Suspected cauda equina syndrome: no reduction in investigation, referral and treatment during the COVID-19 pandemic.

INTRODUCTION: Compression of the cauda equina can lead to bladder, bowel and sexual dysfunction with lower limb pain, numbness and weakness. Urgent surgical decompression aims to prevent progressive neurological deficit. Symptoms of cauda equina syndrome (CES), such as back pain, sciatica and bladder dysfunction are common in the population, but the majority of those investigated do not have radiological cauda equina compression. However, a missed diagnosis can have significant medical, social and legal consequences. We investigated the effect of the COVID-19 pandemic on presentation and management of suspected CES. METHODS: This retrospective cohort study analysed referral, investigation and treatment of CES in a regional neurosurgical centre during the initial COVID-19 surge between March and May 2020 compared with March to May 2019. RESULTS: Referrals for suspected CES were similar during the COVID-19 pandemic (n = 275) compared with 2019 (n = 261, p = 0.596) despite a significant (19%) decrease in total emergency neurosurgical referrals (1248 in 2020 vs 1544 in 2019, p < 0.001). Nineteen (7%) of the suspected CES referrals underwent decompression in 2020, similar to 16 (6%) in 2019 (p = 0.867). There were no differences in outcomes or complications and no evidence of delays in presentation or treatment. CONCLUSIONS: Unlike other emergency neurosurgical conditions, the number of referrals for suspected CES and the percentage of referrals with radiological cauda equina compression were unchanged during the COVID-19 pandemic. The persistence of CES referrals when many people stayed away from hospital highlights the distress and worry caused by suspected CES and its symptoms to both patients and healthcare providers.

Comparison of bowel dysfunction between colorectal cancer survivors and a non-operative non-cancer control group.

AIM: Low anterior resection syndrome (LARS) detrimentally affects quality of life in colorectal cancer survivors. This study assessed the prevalence for LARS in colorectal cancer survivors and the same symptoms in a matched control group. METHOD: Validated instruments, the LARS score and Short Form Survey 12, used to collect functional and quality of life outcomes from patients who had undergone distal colorectal resection at Auckland Hospital (2008-2015) or Dunedin Hospital (2008-2017). A matched non-operative control group was drawn from patients undergoing surveillance colonoscopy. RESULTS: The response rate was 79%. Cross-sectional prevalence of major LARS in rectal cancer patients was 52% at a median follow-up of 52 months. Major LARS prevalence in the sigmoid cancer resection and non-cancer control groups was similar (25% vs 26%, P = 0.6). On univariate analysis anastomotic height [risk ratio (RR) for low anterior resection 4.6, P < 0.001; ultralow anterior resection RR = 15.5, P < 0.001], radiotherapy (RR = 2.6; P = 0.009), stoma (RR = 3.6; P = 0.001) and J pouch reconstruction (vs straight anastomosis, RR = 4.6; P = 0.008) were associated with major LARS for rectal cancer patients. These factors were not significant when the analysis was stratified for anastomotic height. Despite correlation between LARS and Short Form Survey 12 outcomes (physical ρ = -0.2; mental ρ = -0.2) there was no difference in quality of life outcomes between the groups. CONCLUSION: Bowel dysfunction after low anterior resection affects the majority of rectal cancer patients. The high background rate of bowel dysfunction must be considered when assessing the prevalence of LARS.

A comparison of the cost of primary closure or rectus abdominis myocutaneous flap closure of the perineum after abdominoperineal excision.

AIM: Perineal wound complications following abdominoperineal resection continue to be a major challenge. The aim of this study was to compare the clinical outcomes and cost of primary closure (PC) and rectus abdominis myocutaneous (RAM) flap reconstruction. METHOD: This was a retrospective case review of consecutive patients by one surgeon over 11 years. Patient demographics, risk factors, operative details and complications were identified. Inpatient and outpatient costs were calculated. RESULTS: A total of 31 patients underwent a RAM reconstruction and 37 a PC. There were no significant differences in the incidence of wound complications or in the overall costs for either method of perineal closure. When there were no complications the mean costs were significantly higher in the RAM group ($20 948 vs $17 189, P = 0.005), mainly because of the longer operating time. However, the costs of perineal wound complications were greater in the PC group (8394 vs 25 911, P = 0.012). These wounds took longer to heal (median 2 months vs 5.5 months, P = 0.005) and more often required a further reconstructive surgical procedure (RAM 0 vs PC 8, P = 0.006). CONCLUSION: This is the first study reporting on the cost implications of PC and RAM flap reconstruction. The overall costs were similar. This implies appropriate clinical selection when choosing between procedures. While the RAM flap is more expensive to perform, the finding that it decreases the clinical severity and cost of perineal wound complications supports its use when there is a high risk of perineal wound complications.

Value of delayed MRI in angiogram-negative subarachnoid haemorrhage.

AIM: To assess the efficacy of delayed magnetic resonance imaging (MRI) in identifying a structural cause for angiogram-negative subarachnoid haemorrhage. MATERIALS AND METHODS: All patients presenting with spontaneous subarachnoid haemorrhage who had negative computed tomography (CT) angiography and catheter angiography between 2006 and 2012 were reviewed. RESULTS: During the 6 year period, 1023 angiograms were performed for a new presentation of subarachnoid haemorrhage. Of these, 242 (23.7%) did not show a cause for the haemorrhage. A second catheter angiogram was performed in 48 patients, and aneurysms were identified in two patients. Of the remaining 240 patients, 131 underwent a subsequent MRI brain. One hundred and five (80.2%) MRI examinations were performed 4 or more weeks after angiography. In two patients, cavernomas were identified as the likely bleeding source. In both patients, the pattern of subarachnoid haemorrhage surrounding a small intraparenchymal haemorrhage on the initial CT suggested the diagnosis. Thirty-nine patients underwent MRI of the cervical spine, none of which identified a cause for the haemorrhage. None of the patients re-presented to our centre during the 6 year study period. CONCLUSION: Delayed MRI following angiogram-negative subarachnoid haemorrhage has a low (1.5%) yield and is not routinely necessary. MRI may be useful to characterize the diagnosis in patients with clinical or radiological features of an underlying abnormality such as a cavernoma.

Post-operative cyclizine misuse.

Cyclizine is commonly prescribed as an anti-emetic post-operatively. We report a case of a 51-year-old woman who developed addiction to intravenous cyclizine following regular administration at recommended doses. This is the first report of cyclizine misuse post-operatively. We compare this case to cyclizine abuse reported amongst other populations. Prescribers should be aware of the potential of cyclizine as a drug of abuse.

A meta-analysis of randomized, controlled trials assessing the prophylactic use of ceftriaxone. A study of wound, chest, and urinary infections.

BACKGROUND: Ceftriaxone is an effective prophylactic antibiotic. However, there is no consensus about whether ceftriaxone should be used as a first-line antibiotic for the prevention of incisional surgical site infection (SSI). Its role in preventing urinary tract infection (UTI) and pneumonia also is controversial. METHODS: A meta-analysis of randomized, controlled trials assessing the prophylactic use of ceftriaxone between 1983 and 2005 was performed. Medline, Embase, and Cochrane registers were reviewed. Additional references, review papers, and proceedings from meetings were searched. The Jadad score was used to assess study quality. A meta-analysis with sensitivity analyses was performed for SSI, UTI, and pneumonia. RESULTS: Of 231 reviewed papers, 90 were included. Ceftriaxone prophylaxis was superior to other antibiotics in each category. Sixty-one studies assessed the prevention of SSI (odds ratio (OR), 0.68; 95% confidence interval (CI), 0.53-0.7, p < 0.001; Cochran's Q statistic, p = 0.93). The difference was greatest for abdominal surgery. There was no difference for cardiac surgery. Thirty-five studies assessed the prevention of UTI (OR 0.53; 95% CI 0.43-0.63, p = 0; Cochran's Q statistic, p = 0.97). The difference was greatest in obstetric and gynecological and colorectal surgery. Thirty-seven studies assessed the prevention of pneumonia (OR 0.66; 95% CI 0.54-0.81, p = 0; Cochran's Q statistic, p = 0.65). The difference was greatest in upper abdominal surgery. CONCLUSIONS: The meta-analysis confirms that prophylactic ceftriaxone is more effective than most other prophylactic antibiotics. This reduces SSI, UTI, and pneumonia in procedures where there is an increased risk of these infections. In such procedures, the data support using ceftriaxone as a first-line prophylactic antibiotic.

Feasibility and functional outcome of laparoscopic sacrocolporectopexy for combined vaginal and rectal prolapse.

PURPOSE: Prolapse of multiple pelvic organs causes a variety of symptoms that impair a patient's quality of life. A laparoscopic procedure is described that uses a mesh fixation of the mid-compartment vagina to the sacrum with additional rectopexy to correct both the anatomical deformities and the dysfunction of the posterior compartment. METHODS: Patients with significant rectal and vaginal prolapse with or without rectocele were recruited. A thorough preoperative physiological assessment of each of the compartments of the pelvic floor was carried out. Patients also completed the Pelvic Floor Distress Inventory before and six months after surgery. RESULTS: Ten patients underwent the procedure of laparoscopic sacrocolporectopexy (median age 47 years, interquartile range 43-53). No mortality or morbidity occurred. Median global distress inventory scores were significantly lower postoperatively (8.3, interquartile range 0-20.8 vs. 37.5, interquartile range 16.6-60.4) P = 0.012. All three median subscales were also significantly lower postoperatively. The procedure corrected associated rectoceles and descent of the perineum on straining. CONCLUSION: The described laparoscopic procedure of mesh sacrocolpopexy with rectopexy was safe and feasible and conferred good symptomatic improvement in pelvic floor dysfunction.

Algorithms for the surgical management of retrorectal tumours.

BACKGROUND: Retrorectal tumours are uncommon and may present a surgical challenge. The aim of this study was to identify a surgical strategy based on information gained from the multidisciplinary management of retrorectal tumours. METHODS: This was a retrospective review of 27 patients who had resection of retrorectal tumours between 1998 and 2006. RESULTS: The tumours included ten cystic lesions, two mature teratomas, four chordomas, seven neurogenic tumours, two sarcomas, one angiomyxoma and one gastrointestinal stromal tumour. The diagnosis was suggested initially by non-specific clinical presentation and palpation of a retrorectal mass on examination (16 patients), pelvic imaging (six), obstructed labour (one), recurrent pilonidal sinus (one), recurrent perianal sepsis (one) and return of symptoms after resection (two). Magnetic resonance imaging (MRI) confirmed the diagnosis and enabled surgical planning. The operative approach was perineal (12 patients), abdominal (11) or combined (four). Factors that influenced the operative approach were tumour position, its neoplastic nature, involvement of the pelvic sidewall or pelvic viscera, and size. The retrorectal tumour recurred in three patients. CONCLUSION: A successful multidisciplinary surgical strategy, based on preoperative localization by MRI, has been developed for the treatment of retrorectal tumours.

Clinical variables associated with positive angiographic localization of lower gastrointestinal bleeding.

BACKGROUND: Localizing the source of severe lower gastrointestinal (GI) bleeding is often difficult but is important to plan the extent of colonic resection. The purpose of the present paper was to audit the Auckland Hospital experience of selective angiography, in localizing lower GI bleeding. METHODS: Patients admitted to Auckland Hospital with rectal bleeding and who subsequently had angiography were evaluated by reviewing their clinical notes and radiological results during a 7-year period (1997-2003). Data collected included demographic details, haemodynamic parameters, change in haemoglobin level, requirement of blood transfusion within 24 h before the procedure, site of the bleeding and pathology. RESULTS: The notes of 88 patients (male, n = 51; median age 69 years, range 8-99 years) were available for review and analysis. The site of bleeding was localized in 38 (51%); 30 of them had bleeding in the right colon or small bowel and eight in the left colon. Positive localization correlated with: haemodynamic instability P < 0.0001; drop in haemoglobin level of > or =50 from previous admission (P = 0.02); transfusion requirement of > or =5 units of blood within 24 h (P < 0.0001). Logistic regression analysis showed transfusion requirement of > or =5 units to achieve haemodynamic stability to be the most powerful predictor of accurate localization (odds ratio, 40). CONCLUSION: Catheter angiography for acute lower GI bleeding will successfully localize a point of bleeding in approximately 50% of patients. The most useful clinical indicator for positive angiography was haemodynamic instability particularly in those who require transfusion of > or =5 units of blood to achieve haemodynamic stability.

Peritoneal gallstones following laparoscopic cholecystectomy: incidence, complications, and management.

BACKGROUND: Gallstone spillage during laparoscopic cholecystectomy (LC) is a common intraoperative event. Although gallstones left in the peritoneal cavity were initially considered harmless, a significant number of complications have been reported. Our aim was to quantify the likelihood, and to document the range, of subsequent complications. METHODS: A Medline search from 1987 to January 2003 was performed. Articles with more than 500 LCs that quantified the frequency of complications due to peritoneal gallstones were reviewed, as were representative case studies of different stated complications. RESULTS: Six studies, covering 18,280 LCs, were found. The incidence of gallbladder perforation was 18.3%, that of gallstone spillage was 7.3%, and that of unretrieved peritoneal gallstones was estimated to be 2.4%. There were 27 patients with complications. The likelihood of a complication when gallstone spillage occurred was 2.3%, which increased to 7.0% when unretrieved peritoneal gallstones were documented. CONCLUSION: Spilt gallstones have a small but quantifiably real risk of causing a wide range of significant postoperative problems.

Matched study of three methods for palliation of malignant pyloroduodenal obstruction.

BACKGROUND: The traditional management of pyloroduodenal obstruction is open gastrojejunostomy (OGJ). More recently laparoscopic gastrojejunostomy (LGJ) and endoscopic stenting (ES) have been introduced. The aim of this study was to evaluate the three approaches to the palliation of malignant pyloroduodenal obstruction. METHODS: All patients who underwent surgery (open and laparoscopic) for malignant pyloroduodenal obstruction at Auckland City Hospital between 1989 and 2002 inclusive were identified from International Classification of Diseases (ICD) 10 codes and from the Otago Surgical Audit Database. Patients who had an endoscopic stent were identified from the Endoscribe database. A review of medical records was conducted and data recorded in a structured pro forma. There were 181 patients with malignant pyloroduodenal obstruction of whom 56 patients had OGJ, 14 had LGJ and 16 had ES. Patients in the LGJ and ES groups were matched with those who underwent OGJ with respect to American Society of Anesthesiologists (ASA) grade (I-V), age (within 10 years) and level of obstruction (pylorus, first part of duodenum D1, D2, D3 and D4). The primary outcomes compared between the groups were time to starting free oral fluids and light diet, length of stay and survival. RESULTS: There were no significant differences in age, sex, ASA grade and level of obstruction between the matched OGJ (n=16), LGJ (n=14) and ES (n=16) groups. There was a significant reduction in time to starting free oral fluids and light diet, and length of stay after the procedure, in the ES group. Patients who underwent surgical palliation of the obstruction had significantly more complications than those who underwent stenting (P=0.016). There were no significant differences in requirement for biliary drainage either before or after the procedure between the three groups. Survival was shortest in the ES group. CONCLUSION: This matched study showed significant advantages for ES compared with OGJ and LGJ in the palliation of malignant pyloroduodenal obstruction.

Hepatic adenomas in male patients.

BACKGROUND: Hepatic adenomas are benign tumours of the liver most commonly seen in premenopausal women. However, it is now clear that adenomas may occur in males. This small series reviews the characteristics of hepatic adenomas in males. CASE OUTLINES: Three cases of solitary hepatic adenoma occurring in otherwise well male patients (age 22-48 years) are presented. Two patients presented with abnormal liver function tests while one presented with abdominal pain. Imaging of the lesions demonstrated typical appearances of hepatocellular adenoma, resection was undertaken in all cases and all patients remain alive and well. DISCUSSION: Up to 20% of adenomas are documented as occurring in male patients. Most are solitary and occur in patients without recognised risk factors (steroid therapy and glycogen storage diseases types I and III). However, multiple adenomas are most commonly seen in male patients with risk factors. The imaging characteristics and presentation of adenomas in males are similar to female patients and, most importantly, intraperitoneal rupture and malignant transformation are documented in untreated adenomas in males.

Techniques and complications of pacemaker implantation in four cats.

Pacemakers were successfully implanted in 4 adult and geriatric cats with bradycardia and associated signs. Various implantation techniques were used. Complications developed in 3 of the cats, generally more severe in 2 of the 3 cats in which thoracotomy and celiotomy were performed than in the cat in which a transvenous endocardial pacing technique was used. After surgery, pacemaker functions were reprogrammed noninvasively in 2 cats. All 4 cats survived without syncope for a mean of 33.1 months after surgery.

Permanent transvenous pacemaker implantation in forty dogs.

Permanent transvenous cardiac pacemakers were implanted in 40 dogs. Electrocardiographic diagnoses included persistent atrial standstill (3 dogs), sick sinus syndrome (8 dogs), and high-grade second-degree or third-degree atrioventricular (AV) block (29 dogs). Thirteen dogs were alive and well 4 to 42 months after pacemaker implantation (mean, 16.9 months). The mean and median survival times of the 26 dogs that died or were euthanatized during the study were 17.9 months and 13 months, respectively. Most of these dogs succumbed to problems unrelated to the arrhythmia and pacemaker implant. One dog was lost to follow-up. Complications associated with permanent transvenous pacemaker implantation included lead dislodgement, infection, hematoma formation, skeletal muscle stimulation, ventricular arrhythmia, migration of the pulse generator, and skin erosion. Lead dislodgement was the most common complication, occurring in 7 of 9 dogs paced using untined electrode leads and in 6 of 30 dogs paced using tined leads. Lead dislodgement did not occur in the only dog paced using an actively fixed endocardial lead. It was concluded that permanent transvenous cardiac pacing is a feasible, less traumatic alternative to epimyocardial pacing in dogs, but that successful use of this technique requires careful implantation technique and anticipation of the potential complications.

Naturally occurring cardiomyopathy in the Doberman pinscher: a possible large animal model of human cardiomyopathy?

Currently there is no large animal model of dilated cardiomyopathy. The smaller animal models of cardiomyopathy, such as the Syrian hamster, cannot be studied with echocardiography and cardiac catheterization, and the relevance of these models to human dilated cardiomyopathy is open to question. On the basis of some initial observations in Doberman pinschers, it was speculated that these dogs could have occult left ventricular dysfunction. Accordingly, studies were performed in 46 apparently healthy Doberman pinschers and in 41 mongrel dogs: two-dimensional echocardiography (30 dogs in each group), cardiac catheterization (16 Doberman pinschers and 12 mongrels) and coronary blood flow studies (13 Doberman pinschers and 6 mongrels). In the awake, unsedated dogs studied with echocardiography, left ventricular wall thickening was significantly less in the Dobermans than in the mongrels (28% versus 36%, p = 0.0003). In the anesthetized dogs undergoing cardiac catheterization, left ventricular ejection fraction was significantly lower in the Dobermans than in the mongrels (0.38 versus 0.63, p = 0.0001). Rest coronary blood flow and coronary blood flow reserve were similar in the two groups. It is concluded that apparently healthy Doberman pinschers have occult left ventricular dysfunction. These dogs may serve as a large animal model of dilated cardiomyopathy and should not be used experimentally to study normal cardiac physiology.

Clinical, echocardiographic, and radiographic findings of peritoneopericardial diaphragmatic hernia in two dogs and a cat.

Peritoneopericardial diaphragmatic hernia was diagnosed in 2 dogs and a cat. One dog was referred because of clinical signs of cardiac tamponade and acute decompensation from liver entrapment within the hernia. Surgical correction of the hernia alleviated clinical signs in all 3 animals. Echocardiography was used in combination with radiography to provide a rapid and accurate diagnosis.

Verapamil administration for acute termination of supraventricular tachycardia in dogs.

Verapamil, a calcium channel-blocking drug, was administered IV at a dosage that ranged from 0.05 to 0.15 mg/kg of body weight to 14 dogs with supraventricular tachycardia. The dosage was titrated, administering 0.05 mg/kg every 5 to 30 minutes following the initial 0.05 mg/kg dose in all but 1 dog. The drug terminated the arrhythmia in 12 dogs and slowed the ventricular rate in 1 dog. One dog was unresponsive to verapamil administration and became transiently hypotensive after the administration of a total dose of 0.15 mg/kg over 5 to 6 minutes. Various arrhythmias occurred after verapamil administration, but none required additional treatment or caused serious sequelae. Verapamil was an effective treatment for acutely converting supraventricular tachycardia to sinus rhythm in these dogs. It appears to be safe when administered in the aforementioned dosage range.