Is a 'stump pyo' even a real thing?

RE: Is a 'stump pyo' even a real thing?

Richard Carter — Tue, 05 Jun 2018 13:42:49 GMT

or using cattle thickness cat gut in a small animal?

or multiple ligatures?

or ligating the tip of your glove into the dog?

RE: Is a 'stump pyo' even a real thing?

Evelyn Barbour-Hill — Tue, 05 Jun 2018 13:35:29 GMT

[quote user="Julian Earl"]more common is a stump reaction from the gat-gut ligature. [/quote]

Or from the nylon ligature.

RE: Is a 'stump pyo' even a real thing?

Julian Earl — Tue, 05 Jun 2018 11:41:24 GMT

I have seen one but more common is a stump reaction from the gat-gut ligature. These seem to cause more of a problem, some haematuria, straining and apparent discomfort. I did not suture the ligature into the stump, just left tightly around it.

My understanding is that without ovaries, pyometras cannot develop. Not according to Angelika Von Heimendahl, DIP.ECAR, so ovarian remnants presumably have to be involved in stump pyometras?

RE: Is a 'stump pyo' even a real thing?

Evelyn Barbour-Hill — Tue, 05 Jun 2018 10:26:42 GMT

[quote user="Rob Davis"]

[quote user="Evelyn Barbour-Hill"]

Given that Incurin is a common and generally effective treatment for urinary incontinence (sphincter mechanism incompetence) and given that we may have no record or even idea as to what precise technique was used to spay the bitch many years ago, is this not an argument for always removing the entire uterus in a spay operation?

[/quote]

Given that Incurin is a common and generally effective treatment for urinary incontinence (sphincter mechanism incompetence) and given that it is common practice in many countries where Incurin is used to perform ovariectomies only and given that stump pyometras appear to be extremely uncommon, is this not an argument that it is not necessary to remove the uterus in a spay operation?

[/quote]

Yep

RE: Is a 'stump pyo' even a real thing?

Rob Davis — Tue, 05 Jun 2018 09:03:14 GMT

[quote user="Evelyn Barbour-Hill"]

[/quote]

RE: Is a 'stump pyo' even a real thing?

Beats — Mon, 04 Jun 2018 07:21:07 GMT

[quote user="robloxley"]The only real stump pyo I've ever encountered was a spayed bitch on Incurin for USMI[/quote]

Interesting, I thought pyo was prostestagen related rather than estrogen.

Is this a recognised incurin risk or is anyone aware of other cases of pyo in presence of no ovaries but incurin treatment?

RE: Is a 'stump pyo' even a real thing?

Evelyn Barbour-Hill — Mon, 04 Jun 2018 00:18:41 GMT

[quote user="robloxley"]

The only real stump pyo I've ever encountered was a spayed bitch on Incurin for USMI

[/quote]

RE: Is a 'stump pyo' even a real thing?

Rob Loxley — Sun, 03 Jun 2018 23:35:57 GMT

The only real stump pyo I've ever encountered was a spayed bitch on Incurin for USMI

RE: Is a 'stump pyo' even a real thing?

Liz Barton — Sat, 02 Jun 2018 22:07:19 GMT

[quote user="Niall Taylor"]That is great in principle but the problem with vet med is often there is a serious paucity of studies, especially good ones. Ergo, like it or not, we often have to be guided by weaker forms of evidence, the experiences of others, individual studies, case reports etc.[/quote]

Couldn't agree more Niall!

If we welcome the experience of others (aka anecdote) is there a risk we may lose quality of discussion in favour of quantity? I, for one, think increasing breadth of discussion will enrich the discussion.

[quote user="Mark Hedberg"]the search feature on VetSurgeon isn't very userfriendly,[/quote] Thanks for the heads up - will need to look into that.

[quote user="Mark Hedberg"]honestly i prefer a well thought out reply to a 'use the search it's been discussed before' reply[/quote] I just wanted a source of evidence - happy for it to be discussed afresh, but this is where David said the answers were. I'm very happy to be educated... I'd like to think that's why we're all here!

I, for one, have been put off from posting in the past as I have felt jumped upon by forum regulars much more used to constructing their arguments in a robust, water-tight manner. Also, not knowing the individual personalities it is easy to misinterpret the written word based on our own state of play at the time of reading.

I have great concern over the waning mental health of our population, and our profession is no exception. Bearing in mind 90% vets find their work stressful (RCVS Facts 2014), and lack of confidence is rife (The Veterinary Wellbeing Benchmark Report 2018) it is the responsibility of all those posting to ensure they are kind as well as constructive. We don't know if the person posting is a stressed, overworked individual with looming compassion fatigue and burnout; it wouldn't be unusual! If the tone can be positive, even if not agreeing, that would be a good start.

[quote user="Jill Butterworth"]Knee jerk pain..no time to put it thru' the s*** filter.[/quote]

Totally agree Jill - need me one of these!

RE: Is a 'stump pyo' even a real thing?

TasosX — Fri, 01 Jun 2018 18:45:35 GMT

Actually there is data to support what Marie was stating in rabbits:

https://www.sciencedirect.com/science/article/pii/S0090429596004402

RE: Is a 'stump pyo' even a real thing?

Niall Taylor — Fri, 01 Jun 2018 12:48:18 GMT

[quote user="David Mills"]For too long we have worshipped unquestioningly at the altar of referral centres and universities, and in many cases I have come to realise this is both inappropriate and at times dangerous.[/quote]

I couldn't agree more.

[quote user="Arlo Guthrie"]what technological tweaks could be made to help encourage reference to studies, which almost by definition take the discussion in a less confrontational direction[/quote]

That is great in principle but the problem with vet med is often there is a serious paucity of studies, especially good ones. Ergo, like it or not, we often have to be guided by weaker forms of evidence, the experiences of others, individual studies, case reports etc. And I too find it infuriating when I hear someone telling me that because someone on a CPD day or in a lecture said x, y and z, that was somehow gospel truth by virtue of the fact they happened to be standing at the front with a data-projector remote in their hand at the time. It comes down to one person's experience versus another and there is no reason to think that the opinion of someone in a referral practice is any more valid that that of someone with a high case load in general practice.

One of my particular little bug-bears is the legs over/under debate when turning anaesthetised dogs. Everytime I ask someone why I get mutterings about gastric torsions, no references and a rolling of eyes because I'm such a dinosaur and don't believe the latest thing - now that IS bullshit!

For all the lurking homeopaths desperate to misquote me, obviously all the above applies to something with good a priori mechanisms and rationales. Homeopathy is so massively implausible, some bloke saying I used it and it works counts for nothing!

Niall

RE: Is a 'stump pyo' even a real thing?

Jill Butterworth — Fri, 01 Jun 2018 11:14:10 GMT

I have to confess to wincing at the spat... is that a barometer? I wonder if it's sometimes a function of how stressed/rushed the poster is at the time of writing? Knee jerk pain..no time to put it thru' the s*** filter. I often write a reply then read it back and don't bother posting because its hasty/repeating someone else's view/or I'm feeling sensitive that someone might jump on me for letting a little inconsistency get thru'...

RE: Is a 'stump pyo' even a real thing?

Arlo Guthrie — Fri, 01 Jun 2018 06:39:34 GMT

[quote user="David Mills"]Therefore I believe it can occupy a unique place, not an off the cuff Facebook discussion group, but a (if you like) grown up serious discussion arena. [/quote]

Agree wholeheartedly.

[quote user="David Mills"]However this does raise the stakes somewhat and there is a certain responsibility that comes with posting, that is, anecdote can be useful but opinion / fact needs to be differentiated, and where there is external evidence it should be adequately appreciated.[/quote]

Yes, but what is this, if not anecdotal commentary...

[quote user="David Mills"]Oh please

According to the evidence we have, catgut causes either similar or less tissue reaction than pds and vicryl. And dissolves a lot quicker. There's quite a bit of evidence out there for this.

It really is time we moved away from this referral/University led hatred of Catgut when thousands of vets use it every day without issues. It's classic ivory tower bullshit, nothing more. [/quote]

In fact, this little contretemps had me thinking what technological tweaks could be made to help encourage reference to studies, which almost by definition take the discussion in a less confrontational direction (ie it's more about whether or not the study is rubbish, rather than whether you think a poster's opinion is rubbish).

Could be as simple as adding a box in which to enter the url to a published study, then highlighting that in the post.

[quote user="David Mills"]I didn't think my tone was bullish[/quote]

Yeah, but it ain't about what you think!

[quote user="David Mills"]as it is something I'm particularly interested in academically and also for the health of the profession. For too long we have worshipped unquestioningly at the altar of referral centres and universities, and in many cases I have come to realise this is both inappropriate and at times dangerous.[/quote]

Not disagreeing with any of that, the question in my mind is just whether the point could be made as effectively without making the person you are replying to feel like you are calling them an idiot.

[quote user="David Mills"]Tis all, no biggie here. [/quote]

No biggie here, either. Just trying to think of ways to make the discussions more inclusive, without stifling robustly held opinions.

RE: Is a 'stump pyo' even a real thing?

David Mills — Fri, 01 Jun 2018 01:07:55 GMT

[quote user="Arlo Guthrie"]

[quote user="David Mills"]logically fallacious statements have little place in clinical or scientific discourse.[/quote]

is a pretty brutal way of putting things. Especially written like that, as a statement of fact, and not softened by 'in my opinion' or words to that effect.

[quote user="David Mills"]If this site is to become a home of good clinical discussion, I would proffer that this is not the way to do it[/quote]

Yes, 'the home of good clinical discussion' is absolutely our objective. So much so that I might even make that our strapline, if you don't mind!

But I would proffer that being too brutal is also not the way to do it.

[/quote]

As you and I have discussed, the big advantage of this site is the effort people go to to contribute. Therefore I believe it can occupy a unique place, not an off the cuff Facebook discussion group, but a (if you like) grown up serious discussion arena. However this does raise the stakes somewhat and there is a certain responsibility that comes with posting, that is, anecdote can be useful but opinion / fact needs to be differentiated, and where there is external evidence it should be adequately appreciated. Further, I appreciate rational logical debate, as many people do, including the Campaign for Rational Veterinary Medicine - I don't see how my replies were any different than the letters your group have produced.

That's all really, I didn't think my tone was bullish but it was black and white, as it is something I'm particularly interested in academically and also for the health of the profession. For too long we have worshipped unquestioningly at the altar of referral centres and universities, and in many cases I have come to realise this is both inappropriate and at times dangerous.

Tis all, no biggie here.

RE: Is a 'stump pyo' even a real thing?

Arlo Guthrie — Thu, 31 May 2018 18:04:35 GMT

[quote user="Mark Hedberg"]I thought David's reply was polite and well thought out.[/quote]

Been cogitating over this one for some time.

Yes, David Mills, it was well thought out and, at a push, polite.

I say 'at a push' ... what's been exercising me is whether your points could or should have been made in a gentler way.

For example, telling someone that their

[quote user="David Mills"]logically fallacious statements have little place in clinical or scientific discourse.[/quote]

is a pretty brutal way of putting things. Especially written like that, as a statement of fact, and not softened by 'in my opinion' or words to that effect.

[quote user="David Mills"]If this site is to become a home of good clinical discussion, I would proffer that this is not the way to do it[/quote]

Yes, 'the home of good clinical discussion' is absolutely our objective. So much so that I might even make that our strapline, if you don't mind!

But I would proffer that being too brutal is also not the way to do it. Liz may be strong enough to take it on the chin. Others may not be. And others may read a post like that and think ... 'hell, I am not posting in here if I'm going to be shot down like that'.

It's a difficult one. Sometimes points need to be made very firmly. I just think the original line of argument came across a bit too strongly as 'you're wrong / an idiot and I'm right', when it would have been more productive to say: "I think you're wrong, and this is why / here's a link to research".

The latter allows for the reader to walk away feeling illuminated and grateful. The former, well, er, the opposite of that!

We have new ways of reacting to forum posts coming along soon. At the moment, I have asked for just: "Agree", "Disagree" and "Thank you".

But I wonder whether we need another reaction to be able to voice our disapproval of the way a point has been made. At the moment we only have the 'Report Abuse' button, which doesn't really work and also sounds a bit extreme. I wonder if we need something a bit more low-key. Something like 'Pull your socks up'.

RE: Is a 'stump pyo' even a real thing?

Anthony Todd — Thu, 31 May 2018 15:59:50 GMT

[quote user="Anthony Todd"]No bias at all, just a wee bit of experience and an interest in doing the best and having fewer problems.[/quote]

I think blaming a catgut ligature for a "stump reaction" is a bit of a stretch whereas if catgut was such a "foreign" material one would expect reaction in other areas such as muscle etc yet these don't, or didn't, occur over many ops and many years

BUT

It may be, as there is a hoo-ha about mad-cow disease and animal based suture materials, that current products are coated or prepared differently??

RE: Is a 'stump pyo' even a real thing?

Mark Hedberg — Thu, 31 May 2018 12:55:13 GMT

[quote user="Liz Barton"]

[quote user="David Mills"]It was discussed on another thread a while back, it's freely available on pubmed etc but I'll look it up when I'm back.[/quote]

Thank you! It would have saved a lot of angst had you simply replied to my original post e.g.

'I disagree. Look at the previous thread where this was discussed to see the evidence'

Ta dah!

[/quote]

I'm not sure that's strictly fair, Liz - the search feature on VetSurgeon isn't very userfriendly, and honestly i prefer a well thought out reply to a 'use the search it's been discussed before' reply; i think the latter stifles debate.

Personally I find the suture debate (among others) a fascinating example of evidence vs eminence based medicine - I thought David's reply was polite and well thought out. Obviously I can't claim to interpret perception, but I don't think his reply seemed personal or combative.

Best wishes,
Mark

RE: Is a 'stump pyo' even a real thing?

Liz Barton — Wed, 30 May 2018 21:33:45 GMT

[quote user="David Mills"]It was discussed on another thread a while back, it's freely available on pubmed etc but I'll look it up when I'm back.[/quote]

Thank you! It would have saved a lot of angst had you simply replied to my original post e.g.

'I disagree. Look at the previous thread where this was discussed to see the evidence'

Ta dah!

RE: Is a 'stump pyo' even a real thing?

Dinu Catilina — Wed, 30 May 2018 08:17:01 GMT

Never seen a true stump pyo. I had a case recently with a stump abscess/ granuloma/ something. It was a bitch that I spayed probably 2-3 months before seeing her again for mild vaginal discharge. Ultrasound showed a fluid filled structure at the end of the uterine stumped and the bitch got better with antibiotics. So most likely not a pyo?

Interesting about the length of the stump. I always like to leave a minimum of 1.5 cm between my ligature and the end of the stump and I always wondered if it does matter. I guess I don't know?

When I was neutering in a Romanian shelter we had loads of inflammatory/ infection reactions post neutering when we used catgut. Scrotal swellings were very very common. All gone after we changed to monofilament nylon (could not afford anything else). I wonder if it was related more to not working in a sterile environment?

RE: Is a 'stump pyo' even a real thing?

David Mills — Tue, 29 May 2018 22:44:32 GMT

[quote user="Liz Barton"]Please don't be so bullish. I find your tone neither friendly nor appropriate for clinical debate in which I feel free to air my opinions, experience and knowledge. [/quote]

The only personal part about this was that I disagreed with you on an intellectual level. My point was that your "evidence", hearsay and anecdote, is symptomatic of a wider malaise in the profession, that of slavish absorption of eminence-evidence. It is not healthy.

I'll try and illustrate it thus. Why put "referral" in your anecdote. Do you not think that by their very nature they see the weird and wonderful?

So they see some reactions to Catgut (according to their anecdotes). Do we know how prevalent Catgut usage is vs other materials? If we don't, then I submit that these anecdotes, whilst interesting, are not relevant evidence.

As to tone, well the number of likes versus yours may say something, no?

[quote user="Liz Barton"]Actually it is, [/quote]

Is it? I'd be genuinely fascinated to see the evidence, that is, evidence directly relevant to the patients we treat. So, that is in vivo comparative trials of suture materials in veterinary species.

[quote user="Liz Barton"]Feel free to provide said evidence and enlighten me, as it is apparent this is an important and emotive issue for you.[/quote]

It was discussed on another thread a while back, it's freely available on pubmed etc but I'll look it up when I'm back.

[quote user="Liz Barton"]Too much.[/quote]

How so? I genuinely think it is one of the main thing holding the profession back.

RE: Is a 'stump pyo' even a real thing?

Beats — Tue, 29 May 2018 20:52:29 GMT

I do my bitch spay ligatures with catgut, close linea alba with polydioxanone or nylon, and use catgut SC and intradermal.

If I was given an extra $5 per spay I would use it on a pack of monocryl as I love it and, personally, in my limited experience, have found it less reactive.

This may reflect it coming in a tidy little sterile package with a sharp swaged on needle rather than the inherent properties of the suture material then? My catgut and polydioxanone and nylon come on reels and then get threaded on to a needle.

I have, on rare occasions, found bits of catgut still recognisable many years after an ovarian pedicle has been ligated.

I think as Thomas says, there are two things being talked about in this thread:

1) stump pyometra - a pyometra occurring in the remaining uterus following the continued endogenous production (ovary left behind) or exogenous supplementation of prostaglandins

2) an inflammed / infected lump in the area of a uterine ligature/transection

regarding the latter, I can see how, potentially, a nice sterile little packet of relatively thinner synthetic absorbable monofilament suture may carry a lower risk than a thicker bit of catgut pulled through a potentially-bacteria-contaminated nozzle from a reel?

I don't remember, off-hand, seeing either (1) or (2)

RE: Is a 'stump pyo' even a real thing?

Liz Barton — Tue, 29 May 2018 19:47:53 GMT

[quote user="David Mills"]Please don't be so sensitive.[/quote]

Please don't be so bullish. I find your tone neither friendly nor appropriate for clinical debate in which I feel free to air my opinions, experience and knowledge.

[quote user="David Mills"]Cognitive bias is highly likely. Mine was based on the best available relevant evidence as well as clinical experience. Yours isn't. [/quote]

Actually it is, but you seemed determined that your evidence and experience are more valid than mine. Feel free to provide said evidence and enlighten me, as it is apparent this is an important and emotive issue for you.

[quote user="David Mills"]And worse, this kind on opinion based medicine is harmful to the profession.[/quote]

Too much.

RE: Is a 'stump pyo' even a real thing?

Anthony Todd — Tue, 29 May 2018 18:58:12 GMT

[quote user="Evelyn Barbour-Hill"]Anyone[/quote]

[Just "anyone" as an entrance...]

I can't recall any of our bitch spays coming on heat [up to 7 sites over many years and many vets] yet everyone says to get a "stump pyo" or a mini-pyo from a section of remaining uterus you need some functioning ovary which assumes that some ovarian function post-spay must be occurring??

Is this common?

RE: Is a 'stump pyo' even a real thing?

Anthony Todd — Tue, 29 May 2018 18:37:57 GMT

[quote user="Liz Barton"]No they're not always comparative, which is part of the problem. Google it and you'll find all the evidence you need to support your own pre-existing bias...[/quote]

No bias at all, just a wee bit of experience and an interest in doing the best and having fewer problems.

This, I think is the crux in the particular situation where you are ligating in a critical situation:

The one area where catgut does appear to have an advantage over synthetic materials is that of knot strength. Catgut is often considered easier to knot, and although this is not easy to quantify, knots do appear to hold well with less risk of slippage.

from your reference.

RE: Is a 'stump pyo' even a real thing?

Evelyn Barbour-Hill — Tue, 29 May 2018 18:28:26 GMT

[quote user="Anthony Todd"]Has anyone reasoned that the length of the "stump" [of necrotic avascular tissue] might be associated with "stump granuloma" and nothing to do with the suture material??[/quote]

A good hypothesis. Anyone?