Outcomes from elective colorectal cancer surgery during the SARS-CoV-2 pandemic

This study aimed to describe the change in surgical practice and the impact of SARS-CoV-2 on mortality after surgical resection of colorectal cancer during the initial phases of the SARS-CoV-2 pandemic

Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study

Background: The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection. Methods: This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation. Findings: This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 81·7% (219 of 268) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28–2·40], p\textless0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65–3·22], p\textless0·0001), American Society of Anesthesiologists grades 3–5 versus grades 1–2 (2·35 [1·57–3·53], p\textless0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01–2·39], p=0·046), emergency versus elective surgery (1·67 [1·06–2·63], p=0·026), and major versus minor surgery (1·52 [1·01–2·31], p=0·047). Interpretation: Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery. Funding: National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research

Right Half Hallpike Test

The Half Hallpike Test compliments the Dix Hallpike Test and is traditionally used to assist with the diagnosis of posterior canal-benign paroxysmal positional vertigo (BC-BPPV), cupulolithiasis, as it may produce a greater degree of deflection under the action of gravity without latency when the otoconia are adhered to the cupula [1]. Short-arm PC BPPV may also result in nystagmus which follow excitatory patterns, as the weight of the dislodged otoconia trapped in the utricular side of the PC can lead to ampullofugal endolymph movement [2]. A test is positive when a patient reports vertigo, dizziness, or sensation of movement or falling with nystagmus present. When the head is in this position, it allows the PC to be aligned with the gravitational vector, which causes movement of otoconial debris through the posterior canal. Otoconia within the long-arm of the PC cause excitation (ampullofugal direction of endolymph) and lead to nystagmus generation (upbeat and ipsitorsional). Otoconia within the short-arm of the PC may also cause excitation (ampullofugal direction of endolymph) and lead to nystagmus generation (upbeat and ipsitorsional).[1] Wang W, Yan S, Zhang S, et al. Clinical application of different vertical position tests for posterior canal-benign paroxysmal positional vertigo-cupulolithiasis.Frontiers in neurology. 2022;13. https://doi.org/10.3389/fneur.2022.930542; [2] Scocco DH, Barreiro MA, García IE. Sitting-up vertigo as an expression of posterior semicircular canal heavy cupula and posterior semicircular canal short arm canalolithiasis.Journal of otology. 2022;17(2):101-106. https://doi.org/10.1016/j.joto.2022.02.00

Test Your Knowledge - Oscillopsia

This 65-year-old man with multiple sclerosis described that objects in front of him appear to spontaneously jump or move horizontally for the last few months. He reported that his symptoms occur independent of head movements and head impulse testing was normal. After viewing the video, what is the most likely cause of his "jumping" vision? A. Gaze-evoked nystagmus B. Pendular nystagmus C. Bilateral vestibular loss D. Internuclear ophthalmoplegia (INO). A. Incorrect. This patient has gaze-evoked nystagmus (GEN) due to a defective gaze holding mechanism, also known as the neural integrator. The neural integrator is responsible for turning eye velocity commands into eye position commands so that gaze can remain stable in eccentric gaze. Common causes are drugs (e.g., antiepileptic medications), and when gaze-evoked nystagmus is present in all directions of gaze, this implies a lesion(s) involving the cerebellum (flocculus/paraflocculus) or its connections. However, gaze-evoked nystagmus would only cause oscillopsia in eccentric gaze. GEN is a form of jerk nystagmus as defined by alternating slow and fast phases. B. Correct. This patient has acquired pendular nystagmus (APN), which is demonstrated by back-to-back slow phase eye movements. APN will commonly cause significant "sitting" (independent of head movement) oscillopsia unless vision is very poor. Multiple sclerosis and oculopalatal tremor are the most common etiologies of APN. The APN seen with MS can be conjugate (both eyes move in the same direction with similar amplitude) or disconjugate (both eyes move in the same direction with different amplitude). When disconjugate, the more intense nystagmus is typically present in the eye with poorer vision. This led to the assumption that conduction delays of visual information due to optic nerve demyelination induce eye movements that are unsuccessful in holding the image on the retina (1). However, this theory cannot be the sole mechanism as APN often remains unchanged in dark. Momentary damping of the nystagmus for a few hundred milliseconds can occur after saccades, blinks or vibration applied on the skull (not shown in the video). This lends further support to the idea that APN probably also results from an abnormality in the gaze holding machinery, and saccades or blinks may serve to transiently "reset" the neural integrator (2). C. Incorrect. Bilateral vestibular loss (BVL) will commonly cause "walking oscillopsia" (dependent on head movement) as the impaired vestibulo-ocular reflex (VOR) cannot keep the retinas stable during head movements. This patient had normal head impulse testing. One exception where BVL can cause "sitting oscillopsia" is in the case of severe BVL and a tremor of the head and neck. A head and neck tremor in a patient with normal vestibulo-ocular reflexes shouldn't cause a visual disturbance or oscillopsia. But if the VOR is impaired enough, the oscillations of the tremor will constantly move the head (and eyes) slightly off the fixation point resulting in instability of the retinal images and oscillopsia. This is referred to as ‘pseudonystagmus' because while oscillopsia is experienced in straight ahead gaze, there is no true nystagmus. D. Incorrect. This patient has bilateral INOs, although there are no clear adduction deficits and adduction lag is only appreciated with horizontal saccades. While an INO may cause diplopia, some patients may only notice a blurring of vision with rapid eye movements. Acutely, a patient with a medial longitudinal fasciculus (MLF) lesion may have spontaneous vertical-torsional nystagmus due to vertical semicircular canal pathway imbalance which causes "sitting oscillopsia", but this was not present in this case. Occasionally a patient with MS may complain of "walking oscillopsia", and this often relates to bilateral MLF lesions. Since the vertical semicircular canal (posterior and anterior) pathways travel through the MLF, while the horizontal VOR is preserved, the vertical VOR may be hypoactive. Dynamic visual acuity and head impulses can both be used to interrogate horizontal and vertical VOR function. Finally, the abducting nystagmus due to an INO may cause mild oscillopsia in far lateral gaze similar to GEN, but not in straight ahead gaze. Discussion: This is an MS patient with conjugate horizontal pendular nystagmus (responsible for his oscillopsia), bilateral INOs (bilateral adduction lag with horizontal saccades and abducting nystagmus), gaze-evoked nystagmus, and hypermetric saccades (best seen in the abducting eyes during saccades since there is an adduction lag OU due to the INOs). Oscillopsia is defined as the illusion of movement of the stationary environment. It is a visual sensation and resolves with eyes closed. Vertigo is a false sensation of movement/motion and is a balance sensation that does not resolve with eyes closed. However, a vestibular condition like acute vestibular neuritis can result in oscillopsia due to spontaneous nystagmus (goes away with eyes closed), and vertigo (does not go away with eyes closed) - in this case, both nystagmus and vertigo are the result of asymmetric semicircular canal afferents. A diagnostic approach to determining the probable etiology of oscillopsia begins with an inquiry of whether oscillopsia is dependent on or time-locked to head movements ("walking" oscillopsia - e.g., BVL) or whether it is independent of head movements ("sitting" oscillopsia - e.g., nystagmus or instrusions). When oscillopsia is time-locked to head movement and patients see clearly when they stop moving their head, BVL is the most likely cause, and may be related to ototoxicity from aminoglycosides (e.g., gentamicin) or a variety of other etiologies (nutritional, neurodegenerative, etc). When oscillopsia is triggered by head movements, an etiology like benign paroxysmal positional vertigo (BPPV) should be considered, and Dix-Hallpike performed. Attacks of oscillopsia and vertigo are usually vestibular in origin, and may be due to vestibular migraine, Meniere's, vestibular paroxysmia, BPPV, superior canal dehiscence syndrome (triggered by loud noises and pressure) among others. Our patient had continuous oscillopsia at rest with no head tremor. This indicates the presence of spontaneous nystagmus in primary gaze, and patient indeed had a pendular nystagmus. He also had gaze-evoked nystagmus and bilateral INO, but these cause nystagmus in non-primary gaze and therefore should not elicit oscillopsia. 1. Averbuch-Heller L, Zivotofsky AZ, Das VE, DiScenna AO, Leigh RJ. Investigations of the pathogenesis of acquired pendular nystagmus. Brain 1995;118 ( Pt 2):369-378. 2. Ehling R, Lutterotti A, Brenneis C, Zee DS, Beh SC, Kheradmand A. Damping of monocular pendular nystagmus with vibration in a patient with multiple sclerosis. Neurology 2014;83:1879

The Gans Maneuver for Right Posterior Canal Benign Paroxysmal Positional Vertigo (Video)

This maneuver is recommended for individuals with cervical restrictions or precautions, as the maneuver avoids cervical hyperextension and may reduce cervical pain associated with repositioning maneuvers. The Epley maneuver has higher subjective and objective success rates compared to the Gans maneuver at day one; however, the recovery rates were similar and were not significantly different after a one-week follow-up.[1] Saberi A, Nemati S, Sabnan S, Mollahoseini F, Kazemnejad E. A safe-repositioning maneuver for the management of benign paroxysmal positional vertigo: Gans vs. Epley maneuver; a randomized comparative clinical trial. Eur Arch Otorhinolaryngol. 2017;274(8):2973-2979. https://doi.org/10.1007/s00405-016-4235-7; [2] Roberts RA, Gans RE, Montaudo RL. Efficacy of a new treatment maneuver for posterior canal benign paroxysmal positional vertigo. J Am Acad Audiol. 2006;17(8):598-604. https://doi.org/10.3766/jaaa.17.8.

Bow and Lean Test

The Bow and Lean Test is used to identify the affected side and is designed to be used in conjunction with or after the Supine Roll Test. Within this test a null point may exist where the nystagmus will extinguish because the cupula is in a gravity neutral position. As this test involves the patient's head being positioned downward, wearing fixation removed goggles to view the eyes is recommended. In patients with horizontal canal-canalithiasis the free floating otoconia will move towards the cupula and the nystagmus will beat towards the affected ear within the bow position. In the lean position, the free floating otoconia will move away from the cupula and nystagmus will beat away from the affected ear. In patients with horizontal canal-cupulolithiasis, the nystagmus will beat away from the affected ear within the bow position and towards the affected ear in the lean position.[1] Büki B, Mandalà M, Nuti D. Typical and atypical benign paroxysmal positional vertigo: literature review and new theoretical considerations. J Vestib Res. 2014;24(5-6):415-423. https://doi.org/10.3233/ VES-140535; [2] Choung Y-H, Shin YR, Kahng H, et al. "Bow and lean test" to determine the affected ear of horizontal canal benign paroxysmal positional vertigo. Laryngoscope. 2006;116:1776-81 https://doi.org/10.1097/01.mlg.0000231291.44818.b

The Canalith Repositioning Maneuver/Epley Maneuver for Right Posterior Canal Benign Paroxysmal Positional Vertigo

Posterior canal (PC) accounts for 70-90% cases of BPPV [1-3] and resolves with canalith repositioning maneuvers 90% of the time [4-20]. The Epley maneuver is considered a gold-standard treatment, with class 1 evidence for use.[1] Neuhauser HK. The epidemiology of dizziness and vertigo.In: Handbook of Clinical Neurology. 2016:67. https://doi.org/10.1016/b978-0-444-63437-5.00005-4; [2] Benecke H, Agus S, Kuessner D, Goodall G, Strupp M. The burden and impact of vertigo: findings from the REVERT Patient Registry. Front Neurol. 2013; 4:136. https://doi.org/10.3389/fneur.2013.00136 PMID: 24106487; PMCID: PMC3788351.; [3] Ahn S.K., Jeon S.Y., Kim J.P. Clinical characteristics and treatment of benign paroxysmal positional vertigo after traumatic brain injury. Trauma. 2011;70(2):442-446. https://doi.org/10.1097/ta.0b013e3181d0c3d9; [4] Caruso G, Nuti D. Epidemiological data from 2.270 PPV patients. Audiol Med. 2005;3:7-11. https://doi.org/10.1080/16513860510028310; [5] von Brevern M, Bertholon P, Brandt T, et al. Benign paroxysmal positional vertigo: diagnostic criteria. J Vestib Res 2015;25:105-117. https://doi.org/10.3233/VES-150553; [6] Choi S-Y, Cho JW, Choi J-H, Oh EH and Choi K-D. Effect of the Epley Maneuver and Brandt-Daroff Exercise on Benign Paroxysmal Positional Vertigo Involving the Posterior Semicircular Canal Cupulolithiasis: A Randomized Clinical Trial. Front. Neurol. 2020; 11. https://doi.org/10.3389/fneur.2020.603541; [7] Gupta AK, Sharma KG, Sharma P. Effect of epley, semont maneuvers and Brandt-Daroff exercise on quality of life in patients with posterior semicircular canal benign paroxysmal positional vertigo (PSCBPPV). Indian J Otolaryngol Head Neck Surg. 2019;71(1):99-103. https://doi.org/10.1007/s12070-018-1322-7; [8] Imai T, Uno A, Yamato A, Takimoto Y, Sato G, Matsuda K, Takeda N, Nishiike S, Kawashima K, Iga T, Ueno Y, Ohta Y, Sato T, Kamakura T, Shingai-Higashi K, Mikami S, Kimura N, Nakajima T, Tanaka A and Inohara H. Comparison of the efficacy of the Epley maneuver and repeated Dix-Hallpike tests for eliminating positional nystagmus: A multicenter randomized study. Front. Neurol. 2023; 14. https://doi.org/10.3389/fneur.2023.1095041; [9] Isaradisaikul S, Chowsilpa S, Hanprasertpong C, Rithirangsriroj T. Single cycle versus multiple cycles of canalith repositioning procedure for treatment of posterior canal benign paroxysmal positional vertigo: A randomized controlled trial. Otology & neurotology. 2021;42(1):121-128. https://doi.org/10.1097/mao.0000000000002894; [10] Jaffar M, Ghous M, Ayaz M, Khan AA, Akbar A, Haleem F. Effects of half-somersault and brandt-daroff exercise on dizziness, fear of fall and quality of life in patients with posterior canal benign paroxysmal positional vertigo: A randomized control trial. Journal of the Pakistan Medical Association. 2023;73(1):139-142. https://doi.org/10.47391/jpma.3333; [11] Lee JD, Shim DB, Park HJ, et al. A multicenter randomized double-blind study: Comparison of the epley, semont, and sham maneuvers for the treatment of posterior canal benign paroxysmal positional vertigo. Audiology & neurotology. 2014;19(5):336-341. https://doi.org/10.1159/000365438; [12] Lee HJ, Jeon E, Lee D, Seo J. Therapeutic efficacy of the modified epley maneuver with a pillow under the shoulders. Clinical and experimental otorhinolaryngology. 2020;13(4):376-380. https://doi.org/10.21053/ceo.2019.01830; [13] Lee C, Lee C, Wu P, Wang C, Chen H, Shih C. Efficacy of combined canalith-repositioning procedure and supine to prolonged lateral position in treating posterior canal benign paroxysmal positional vertigo. Auris, nasus, larynx. 2021;48(5):834-840. https://dx.doi.org/10.1016/j.anl.2021.01.009.; [14] Lovato A, Marioni G, Monzani D, Rossettini G, Genovese E, de Filippis C. Physical therapy for benign positional vertigo of posterior canal: The role of alternated epley and semont maneuvers. Ear, nose, & throat journal. 2023;102(2):NP60-NP64.https://doi.org/10.1177/0145561320980183; [15] Mishra P, Sindhu KLS, Chethana R, Kaushik M. Epleys versus semonts manoeuvre in posterior canal benign paroxysmal positional vertigo. Indian J Otolaryngol Head Neck Surg. 2023. https://doi.org/10.1007/s12070-023-03624-5; [16] Oh S, Kim J, Choi K, et al. Switch to semont maneuver is no better than repetition of epley maneuver in treating refractory BPPV. J Neurol. 2017; 264(9):1892-1898. https://doi.org/10.1007/s00415-017-8580-2; [17] Piromchai P, Eamudomkarn N, Srirompotong S, Ratanaanekchai T, Yimtae K. The efficacy of a home treatment program combined with office-based canalith repositioning procedure for benign paroxysmal positional Vertigo-A randomized controlled trial. Otology & neurotology. 2019;40(7):951-956.  https://doi.org/10.1097/mao.0000000000002310; [18] Saberi A, Nemati S, Sabnan S, Mollahoseini F, Kazemnejad E. A safe-repositioning maneuver for the management of benign paroxysmal positional vertigo: Gans vs. Epley maneuver; a randomized comparative clinical trial. Eur Arch Otorhinolaryngol. 2017;274(8):2973-2979. https://doi.org/10.1007/s00405-016-4235-7; [19] Sinsamutpadung C, Kulthaveesup A. Comparison of outcomes of the epley and semont maneuvers in posterior canal BPPV: A randomized controlled trial. Laryngoscope Investigative Otolaryngology. 2021;6(4):866-871.https://doi.org/10.1002/lio2.619; [20] Strupp M, Goldschagg N, Vinck A, et al. BPPV: Comparison of the SémontPLUS with the sémont maneuver: A prospective randomized trial. Front Neurol. 2021;12. https://doi.org/10.3389/fneur.2021.65257

Kim Maneuver for Anterior Canal BPPV (Video)

The Kim Maneuver for Anterior Canal can be used to treat individuals with anterior canal BPPV. 1. The patient's head is turned 45 degrees towards the unaffected side. 2. The patient transitions into a supine position with the head hanging 30 degrees below the horizon. 3. After two minutes, the head is positioned in a neutral position (supine). 4. After one minute, the patient returns to a seated position with the chin tilted down about 30 degrees.Kim YK, Shin JE, Chung JW. The effect of canalith repositioning for anterior semicircular canal canalithiasis. ORL J Otorhinolaryngol Relat Spec. 2005;67:56-60. https://doi.org/10.1159/00008433

Short Canal Repositioning Maneuver for Anterior Canal BPPV

The Short Canal Repositioning Maneuver is used to treat anterior canal BPPV. 1. The patient's head is rotated 45-degrees towards the affected side. 2. The patient's maintains head in a 45-degree position and enters a head hanging position (40 degrees below the horizontal). 3. The patient then maintains extension while turning their head to the opposite side. 4. The patient returns to sitting.D'Albora Rivas R, Teixido M, Casserly R, Mónaco M. Short CRP for anterior canalithiasis: a new maneuver based on simulation with a biomechanical model. Front. Neurol. (2020) 11:857. https://doi.org/10.3389/fneur.2020.0085

The Kim Maneuver for Right Horizontal Cupulolithiasis (Video)

The Kim Maneuver is used to treat horizontal canal cupulolithiasis cases where the otoconia may be located on either side of the cupula. 1. The patient begins in a supine position. 2. The patient's head is turned 135 degrees towards the affected side and oscillation is applied to the affected side for 30 seconds. The patient maintains this position for two minutes. 3. The patient's head is rotated from 135 degrees to 90 degrees and oscillation is applied to the affected side for 30 seconds. The patient maintains this position for two minutes. 4. The patient returns to a supine position and maintains this position for two minutes. 5. The patient's head is rotated 90 degrees towards the unaffected side and oscillation is applied to the affected side for 30 seconds This position is maintained for two minutes. 6. The patient transitions to a prone position.Kim SH, Jo SW, Chung WK, Byeon HK, Lee WS, A cupulolithrepositioning maneuver in the treatment of horizontal canal cupulolithiasis. Auris Nasus Larynx 39 (2012) 163-168. https://doi.org/10.1016/j.anl.2011.03.00