Urology

Case summary
A woman in her mid-70s was electively admitted to a tertiary hospital for a laparoscopic right nephroureterectomy. A low-grade urothelial carcinoma in the renal pelvis had been diagnosed by pyeloscopy and histological confirmation. The patient’s medical history included hypertension, atrial fibrillation, inguinal herniorrhaphy and a known right-sided diaphragmatic hernia. 

The operation began laparoscopically with a retroperitoneal approach but was converted to an open approach via a costal incision due to bleeding and difficult dissection. A lower lateral abdominal incision was performed for the distal ureterectectomy. Approximately 1L of blood was lost. The patient received four units of packed red blood cells, along with additional fresh frozen plasma and platelets. The patient was transferred to a surgical high dependency unit where normal recovery occurred for the first two days. The patient was transferred to the urology ward on day 2. 

Over days 3 to 5, the patient had nausea and vomiting with minimal bowel movements. On day 6, bowel function seemed to be improving. There was noted high drain outputs and wound discharge over the subsequent days. Nausea with vomiting was an ongoing issue, along with borderline oliguria. On day 10, a computed tomography (CT) scan of the abdomen was ordered to investigate the high wound and drain outputs. This reportedly showed a possible adhesive small bowel obstruction, with the diaphragmatic hernia looking similar to the preoperative imaging. Over the next few days there was little clinical change. 

On day 13, a medical emergency team (MET) call was placed for hypotension and worsening pain. Another CT scan showed increasing distension of the bowel contents in the diaphragmatic hernia. The patient was noted to be grossly acidotic (pH of 7.11). Shortly after the CT scan the patient had a witnessed cardiac arrest. Cardiopulmonary resuscitation was performed but the patient was unable to be resuscitated. The coroner’s report states that the most likely cause of death was bowel ischaemia due to the diaphragmatic hernia. 

Discussion 
The choice of operation was appropriate, given the pathology. The decision to convert to an open procedure was appropriate, as was the approach to the distal ureterectomy portion of the operation. The patient had an intermittently slow recovery. 

It could be argued that parenteral nutrition should have started earlier; however, the assessor does not believe that malnutrition was a factor in this patient’s death. Similarly, earlier identification of the cause of the high drain outputs and management of the fluid balance could have occurred. Whether the output was a urine leak or purely serum was not clearly established. Nevertheless, the assessor is uncertain that this would have greatly affected the outcome. 

The CT scan showed a probable small bowel obstruction. A general surgical opinion should have been sought at this point. The standard management of fluids, electrolyte management, parenteral nutrition and possible nasogastric tube (NGT) could have been considered. However, this did not occur. The notes state: ‘continue pro-kinetics’. Metoclopramide was prescribed regularly. Presumably the bowel ischaemia from the diaphragmatic hernia, which was the final cause of death, was made worse by the progression of the small bowel obstruction displacing more bowel content and increasing intra-abdominal pressure through the diaphragmatic hernia. Management at the time of peri-arrest was appropriate and not delayed (there was only a matter of hours between the MET call and subsequent death).

Clinical lesson
Earlier involvement of other surgical subspecialties in this case—specifically General Surgery—may have led to a different outcome. 

When a patient has a slow and intermittent recovery after major surgery, it is sometimes difficult to appreciate what is improvement and what is deterioration. This patient had a complicated operation, thus there should have been a higher degree of suspicion for potential postoperative issues. Nausea and vomiting for the first five days, persistent drain outputs, and reduced urine output and poor nutrition are red flags that should have prompted earlier radiological investigations. 

Regardless of the timing of the CT scan, General Surgery should have been consulted after the first scan. What difference this would have made to the outcome is difficult to know, but intra-abdominal decompression with a NGT would have likely helped this patient.