Bladder Rupture following Conversion to Enteric Drainage after Pancreatic Transplantation.

Complications associated with bladder-drained pancreatic transplant are not uncommon and include urinary tract infections and reflux pancreatitis. Bladder rupture with peritoneal leak is a rare complication after pancreatic transplantation and can present as an acute abdomen with rapidly deteriorating renal function. We describe the first case of a urine leak into the peritoneal cavity occurring after conversion from bladder to enteric drainage. A high index of suspicion is required to diagnose such a complication.

Achieving waiting list reform: a pilot program integrating waiting time, category and patient factors.

Equity in resource allocation is central to the tenet of social justice in health care. The management of surgical waiting lists is of critical importance to clinicians, patients and regulators. In most hospital environments, the basic process has remained unchanged for decades. Patients are assigned to one of three urgency-related categories. Clinicians consequently administer three competing patient pools. The basis by which patients are selected for treatment may be difficult to define. The specific clinical circumstances of each patient are often unreported and may be unknown to those administering the list. Waiting list bias is also recognised. This may reflect clinician advocacy, pressure to meet category timeframe restrictions or perceived training requirements. In this environment, it is difficult to demonstrate propriety in care. We report the implementation of a pilot program to redesign waiting list management within a South Australian public hospital unit. This allows assemblage of patients into a single list. Overall priority is determined by balancing clinical acuity and waiting time. The determination of acuity takes into account both the primary category and the specific characteristics of each patient that are relevant to their intended procedure. Uniquely, the process is applicable to lists containing patients with dissimilar conditions. This paper reviews the limitations of current approaches in meeting reasonable community expectations. The principles and social justification underpinning this reform are introduced. Finally, the benefits offered by the program are discussed and interim results are reported.

Challenges in non-muscle invasive bladder cancer: lessons from a regional review.

BACKGROUND: Surveillance programmes for bladder cancer are invasive and expensive. Existing guidelines are complex, and the capacity to implement these is untested. The present study examined treatment consistency, and ease of guideline implementation, for patients undergoing surveillance of non-muscle invasive bladder cancer. METHOD: Eligible cancers treated between 1 January 2005 and 30 June 2009 were identified from a prospective database in a regional South Australian Urology service. Each was analysed with respect to the timing of cystoscopic surveillance and the use of intraoperative chemotherapy. For high-risk patients, the use of urine cytology, upper tract imaging, adjuvant therapy and re-resection of T1 cancers was reviewed. RESULTS: Eight hundred and nineteen cystoscopies were performed in the surveillance of 313 cancers in 193 patients. Within each risk category, the pattern of cystoscopic surveillance varied widely. In high-risk patients, the use of cytology, upper tract imaging, adjuvant therapy and re-resection was infrequent (3-56%). An attempt was made to standardize management through the implementation of guidelines. No overall practice improvement was observed after 18 months. Difficulty incorporating new algorithms into practice and ensuring a consistent longitudinal focus in care were felt contributory. Of 78 low-risk cancer patients, 55% underwent more cystoscopies than would have been expected. In 235 cancer patients at high or intermediate risk, 43% received less follow-up than would have been recommended. CONCLUSION: Surveillance patterns were inconsistent across all risk categories. The development of consensus recommendations did not significantly alter clinical practice. Implementation of clinical guidelines for this important disease represents a significant challenge in acute hospital settings.

Bilateral renal inflammatory pseudotumour effectively treated with corticosteroid.

Inflammatory pseudotumour (IPT) is a rare disease of unknown cause that most commonly involves the lung but can occur in almost any site in the body. Occurrence in the kidneys is very rare and bilateral renal involvement even rarer. There are 34 previously reported cases in the English-language medical literature between 1966 and 2008. Herein we report a case of IPT infiltrating both kidneys. We have also reviewed the clinical features, radiological findings, treatment and outcome of renal IPT. Clinical features at presentation are commonly non-specific. Features on imaging are inadequate to make a diagnosis of IPT or to clearly distinguish it from malignancy. Consequently diagnosis has frequently been made after nephrectomy and on a few occasions with the aid of percutaneous or open biopsies. The majority of renal IPT (83%) have been treated with nephrectomy and those cases with bilateral IPT have received corticosteroids.

Adequacy of consent documentation in a specialty surgical unit: time for community debate?

OBJECTIVE: To determine the adequacy of consent documentation related to descriptions of intended procedures, associated risks and treatment alternatives, and to analyse trends in the adequacy of consent documentation in a specialty surgical unit. DESIGN, PATIENTS AND SETTING: Retrospective reviews of consent forms for all patients on the Urology Unit waiting list of the Repatriation General Hospital, Adelaide on three occasions. Reviews were undertaken during 2005, 2007 and 2008, with a minimum of 12 months between reviews. RESULTS: 1280 consent documents were evaluated. No trend in the studied criteria of adequacy of documentation was observed during the study period. Overall, 18.5% of consent forms described procedures using plain language. In 15.3% of consent forms, a significant component of the procedure was described using only an acronym, without further explanation. In 6.6% of consent forms, procedure descriptions contained only acronyms, abbreviations or technical terminology, with no plain language word. The purpose of the operation was conveyed in 10.1% of consent forms. Relevant risks were provided in 4.1%. Any indication of the magnitude of procedural risks was provided in only four of 1280 forms. No consent form provided information about alternative treatments. CONCLUSIONS: We believe these findings are broadly representative of current hospital practice and that the community should consider whether an acronym or technical terminology is appropriate for documenting consent. If not, can minimum practice standards be defined, and should any emerging recommendations be mandated?

Laparoscopic donor nephrectomy: meeting the challenge of consumerism?

BACKGROUND: Despite the increasing adoption of laparoscopic donor nephrectomy, no study has examined donor perceptions following this procedure. In particular, it has been tacitly assumed that a less invasive procedure might in itself provide a more satisfactory donor experience. The present study reviews the experience of donors undergoing laparoscopic nephrectomy, and examines the extent to which contemporary management practice addresses issues relevant to consumerism. METHODS: Forty-two donors participated in a structured telephone interview, and 33 (79%) returned a written questionnaire. RESULTS: Coming through the survey was a strong sense of commitment to donation, and most respondents were satisfied with the experience. The main criticisms related to hotel services, the duration of the preoperative investigations, the perceived quality of nursing care on the general wards, medical communication and the duration of postoperative follow up. The self-reported time to meet recovery goals was extremely broad. CONCLUSIONS: Considering the nature of criticisms offered by the respondents, it is concluded that the expectations of donors as health-care consumers will only be met through modification of existing protocols.

Audits, errors and the misplace of clinical indicators: revisiting the Quality in Australian Health Care Study.

Publication of the Quality in Australian Health Care Study in 1995 represented a defining moment for Australian health care providers. The high incidence and cost of preventable adverse events underscored a need for defined process, error recognition and audit cycle. Despite this, surgical audit has continued to emphasize clinical indicators relevant to technical performance. The greatest burden of preventable error can be traced to deficiencies in the process by which management expectations are supported. Recognizing this, the focus of clinical audit must be expanded. In particular, outcome assessment should be routine rather than sporadic, and should broadly encompass safety, effectiveness and efficiency. Devolving this responsibility to paraclinical groups is in itself insufficient. Quality and safety cannot be adequately addressed unless surgeons actively participate in audit cycle. Failure to meet this challenge in a transparent and timely manner potentially undermines the future of professional autonomy.

Influence of adhesive drapes on intraperitoneal volume and pressure during laparoscopy.

BACKGROUND: The influence of adhesive skin drapes on abdominal wall compliance during laparoscopy has not previously been studied. METHODS: The effect of removing an adhesive abdominal drape on intraperitoneal volume and pressure was studied in 15 patients undergoing a variety of laparoscopic procedures. The internal consistency of this data was evaluated by comparing the observed response to that which was predicted from analysis based on the theory of elasticity. RESULTS: Removal of an adhesive skin drape after induction of a 15-mmHg pneumoperitoneum was associated with changes in intraperitoneal pressure and volume. These changes were statistically significant, highly predictable and clinically relevant. CONCLUSIONS: On the basis of the present observations, we recommend that extensive coverage by adhesive drapes should be avoided for those patients or procedures in which elevated intraperitoneal pressure may be particularly deleterious.

Segmental infarction with graft dysfunction: an emerging syndrome in renal transplantation?

BACKGROUND: Segmental allograft infarction is a poorly characterized complication following renal transplantation. The present study was undertaken with the goal of defining the incidence, clinical characteristics, pathogenesis, and prognosis of this entity. METHODS: A retrospective study was performed, reviewing the renal scans performed on all renal transplant recipients at our institution, from January 1997 to January 2000. Segmental infarction was diagnosed on the basis of a significant elevation in lactate dehydrogenase (>500 U/l) together with a photopenic perfusion defect. In these patients, graft characteristics, operative details, clinical course, and long-term outcomes were evaluated. RESULTS: Segmental infarction was identified in 13 of 277 consecutive renal transplant recipients (4.7%). In nine recipients the onset of infarction occurred within 24 h after transplantation. All received marginal grafts, and in five recipients the transplant operation was complicated by major blood loss. Eight of these recipients exhibited primary non-function, or developed dialysis-dependent renal failure after the onset of infarction. In four patients, the onset of infarction occurred after 24 h (35 h to 10 days). One recipient demonstrated primary non-function, and renal function deteriorated after the onset of infarction in the remaining three. Overall, long-term graft function was impaired. Two allografts never functioned, and six recipients had nadir creatinine clearances below 60 ml/min. CONCLUSIONS: The pathogenesis of segmental infarction appears to be multi-factorial, reflecting the combination of an initiating anatomic lesion and potentiating thrombogenic milieu. Segmental infarction typically occurs in the early postoperative period, and prompt diagnosis is difficult to obtain. In view of this, prophylactic heparin may be warranted for those at highest risk. There was no correlation between the infarct area and the graft function, and the long-term graft function is compromised out of proportion to the extent of parenchymal loss. This finding highlights the role of predisposing factors, particularly marginal graft quality, in determining the functional outcome. Segmental infarction may be more frequently encountered as cadaveric organ shortages encourage greater use of marginal donor kidneys.