Carotid endarterectomy at Wellington Hospital.

AIM: To evaluate the morbidity and mortality of carotid endarterectomy at Wellington Hospital. METHOD: A retrospective study of all patients undergoing carotid endarterectomy at Wellington Hospital in the four year period from June 1987 to June 1991 was performed. Data was collected from chart review. A general practitioner questionnaire was sent to assess posthospitalisation outcome. RESULTS: One hundred and one carotid endarterectomies were performed in 89 patients. The overall combined 30 day mortality and disabling stroke rate in symptomatic patients was 5.1%. CONCLUSIONS: Carotid endarterectomy is performed at Wellington Hospital with an acceptable 30 day mortality and disabling stroke rate.

Femoral neuropathy following renal transplantation.

Femoral neuropathy is an uncommon complication that can occur subsequent to a number of abdominal and/or pelvic procedures. The neuropathy is usually evident immediately after the operation, but there may be some delay in diagnosis of the clinical problem. The neuropathy generally resolves completely after a period of time, but in some instances there may be a residual deficit. Four cases of femoral neuropathy are described which developed after operation for renal transplantation.

Endstage renal failure due to polycystic kidney disease managed by continuous ambulatory peritoneal dialysis.

Over a five and one half year period, four of nine patients with endstage renal failure due to polycystic kidney disease managed by continuous ambulatory peritoneal dialysis (CAPD) developed peritonitis following intestinal perforation. Two patients had colonic perforation associated with diverticular disease, one necrosis of the terminal ileum, and one acute appendicitis. Two of the patients died subsequent to these complications. The survivors had early transfer to haemodialysis. In contrast, over the same period, only two of 125 patients with renal failure due to other causes and managed by CAPD had acute intestinal perforation. In both cases this was associated with acute appendicitis. Both patients survived. All episodes of peritonitis in CAPD patients with polycystic kidneys demand very close monitoring, cessation of CAPD, and early surgical intervention. CAPD is relatively contraindicated in such patients.

Continuous ambulatory peritoneal dialysis and acute appendicitis.

Peritonitis in patients on continuous ambulatory peritoneal dialysis while usually due to contamination of the dialysis line by skin organisms may also be due to intra-abdominal pathology. Three cases are described in whom peritonitis was due to acute appendicitis. The recognition of an intra-abdominal source of infection in patients on CAPD is discussed, and surgical management stressed.

Living-related renal transplantation: Wellington experience.

Living-related renal transplantation as treatment for end-stage renal failure has not been used widely in Australasia. The results of such treatment in 31 patients at Wellington Hospital are described. The five year graft survival of 80.2% encourages us to continue with an active policy of living related transplantation.

Long-term experience of Thomas shunts on the iliac vessels.

Thomas shunts have been utilized 24 times in 20 patients to provide secondary vascular access in an often poor-risk group of patients, including children. Twenty of the shunts were on the iliac vessels. Five shunts are in current use, the longest having been in situ for 83 months. Another 13 shunts provided access until renal transplantation or death of the patient. Six shunts developed deep infection which usually extended to the Dacron-arterial anastomosis; the management of these infected iliac shunts was difficult and hazardous. No definite advantage for the iliac placement of shunts has been established, and its use at this site cannot be recommended. Although the Thomas shunt can provide good long-term access, our experience suggests that its use should be limited to that of a "shunt of last resort".

Gastrointestinal complications following renal transplantation.

Gastrointestinal complications occurred in 19 of 290 recipients (6.6%) of the 325 cadaveric renal allografts undertaken between September 1969 and December 1978. The mortality was 42.1%. Upper gastrointestinal complications, principally haemorrhage, occurred in 12 patients (4.1%), 11 of whom were males, usually within four months of transplantation, and often associated with acute rejection and its treatment. Surgery was required in five patients. The overall mortality was 16.7%. Colonic complications occurred in five patients (1.7%), four of whom died, the absence of specific signs having led to a significant delay in diagnosis. One patient died from abdominal vascular disease, and one from carcinoma of the gallbladder. To decrease the high morbidity and mortality, both medical and appropriate surgical prophylaxis for peptic ulceration and diverticular disease are necessary, as is an awareness of the transplant recipient's propensity to develop a gastrointestinal complication at any time, up to years after transplantation. Early recognition and treatment of such complications are essential.

Further experience with an external ureterovesical anastomosis in renal transplantation.

Review of the results of the use of an external ureterovesical anastomosis in 266 renal transplantations showed that urinary fistulae occurred in 34 patients (12.8%), and ureteric obstruction in six (2.3%). The fistulae were due to technical failure of the anastomosis in 13 patients, to distal ureteric necrosis in 13, to total ureteric necrosis in six, and to other causes in two. Fistula management was successful in 26 cases (76.5%), but multiple operations were often necessary and wound complications frequent (41.2%). The continuing high incidence of urological complications following ureterovesical anastomosis has resulted in increasing use of ureteroneocystostomy as the primary form of urinary reconstruction after transplantation in this unit.