoscopic, or robotic SC between January 1, 2009 and December 31, 2019 at hospitals within a large health maintenance organization and a single academic medical center in Southern California.Of 3231 patients, 32 (1.0%) who underwent SC experienced a subsequent bowel obstruction. Thirteen (40.6%) of the 32 patients underwent SC using an open abdominal approach, and 19 (59.4%) via laparoscopic or robotic approach. Among the 32 patients experiencing bowel obstruction, medical management was undertaken in 19 (59.4%). Of the 13 patients managed surgically, 8 (61.5%) had severe bowel obstruction requiring bowel resection, and 3 (23.1%) had partial mesh excision. Two (10.5%) of the medically managed, and 2 (15.4%) of the surgically managed cases had recurrent obstruction.Findings in this small case series suggest that the type of hysterectomy may not be a risk factor for bowel obstruction. The timing of occurrence of this complication spans from days to nearly a decade after SC, which emphasizes the need for surveillance in the immediate postoperative period as well as long-term. Conservative management may be effective long-term as shown by similar rates of recurrence between medically and surgically managed patients. The data provide information to guide surgeons in patient selection, informed counseling, surgical planning before SC, and may aid in diagnosis and management of bowel obstruction after SC. The study is limited by its small sample size secondary to the low prevalence of bowel obstruction.

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