Letters to the editor
195
Reference 1. Douglas C, Morris O. The ‘keystone concept’: time for some science. ANZ J. Surg. 2013; 83: 498–9.
Michael W. Findlay,*†‡ PhD, FRACS Stephen Kleid,*† MBBS, FRACS *Peter MacCallum Cancer Centre; †University of Melbourne Department of Surgery, Royal Melbourne Hospital, Parkville, Victoria, Australia, and ‡Department of Surgery, Stanford University, Stanford, California, USA
Imad A. Jaboury, FRCS, FRACS Department of Surgery, Albany Health Campus, Albany, Western Australia, Australia doi: 10.1111/ans.12501
Dear Editor, Response to Re: Bugosa hernia: a hernia of the conjoint tendon
doi: 10.1111/ans.12499
Dear Editor, Alternative guide to utilization of computed tomography in appendicitis Regarding Alvarado score: a guide to computed tomography (CT) utilization in appendicitis,1 I use an alternative guide to utilization of CT in appendicitis that is based on the age and sex of the patient. Each group of patients have different causes of right iliac fossa (RIF) pain, the appendicitis assumes different position in the ladder of differential diagnosis of RIF pain and each group have different risk rate from CT. The risk is higher in younger ages and in female.2 For patients with age over 40, I use CT more routinely as the advantages exceed the risks. It achieves the lowest negative result, avoids unnecessary operation in older patients with as expected higher comorbidities, and helps to diagnose other more common causes of RIF pain in that group such as caecal diverticulitis, caecal carcinoma and even Iliac artery aneurysm. The increased risk of cancer from CT is lower in older ages.2 For male children up to the age of 20 and for female children up to the age of 13, mesenteric adenitis is a more common cause of pain; I am very reluctant to give them CT radiation. The American Cancer Society estimates that in the future, cancer will develop from every 300 abdomen/pelvis scans.3 For women at the ages of 14–40, the tubovarian conditions are the more common causes of RIF pain; it is safer to rely on ultrasound, observation, diagnostic laparoscopy and magnetic resonance imaging, which is as sensitive and specific as CT.4 This group is at a higher risk of cancer from CT than both the men at same age as well as older women.2,3 For men at the ages 20–40, a low negative rate can be achieved on clinical ground and CT is only occasionally needed.
References 1. Tan W, Pek W, Kabir T et al. Alvardo score: a guide to computed tomography utilization in appendicitis. ANZ J. Surg. 2013; 83: 748–52. 2. Einstein A, Henzlova M, Rajagopalan S. Estimating risk of cancer associated with radiation CT angiography. JAMA 2007; 298: 317–23. 3. Miglioretti L, Johnson E, Williams A et al. The use of computed tomography in pediatrics and the associated radiation exposure and estimated cancer risk. JAMA Pediatr. 2013; 167: 700–7. 4. Stoker J. Magnetic resonance imaging and the acute abdomen. Br. J. Surg. 2008; 95: 1193–4.
© 2014 Royal Australasian College of Surgeons
I was delighted to have a reply to our letter1 from Claxton2 published in the October 2013 issue of ANZ Journal of Surgery. The purpose of our letter was to make surgeons aware of the condition and to create discussion concerning its incidence in Australia and New Zealand. I have only seen four cases and the one we presented was repaired laparoscopically without any complications. The experience that Claxton has of this condition is extensive as he actually worked in Uganda where the problem is endemic. I valued his comments as they have put the discussion into context. I obtained my FRCS Ed in 1972 and it was probably his original article that made me aware of the condition when I read it in the journal of the Royal College of Surgeons in Edinburgh. Are there any other surgeons who have experience of this hernia? References 1. Read T, Maguire E. Bugosa hernia: a hernia of the conjoint tendon. ANZ J. Surg. 2013; 83: 296. 2. Claxton RC. Re: Bugosa hernia: a hernia of the conjoint tendon. ANZ J. Surg. 2013; 83: 796–7.
Errol J. Maguire, AM, RFD, FRACS Department of Surgery, Gold Coast University Hospital, School of Medicine, Griffith University, Gold Coast, Queensland, Australia doi: 10.1111/ans.12487
Dear Editor, Diagnosis of primary pyomyositis We present an uncommon but potentially life-threatening case of primary pyomyositis, an important differential diagnosis of necrotizing fasciitis. A 19-year-old woman presented with a 5-day history of fever, posterior left-sided knee pain and difficulty in weight-bearing. At admission, she appeared unwell with sweats and tachycardia. Examination revealed marked swelling and erythema in the popliteal fossa extending to the left thigh. Inflammatory markers were raised. Septic arthritis was excluded early during admission. Despite empirical antibiotics (vancomycin, meropenem and clindamycin), she deteriorated clinically and became haemodynamically unstable on day 3, with increased swelling, induration and erythema of the left thigh. Two explorations on consecutive days revealed normal-appearing deep fascia, healthy looking muscle and slightly turbid fluid, insufficient to make the diagnosis of necrotizing fasciitis.
196
Letters to the editor
Dear Editor, Recurrence of acute colonic pseudo-obstruction post-caesarean section: a case report
Fig. 1. Axial magnetic resonance imaging scan of necrotic short head of left biceps femoris (arrow).
The patient failed to improve clinically and magnetic resonance imaging (MRI) was performed on day 5 to aid diagnosis. The MRI confirmed primary myositis involving the short head of biceps femoris with extensive surrounding oedema (Fig. 1). At this time, the formal histology report of the deep fascia sampled during exploratory surgery revealed patchy chronic inflammatory infiltrates with no necrosis, and microbiology confirmed β-haemolytic streptococcus Group-A infection. Subsequently, the patient was returned to theatre on multiple occasions for deeper exploration and debridement of the posterior thigh compartment musculature. The short head of biceps alone was found to be necrotic, in close proximity to the sciatic nerve and popliteal vessels. She began to improve and was discharged home on oral clindamycin on day 27. Staphylococcus aureus accounts for over 90% of bacterial pyomyositis, a condition usually diagnosed late, followed by increased morbidity and significant mortality rate.1,2 Clinical diagnosis of pyomyositis may be difficult; MRI is an important adjunct to exploratory surgery in making an early diagnosis.3,4
References 1. Annamalai AK, Gopolakrishan C, Sureshkumar G, Chelian M, Srinivasan KG. Pyomyositis. Postgrad. Med. J. 2013; 89: 179–80. 2. Malhotra P, Singh S, Sud A, Kumari S. Tropical pyomyositis: experience of a tertiary care hospital in north-west India. J. Assoc. Physicians India 2000; 48: 1057–9. 3. Yu CW, Hsiao JK, Hsu CY, Shih TT. Bacterial pyomyositis: MRI and clinical correlation. Magn. Reson. Imaging. 2004; 22: 1233–44. 4. Chan O, Nawaz SZ, Hughes S, Skinner JA. Extensive pyogenic myositis of the hip in an immune-competent patient. JRSM Short Rep. 2011; 2: 90.
Acute colonic pseudo-obstruction (ACPO) is a rare complication of caesarean section. Its incidence is unknown. Eighty-five cases were identified in the literature (MEDLINE with search terms ‘pseudoobstruction’, ‘caesarean’ and ‘Ogilvie’). We describe a unique case of recurrence of ACPO after caesarean section and the consequences of progression of disease. A 36-year-old woman (G2 P2) presented with a 2-day history of abdominal distension and pain post-elective caesarean section. This is on a background of previous ACPO after her first caesarean section, where she was managed with endoscopic decompression. Twenty-four hours after delivery, she experienced increasing abdominal distension and pain. She was given opioid analgesia, simethicone and reassured. Forty-eight hours after delivery, she was reviewed for worsening symptoms. Abdominal X-ray revealed a dilated ascending colon. Computed tomography of the abdomen/ pelvis demonstrated a caecal diameter of 8 cm with no evidence of ischaemia or mechanical obstruction (Fig. 1). She was then found to have signs of peritonism and a white cell count of 19 × 109/L. She underwent urgent laparotomy, revealing an ischaemic-ascending colon with serosal tears. Right hemicolectomy with end-to-side anastomosis and loop ileostomy was performed, with planned reversal in 3 months. She was discharged 5 days post-laparotomy with no post-operative complications. Early recognition of ACPO is essential, particularly with increasing caesarean section rates. Patient age, caecal diameter and timing of decompression influence mortality rate (15% versus 36–44%), because of ischaemia and perforation.1 The last reported deaths from ACPO post-caesarean section in the UK were in 2002. A common factor leading to delayed management was an initial diagnosis of ileus by junior doctors.2 This case demonstrates failure to identify previous ACPO after her first caesarean section and inappropriate use of simethicone and opioid analgesia leading to progression of disease and the need for laparotomy. Early recognition, investigation and management are important steps in preventing ischaemia and perforation.
Syma Iqbal, MBBS Imeldah Motoroko, MBBS, BMed Cheng H. Lo, FRACS Plastics and Reconstructive Surgery, Western Health, Melbourne, Victoria, Australia doi: 10.1111/ans.12489 Fig. 1. Computed tomography of the abdomen demonstrating dilatation of the ascending colon.
© 2014 Royal Australasian College of Surgeons
195
Reference 1. Douglas C, Morris O. The ‘keystone concept’: time for some science. ANZ J. Surg. 2013; 83: 498–9.
Michael W. Findlay,*†‡ PhD, FRACS Stephen Kleid,*† MBBS, FRACS *Peter MacCallum Cancer Centre; †University of Melbourne Department of Surgery, Royal Melbourne Hospital, Parkville, Victoria, Australia, and ‡Department of Surgery, Stanford University, Stanford, California, USA
Imad A. Jaboury, FRCS, FRACS Department of Surgery, Albany Health Campus, Albany, Western Australia, Australia doi: 10.1111/ans.12501
Dear Editor, Response to Re: Bugosa hernia: a hernia of the conjoint tendon
doi: 10.1111/ans.12499
Dear Editor, Alternative guide to utilization of computed tomography in appendicitis Regarding Alvarado score: a guide to computed tomography (CT) utilization in appendicitis,1 I use an alternative guide to utilization of CT in appendicitis that is based on the age and sex of the patient. Each group of patients have different causes of right iliac fossa (RIF) pain, the appendicitis assumes different position in the ladder of differential diagnosis of RIF pain and each group have different risk rate from CT. The risk is higher in younger ages and in female.2 For patients with age over 40, I use CT more routinely as the advantages exceed the risks. It achieves the lowest negative result, avoids unnecessary operation in older patients with as expected higher comorbidities, and helps to diagnose other more common causes of RIF pain in that group such as caecal diverticulitis, caecal carcinoma and even Iliac artery aneurysm. The increased risk of cancer from CT is lower in older ages.2 For male children up to the age of 20 and for female children up to the age of 13, mesenteric adenitis is a more common cause of pain; I am very reluctant to give them CT radiation. The American Cancer Society estimates that in the future, cancer will develop from every 300 abdomen/pelvis scans.3 For women at the ages of 14–40, the tubovarian conditions are the more common causes of RIF pain; it is safer to rely on ultrasound, observation, diagnostic laparoscopy and magnetic resonance imaging, which is as sensitive and specific as CT.4 This group is at a higher risk of cancer from CT than both the men at same age as well as older women.2,3 For men at the ages 20–40, a low negative rate can be achieved on clinical ground and CT is only occasionally needed.
References 1. Tan W, Pek W, Kabir T et al. Alvardo score: a guide to computed tomography utilization in appendicitis. ANZ J. Surg. 2013; 83: 748–52. 2. Einstein A, Henzlova M, Rajagopalan S. Estimating risk of cancer associated with radiation CT angiography. JAMA 2007; 298: 317–23. 3. Miglioretti L, Johnson E, Williams A et al. The use of computed tomography in pediatrics and the associated radiation exposure and estimated cancer risk. JAMA Pediatr. 2013; 167: 700–7. 4. Stoker J. Magnetic resonance imaging and the acute abdomen. Br. J. Surg. 2008; 95: 1193–4.
© 2014 Royal Australasian College of Surgeons
I was delighted to have a reply to our letter1 from Claxton2 published in the October 2013 issue of ANZ Journal of Surgery. The purpose of our letter was to make surgeons aware of the condition and to create discussion concerning its incidence in Australia and New Zealand. I have only seen four cases and the one we presented was repaired laparoscopically without any complications. The experience that Claxton has of this condition is extensive as he actually worked in Uganda where the problem is endemic. I valued his comments as they have put the discussion into context. I obtained my FRCS Ed in 1972 and it was probably his original article that made me aware of the condition when I read it in the journal of the Royal College of Surgeons in Edinburgh. Are there any other surgeons who have experience of this hernia? References 1. Read T, Maguire E. Bugosa hernia: a hernia of the conjoint tendon. ANZ J. Surg. 2013; 83: 296. 2. Claxton RC. Re: Bugosa hernia: a hernia of the conjoint tendon. ANZ J. Surg. 2013; 83: 796–7.
Errol J. Maguire, AM, RFD, FRACS Department of Surgery, Gold Coast University Hospital, School of Medicine, Griffith University, Gold Coast, Queensland, Australia doi: 10.1111/ans.12487
Dear Editor, Diagnosis of primary pyomyositis We present an uncommon but potentially life-threatening case of primary pyomyositis, an important differential diagnosis of necrotizing fasciitis. A 19-year-old woman presented with a 5-day history of fever, posterior left-sided knee pain and difficulty in weight-bearing. At admission, she appeared unwell with sweats and tachycardia. Examination revealed marked swelling and erythema in the popliteal fossa extending to the left thigh. Inflammatory markers were raised. Septic arthritis was excluded early during admission. Despite empirical antibiotics (vancomycin, meropenem and clindamycin), she deteriorated clinically and became haemodynamically unstable on day 3, with increased swelling, induration and erythema of the left thigh. Two explorations on consecutive days revealed normal-appearing deep fascia, healthy looking muscle and slightly turbid fluid, insufficient to make the diagnosis of necrotizing fasciitis.
196
Letters to the editor
Dear Editor, Recurrence of acute colonic pseudo-obstruction post-caesarean section: a case report
Fig. 1. Axial magnetic resonance imaging scan of necrotic short head of left biceps femoris (arrow).
The patient failed to improve clinically and magnetic resonance imaging (MRI) was performed on day 5 to aid diagnosis. The MRI confirmed primary myositis involving the short head of biceps femoris with extensive surrounding oedema (Fig. 1). At this time, the formal histology report of the deep fascia sampled during exploratory surgery revealed patchy chronic inflammatory infiltrates with no necrosis, and microbiology confirmed β-haemolytic streptococcus Group-A infection. Subsequently, the patient was returned to theatre on multiple occasions for deeper exploration and debridement of the posterior thigh compartment musculature. The short head of biceps alone was found to be necrotic, in close proximity to the sciatic nerve and popliteal vessels. She began to improve and was discharged home on oral clindamycin on day 27. Staphylococcus aureus accounts for over 90% of bacterial pyomyositis, a condition usually diagnosed late, followed by increased morbidity and significant mortality rate.1,2 Clinical diagnosis of pyomyositis may be difficult; MRI is an important adjunct to exploratory surgery in making an early diagnosis.3,4
References 1. Annamalai AK, Gopolakrishan C, Sureshkumar G, Chelian M, Srinivasan KG. Pyomyositis. Postgrad. Med. J. 2013; 89: 179–80. 2. Malhotra P, Singh S, Sud A, Kumari S. Tropical pyomyositis: experience of a tertiary care hospital in north-west India. J. Assoc. Physicians India 2000; 48: 1057–9. 3. Yu CW, Hsiao JK, Hsu CY, Shih TT. Bacterial pyomyositis: MRI and clinical correlation. Magn. Reson. Imaging. 2004; 22: 1233–44. 4. Chan O, Nawaz SZ, Hughes S, Skinner JA. Extensive pyogenic myositis of the hip in an immune-competent patient. JRSM Short Rep. 2011; 2: 90.
Acute colonic pseudo-obstruction (ACPO) is a rare complication of caesarean section. Its incidence is unknown. Eighty-five cases were identified in the literature (MEDLINE with search terms ‘pseudoobstruction’, ‘caesarean’ and ‘Ogilvie’). We describe a unique case of recurrence of ACPO after caesarean section and the consequences of progression of disease. A 36-year-old woman (G2 P2) presented with a 2-day history of abdominal distension and pain post-elective caesarean section. This is on a background of previous ACPO after her first caesarean section, where she was managed with endoscopic decompression. Twenty-four hours after delivery, she experienced increasing abdominal distension and pain. She was given opioid analgesia, simethicone and reassured. Forty-eight hours after delivery, she was reviewed for worsening symptoms. Abdominal X-ray revealed a dilated ascending colon. Computed tomography of the abdomen/ pelvis demonstrated a caecal diameter of 8 cm with no evidence of ischaemia or mechanical obstruction (Fig. 1). She was then found to have signs of peritonism and a white cell count of 19 × 109/L. She underwent urgent laparotomy, revealing an ischaemic-ascending colon with serosal tears. Right hemicolectomy with end-to-side anastomosis and loop ileostomy was performed, with planned reversal in 3 months. She was discharged 5 days post-laparotomy with no post-operative complications. Early recognition of ACPO is essential, particularly with increasing caesarean section rates. Patient age, caecal diameter and timing of decompression influence mortality rate (15% versus 36–44%), because of ischaemia and perforation.1 The last reported deaths from ACPO post-caesarean section in the UK were in 2002. A common factor leading to delayed management was an initial diagnosis of ileus by junior doctors.2 This case demonstrates failure to identify previous ACPO after her first caesarean section and inappropriate use of simethicone and opioid analgesia leading to progression of disease and the need for laparotomy. Early recognition, investigation and management are important steps in preventing ischaemia and perforation.
Syma Iqbal, MBBS Imeldah Motoroko, MBBS, BMed Cheng H. Lo, FRACS Plastics and Reconstructive Surgery, Western Health, Melbourne, Victoria, Australia doi: 10.1111/ans.12489 Fig. 1. Computed tomography of the abdomen demonstrating dilatation of the ascending colon.
© 2014 Royal Australasian College of Surgeons
