Do you have questions about endoscopic retrieval of foreign bodies? (Clinical Article Club)

RE: Do you have questions about endoscopic retrieval of foreign bodies? (Clinical Article Club)

Alasdair Hotston Moore — Wed, 31 May 2023 08:43:54 GMT

Surgical principles would support the use of a single dose of perioperative antibiotics at the time of OHE for cases of pyometra with no evidence of septicaemia because you are entering a hollow viscus containing significant numbers of bacteria.

RE: Do you have questions about endoscopic retrieval of foreign bodies? (Clinical Article Club)

Stigen — Tue, 30 May 2023 11:30:21 GMT

I`m in Norway. I do lots of pyometras, but never use any antibiotics, unless of course they have burst and leaked into the abdomen, but even then I think rigourous flushing with saline works pretty well. Back in the days I remember some also used metronidazole infusion in those cases.

As long as the pyometra is closed and the whole thing is removed in surgery there is no need for antibiotics.

RE: Do you have questions about endoscopic retrieval of foreign bodies? (Clinical Article Club)

Lucy Fleming — Sun, 07 May 2023 11:17:50 GMT

I remember being mentioned in a university lecture that many cases of pyometra were effectively "sterile", and given that you should be removing almost all the affected tissue, not using antibiotics should be a pretty defensible choice. I think I'd be pretty happy not to use them in most patients. Might be a bit wimpier about not using antibiotics for GI surgery...

RE: Do you have questions about endoscopic retrieval of foreign bodies? (Clinical Article Club)

Clive Ansell — Sun, 07 May 2023 09:59:19 GMT

[quote userid="3213" url="~/001/nonclinical/f/life-in-practice-discussions/30618/do-you-have-questions-about-endoscopic-retrieval-of-foreign-bodies-clinical-article-club/241496#241496"]My most interesting take away was no antibiotics for pyometra which was interesting (and seemed to produce perfectly good results). Their antibiotic usage was v different to general uk use.[/quote]

It takes a decent pair of cojones to take that leap of faith I suppose, given that if it goes mammaries up clients will complain and colleagues will critisise.

Not that long ago, it was the norm here to give antibiotics to cases of bad dental disease, it certainly was when I qualified in 1996, and now it has almost become the norm not to use them at all. I rarely give antibiotics to dental cases now.

Just a matter of time before we adopt the same approach to other conditions, such as pyometra.

RE: Do you have questions about endoscopic retrieval of foreign bodies? (Clinical Article Club)

mel kavanagh — Sat, 06 May 2023 20:50:26 GMT

[quote userid="8991" url="~/001/nonclinical/f/life-in-practice-discussions/30618/do-you-have-questions-about-endoscopic-retrieval-of-foreign-bodies-clinical-article-club/241405#241405"]I spoke to a vet who works in Sweden recently. Apparently their experience is almost 180 from the UK where owners regularly question if abx are needed - especially where drains are in place, superficial pyodermas, uncomplicated UTIs etc.[/quote]

Hi David,

I worked in Sweden for 6 weeks a few years ago - 1st period of UK Covid lockdown. Busy clinic. Lots of kit and v high standards overall - perhaps a bit 'every headache is a brain tumour 'til proved otherwise'. My most interesting take away was no antibiotics for pyometra which was interesting (and seemed to produce perfectly good results). Their antibiotic usage was v different to general uk use.

Firstly vets in sweden cannot legaly hand out bottles of antibiotics to clients. They email a prescription to what i took to be some sort of national human pharmacy database and pet owners could go to any chemist, give their details and collect and pay for the relevant prescription. So if you can't make money flogging pills, hey presto you sell less of them. Instead all cat bite abscesses had sedation, wounds opened and flushed and penrose drains placed for a few days - about £300 a pop if my maths was correct ( but c£50 for a half hour taxi ride too so life is expensive in Sweden).

And vets who didn't work for the State - private clinics not obliged to provide 24 hour cover - though hospital had overnight staff and vet for in patients

Didn't get any sense that clients were any better informed than UK clients. Clients are used to what they are used to.

RE: Do you have questions about endoscopic retrieval of foreign bodies? (Clinical Article Club)

David Mills — Fri, 21 Apr 2023 19:49:35 GMT

[quote userid="8663" url="~/001/nonclinical/f/life-in-practice-discussions/30618/do-you-have-questions-about-endoscopic-retrieval-of-foreign-bodies-clinical-article-club/241396#241396"]Simply, we have bigger fish to fry in the context on antibiotic stewardship[/quote]

Indeed, but this thread was a question (from EBH) about antibiotics, which was valid and pertinent no?

Mighty oaks etc. To me, antibiotic stewardship applies everywhere with a critical analysis of when they are needed, required, desirable, questionable or not indicated. So we should, and must in my opinion, question it wherever it is raised as a treatment possibility. Regardless of where they are overused elsewhere.

I spoke to a vet who works in Sweden recently. Apparently their experience is almost 180 from the UK where owners regularly question if abx are needed - especially where drains are in place, superficial pyodermas, uncomplicated UTIs etc. Sounds like heaven. We know UK owners (and patients of GPs) often see abx as a panacea so shouldn't we be the ones to question ourselves (in the absence of such owners) regardless of the case in front of us?

RE: Do you have questions about endoscopic retrieval of foreign bodies? (Clinical Article Club)

Alasdair Hotston Moore — Fri, 21 Apr 2023 12:25:00 GMT

Perhaps I should say: it seems odd to be so concerned.....

Simply, we have bigger fish to fry in the context on antibiotic stewardship

RE: Do you have questions about endoscopic retrieval of foreign bodies? (Clinical Article Club)

dred.hall — Fri, 21 Apr 2023 12:03:49 GMT

Whilst Alasdair can defend himself, I re-iterate that the use of ABs in inhaled FBs (with the qualification that we are talking about plant material where the first attempt at removal failed) MAY be inappropriate but there is no evidence either way. Whereas the harmful effects of AB misuse in canine acute diarrhoea have been clearly demonstrated, and numerically this is a much bigger problem.

RE: Do you have questions about endoscopic retrieval of foreign bodies? (Clinical Article Club)

David Mills — Fri, 21 Apr 2023 11:53:51 GMT

[quote userid="8663" url="~/001/nonclinical/f/life-in-practice-discussions/30618/do-you-have-questions-about-endoscopic-retrieval-of-foreign-bodies-clinical-article-club/241382#241382"]indeed, it seems odd to be concerned about antibiotic use in rare cases (inhaled FBs) given the continuing overuse in acute diarrhoea....[/quote]

Seems a strange logic - so because abx are overused elsewhere it justifies their use in inhaled FB or other rare cases?

RE: Do you have questions about endoscopic retrieval of foreign bodies? (Clinical Article Club)

dred.hall — Thu, 20 Apr 2023 09:30:24 GMT

Certainly AB misuse in canine acute diarrhoea is a bigger problem:

Singleton, D. A., et al (2019). "Pharmaceutical Prescription in Canine Acute Diarrhoea" Frontiers in Veterinary Science 6: 14.

However, as Tesco always say, "every little helps"

RE: Do you have questions about endoscopic retrieval of foreign bodies? (Clinical Article Club)

Alasdair Hotston Moore — Thu, 20 Apr 2023 08:47:04 GMT

indeed, it seems odd to be concerned about antibiotic use in rare cases (inhaled FBs) given the continuing overuse in acute diarrhoea....

RE: Do you have questions about endoscopic retrieval of foreign bodies? (Clinical Article Club)

dred.hall — Tue, 18 Apr 2023 09:00:17 GMT

"both the medical and the veterinary professions need to abandon their love affairs with antibiotic drugs"

Absolutely, and one of the biggest areas we need to improve in small animal practice is the inappropriate use of antibacterials in dogs with acute diarrhoea. And I would agree that they are rarely needed in patients with bronchial FBs.

RE: Do you have questions about endoscopic retrieval of foreign bodies? (Clinical Article Club)

Evelyn Barbour-Hill — Tue, 18 Apr 2023 00:19:05 GMT

I'm not criticising the decisions in individual cases of Dr. Hall or any posters, but both the medical and the veterinary professions need to abandon their love affairs with antibiotic drugs.

Yes,I was as guilty as anyone for some 46 years and sometimes still have a lapse.

Anecdote alert!

I once had a big abscess in an armpit. First it was drained by needle and syringe, and when that was unsuccessful it was excised in it's entirety. The very enlightened surgeon gave no antibiotic drug at any time – as he rather oddly put it "we will withhold antibiotics", as if antibiotic treatment was somehow expected or the norm. The enormous hole was just left open and it healed in no time. Of course if I had been febrile or there had been cellulitis the situation would have been different.

RE: Do you have questions about endoscopic retrieval of foreign bodies? (Clinical Article Club)

dred.hall — Mon, 17 Apr 2023 09:44:24 GMT

David

An important question and, to be honest, in most cases I wouldn't give antibiotics after successfully removing a bronchial foreign body first time. But in this case there had already been one unsuccessful attempt and clearly quite a lot of trauma. Where there is particulate matter remaining and significant bleeding (the red stuff in the image is fresh blood, not artefact) it might be justified as, unlike in skin, you can't see if infection develops. Culture and sensitivity is unlikely to be helpful - it will be a mixed infection just as in patients with aspiration pneumonia after inhaling food.

There is very little evidence about using antibiotics post-removal: a recent paper (Flageollet et al. JSAP (2023), 1–8, DOI: 10.1111/jsap.13600) described mucopurulent material in the airways and bronchial nodules, but did not comment on the use of antibiotics after successful removal of vegetal material. One could argue that defensive use of ABs in this situation is wrong but there is a need for a prospective study.

PS. Although the image is magnified this is the right caudal mainstem bronchus, so not a minor airway.

RE: Do you have questions about endoscopic retrieval of foreign bodies? (Clinical Article Club)

David Mills — Sun, 16 Apr 2023 21:12:50 GMT

I'm not actually being critical here, just trying to understand the decision-making process/justification.

That photo is 'dramatic'. It's close up, some magnification, and over expression of some colours through lighting (esp red).

However.

If that was a skin wound bleeding like that we wouldn't give abx. Airways have plenty of inherent and functional defences against infection, even when inflamed. Many inflammtory airway animals, lungworm animals, others, we never get to scope and don't give abx (and probably a lot, or some, look like this) and hey recover fine.

So why in this case? Is visual 'oooo' enough of a justification?

Moreover, if we were to C+S this post removal and it came back negative, would we still give abx?

RE: Do you have questions about endoscopic retrieval of foreign bodies? (Clinical Article Club)

dred.hall — Sun, 16 Apr 2023 11:16:46 GMT

Depends! Probably not unless there is still a lot of particulate matter left or there is severe trauma to the bronchial mucosa as in this image after removal.

RE: Do you have questions about endoscopic retrieval of foreign bodies? (Clinical Article Club)

David Mills — Sat, 15 Apr 2023 22:29:06 GMT

Would you give antibiotics post-removal?

RE: Do you have questions about endoscopic retrieval of foreign bodies? (Clinical Article Club)

Alasdair Hotston Moore — Sat, 15 Apr 2023 21:40:53 GMT

Also, less pus and easier to see next time

RE: Do you have questions about endoscopic retrieval of foreign bodies? (Clinical Article Club)

dred.hall — Sat, 15 Apr 2023 15:47:18 GMT

Good question and probably no evidence either way, but if I had a putrefying ear of barley sitting in my lungs after the trauma of a failed extraction, I would want antibiotics.

RE: Do you have questions about endoscopic retrieval of foreign bodies? (Clinical Article Club)

Evelyn Barbour-Hill — Sat, 15 Apr 2023 00:29:13 GMT

[quote userid="11308" url="~/001/nonclinical/f/life-in-practice-discussions/30618/do-you-have-questions-about-endoscopic-retrieval-of-foreign-bodies-clinical-article-club/241297#241297"]

'nah, leave it a couple of days, give antibiotics and then we'll try again. It'll go mushy and come right out'.

[/quote]

This is probably a tangent, but why the antibiotic treatment? Serious question.

RE: Do you have questions about endoscopic retrieval of foreign bodies? (Clinical Article Club)

dred.hall — Thu, 13 Apr 2023 20:12:10 GMT

Anthony

That someone was an RVC graduate!

I actually learned to wait and try again for large pulmonary FBs from Paul Wotton.

RE: Do you have questions about endoscopic retrieval of foreign bodies? (Clinical Article Club)

Anthony Dennison — Thu, 13 Apr 2023 11:00:52 GMT

[quote userid="3141" url="~/001/nonclinical/f/life-in-practice-discussions/30618/do-you-have-questions-about-endoscopic-retrieval-of-foreign-bodies-clinical-article-club/241248#241248"]However, Storz now offer "disposable" videobronchoscopes (made for COVID patients) which only cost hundreds and at 3.5 mm tip diameter are ideal for cats and small dogs. https://www.karlstorz.com/gb/en/mtp-single-use-products.htm. Although only single-use in human patients, they are being re-used in referral centres although you need ethylene oxide to sterilise them fully.[/quote]

This is really useful information, thank you!

I still vividly remember at Langford someone attempting bronchoscopic removal of an ear of corn from a weimeraner's lung that wasn't going to plan. Surgeons started planning a thoracotomy when you walked in and said 'nah, leave it a couple of days, give antibiotics and then we'll try again. It'll go mushy and come right out'.

And it did!

RE: Do you have questions about endoscopic retrieval of foreign bodies? (Clinical Article Club)

Alasdair Hotston Moore — Thu, 06 Apr 2023 23:07:15 GMT

I may have damaged a scope with those forceps myself lol. But they are the tool for the job (bones)

RE: Do you have questions about endoscopic retrieval of foreign bodies? (Clinical Article Club)

dred.hall — Thu, 06 Apr 2023 18:43:23 GMT

Thanks Alasdair

The new surgeons at Langford are unwilling to remove oesophageal FBs under fluoroscopic guidance, and these cases are now seen by Medicine. However, they still use the long rigid forceps but under endoscopic guidance, although the potential for trashing the scope is a concern.

RE: Do you have questions about endoscopic retrieval of foreign bodies? (Clinical Article Club)

dred.hall — Thu, 06 Apr 2023 18:40:07 GMT

Robert

I am not paid by Storz so can honestly say that the best all-round veterinary videogastroscope is probably the Storz Silverscope. There are of course other endoscope suppliers (Burtons, VES) and they may have cheaper options.

The Silverscope has a tip diameter of 7.9 mm, a 1.4 m working length and a 2.8 mm working/biopsy channel, which is big enough for grasping instruments as well as allowing large biopsies. It is compatible with their Telepack (integrated light source, air pump and monitor), which you can also use for rigid endoscopy.

However, it is expensive (~£16,000, but still 1/3 the price of a new Olympus scope!) and it is a compromise if you can only afford one scope: it won't pass the pylorus of small dogs and cats (~ <2.5 kg) but at 1.4 m length can reach the duodenum of large/giant breeds, although this makes it quite unwieldy in smaller patients. Also the tip is too wide for bronchoscopy in cats. However, Storz now offer "disposable" videobronchoscopes (made for COVID patients) which only cost hundreds and at 3.5 mm tip diameter are ideal for cats and small dogs. https://www.karlstorz.com/gb/en/mtp-single-use-products.htm. Although only single-use in human patients, they are being re-used in referral centres although you need ethylene oxide to sterilise them fully.