Use of Sacral Nerve Stimulation for the Treatment of Overlapping Constipation and Fecal Incontinence

BACKGROUND Fecal incontinence and constipation are common gastrointestinal complaints, but rarely occur concurrently. Management of these seemingly paradoxical processes is challenging, as treatment of one symptom may exacerbate the other. CASE REPORT A 51-year-old female with lifelong neurogenic bladder secondary to spina bifida occulta presented with progressive symptoms of daily urge fecal incontinence as well as hard bowel movements associated with straining and a sensation of incomplete evacuation requiring manual disimpaction. Pelvic floor testing showed poor ability to squeeze the anal sphincter, which indicated sphincter weakness as a major contributor to her fecal incontinence symptoms. Additionally, on defecography she was unable to widen her posterior anorectal angle or relax the anal sphincter during defecation consistent with dyssynergic defecation. A sacral nerve stimulator was placed for management of her fecal incontinence. Interestingly, her constipation also dramatically improved with sacral neuromodulation. CONCLUSIONS This unique case highlights the emerging role of sacral nerve stimulation in the treatment of complex pelvic floor dysfunction with improvement in symptoms beyond fecal incontinence in a patient with dyssynergic-type constipation

Clip Artifact after Closure of Large Colorectal Endoscopic Mucosal Resection Sites: Incidence and Recognition

Background Clip closure of large colorectal EMR defects sometimes results in bumpy scars that are normal on biopsy. We refer to these as “clip artifact.” If unrecognized, clip artifact can be mistaken for residual polyp, leading to thermal treatment and potential adverse events. Objective To describe the incidence of and define predictors of clip artifact. Design Review of photographs of scars from consecutive clipped EMR defects. Setting University outpatient endoscopy center. Patients A total of 284 consecutive patients with clip closure of defects after EMR of lesions 20 mm or larger and follow-up colonoscopy. Interventions EMR, clip closure. Main Outcome Measurements Incidence of clip artifact. Results A total of 303 large polyps met the inclusion criteria. On review of photographs, 96 scars (31.7%) had clip artifact. Clip artifact was associated with increased numbers of clips placed (odds ratio for each additional clip, 1.2; 95% confidence interval, 1.02-1.38) but not polyp histology, size, or location. The rate of residual polyp by histology was 8.9% (27/303), with 21 of 27 scars with residual polyp evident endoscopically. The rate of residual polyp evident only by histology in scars with clip artifact (3/93; 3.2%) was not different from the rate in scars without clip artifact (3/189; 1.6%). Limitations Retrospective design. Sites closed primarily with 1 type of clip. Single-operator assessment of endoscopic photographs. Conclusion Clip artifact occurred in the scars of approximately one-third of large clipped EMR sites and increased with number of clips placed. Clip artifact could be consistently distinguished from residual polyp by its endoscopic appearance

Systematic review and case series: flexible sigmoidoscopy identifies most cases of checkpoint inhibitor‐induced colitis

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/149542/1/apt15263_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/149542/2/apt15263.pd

Experimental and analytical study of methods to improve the performance of railplugs

This thesis reports results of an experimental study of various parameters that affect the performance of railplugs. Their performance was quantified by the distance that the arc traveled along the rails from the initiation point. Travel along the rails is thought to be an important performance metric because rail-travel limits excessive local wear and produces a distributed ignition source which can potentially reduce mixture inhomogeneity induced ignition problems. Parameters considered included rail shape, rail divergence angle, initiation gap distance, electrical polarity, the extent to which the rails were enclosed, components in the circuit, external magnetic field, and delivered energy. The cross-sectional shape was found to be important to arc travel. Smaller rail divergence angles tended to enhance arc travel. Arc travel distance decreases with increasing pressure. Arc travel was shorter for fully enclosed railplugs then for an unenclosed plug; however, a partially enclosed designed showed promiseMechanical Engineerin