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BIOCHEMICAL DISTURBANCES AFTER TRANSPLANTATION of the URETERS by A 403 Postgrad Med J: first published as 10.1136/pgmj.30.346.405 on 1 August 1954. Downloaded from BIOCHEMICAL DISTURBANCES AFTER TRANSPLANTATION OF THE URETERS By A. W. WILKINSON, Ch.M., F.R.C.S. (Edin.) Senior Lecturer in Surgery, University of Aberdeen Complete diversion of the urinary flow to the there may be reflux of gas and faecal fluid from large bowel was first deliberately achieved in 185I the colon up the ureter. by Simon, who pr'oduced fistulae between the After transplantation all the urine is discharged lower ends of the ureters and the rectum in a boy into the colon and for up to a week after operation aged I3 years who had extroversion of the bladder, the bowel is drained through an indwelling rectal the patient survived for io months and died of tube; most patients become continent soon after the effects of infection; accidental fistulous con- removal of this tube. Subsequently they are able nection between the bladder and bowel may not to distinguish between fluid and solid contents have been uncommon before this time following and they empty the bowel at varying intervals perineal lithotomy. During the ensuing ioo years of from 2 to 5 hours during the day and rise once thousands of patients have had their ureters trans- or twice during the night. The combined output planted by more than 8o different techniques, the of water in urine and faeces is increased after thisProtected by copyright. chief indications being congenital anomalies such operation and the daily consumption of water as extroversion of the urinary bladder, some forms rises. of vesical fistulae and tuberculosis or carcinoma The typical biochemical disturbance is usually of the bladder. found in continent patients after complete diver- The reduction of infective complications fol- sion of their urine to the colon; it may come on lowing the introduction of the sulphonamide and at any time after operation, but appears to become antibiotic drugs and improvements in anaesthesia, commoner the longer the patient survives opera- blood transfusion and other types of fluid therapy tion and when renal function is impaired. The led to a marked reduction in the early mortality commonest type of disturbance is an elevation of and morbidity following this operation. It was the plasma chloride concentration which is usually recognized many years ago that patients who sur- accompanied by depression of the plasma, bicar- vived the operation for more than six months or bonate concentration, the so-called ' hyperchlo- a year were liable to suffer from recurrent bouts raemic acidosis'. Flocks (I949) found mild to of fever with loss of appetite, nausea and tiredness. moderate acidosis in 62 per cent. of patients'after http://pmj.bmj.com/ It has become increasingly evident that such dis- bilateral ureterosigmoidostomy. Ferris and Odel turbances cannot always be ascribed to ascending (1950) reviewed I41 patients and found that in infection and pyelonephritis and that a significant 79 per cent. the plasma chloride concentration part of the late post-operative disturbances have a was above normal, and that in 75 per cent. this chemical basis. had occurred within a year of operation; in 8o Until recently indirect anastomosis by either per cent. plasma bicarbonate was below the the Coffey (I9II) or Stiles (i9ii) method was by normal range and this had occurred within a year on September 29, 2021 by guest. far the commonest procedure; in this a length of of operation in 77 per cent. Two-stage transplan- ureter is laid in a tunnel made in the wall of the tations were done in i6 of their patients, the pelvic colon with the distal end of the ureter pro- plasma chloride concentration was raised in two jecting into the lumen of the colon. This results and' bicarbonate was lowered in five patients after in a valvular formation, but the lower end of the only one ureter had been transplanted. Jacobs ureter is liable to stenosis and the formation of and Stirling (1952) found that six months or calculi and concretions, with hydronephrosis and more' after bilateral ureterosigmoidostomy there dilatation of the ureter. During the'last six years was depression of plasma concentrations of bicar- a direct anastomosis of the Nesbit (1949) type, bonate in 8i per cent. and of potassium in 30 per in which the mucosa of the ureter is sutured to cent., and elevation of plasma concentrations of that of the colon, has been employed more fre- chloride in 48 per cent., urea in 76 per cent., and quently. The disadvantage of this method is that sodium in less than io per cent. of the patients on POSTGRADUATE MEDICAL 4i JOURNAL August 1954Postgrad Med J: first published as 10.1136/pgmj.30.346.405 on 1 August 1954. Downloaded from whom these observations were made. Contrary combined with the consumption of a normal full to the belief of Flocks-and of Foster, Drew and diet (Ferris and Odel, 1950). Even the disordered Wiss that the tendency to acidosis disappears after blood chemistry returns to within normal limits six months from operation, Jacobs and'Stirling in most cases if rectal drainage is continued for found that there was a progressive increase in the four or five days. Relief has also been obtained incidence and severity of the abnormality of the after unilateral nephrostomy or by caecostomy. bicarbonate, chloride and urea concentrations as Intravenous therapy seems seldom to have been time elapsed, and that acidosis and retention of necessary, except in cases complicated by severe urea were more common in patients whose renal potassium deficiency, but when patients are semi- function was poor. conscious or comatose, prompt relief usually Most of the patients show similar clinical depends on the early intravenous administration features. At first they are easily tired or feel of potassium salts. In most cases it is enough to weak and their appetite becomes poor; later there increase the fluid intake by persuading the patients may be nausea with revulsion for food and to drink up to six pints each day. vomiting, irritability and increasing drowsiness. Prevention of the disturbance has been attemp- From an early stage they notice a salty taste in ted by various measures and it is difficult to judge their mouths, later thirst becomes progressively how effective some of these have been. The most more severe. Most of them experience rectal important single measure is generally believed to urgency and frequency and the rectal fluid is be the regular emptying of the bowel at short unusually watery and its volume is increased. intervals of from two to three hours by day and Not all conform to this pattern and it is note- on one or two occasions during the night; this worthy that some patients may show severe dis- has been recommended regardless of whether the tortion of their blood chemistry without experi- author believed in selective absorption of chloride, encing any symptoms or alteration in fluid intake or back pressure and renal damage, or both, as or output. the cause of the acidosis. Regardless of surgicalProtected by copyright. Diefenbach, Fisk and Gibson (95i) drew belief, this advice seems to be good. There is attention to the possible importance of potassium fairly wide agreement, too, that the daily intake of deficiency in this syndrome when they reported chloride should be restricted, some advocate the case of a man whose presenting feature was a merely avoiding the addition of salt to the food complete flaccid quadriplegia with an associated on the plate, while others advise the full rigours low serum potassium concentration sixteen months of a ' salt-free ' diet. Those who have had the after bilateral transplantation of the ureters to misfortune to encounter patients with advanced the colon; in this case there was little alteration potassium deficiency in addition to acidosis in plasma bicarbonate, chloride or urea concen- naturally advocate the regular prophylactic ad- trations and there was a rapid response to the ministration of potassium citrate, in addition to intravenous administration of Darrow's solution. some form of chloride restriction. Because their Foster, Drew and Wiss (r95o) had already re- daily output of water is increased most patients ported a patient of theirs who, following two drink more after operation and this natural inclina-http://pmj.bmj.com/ premonitory disturbances marked by hiccup and tion should be strongly encouraged. acidosis, was admitted after rigors, anorexia and Broadly speaking, two explanations of hyper- weakness in a semi-conscious state with a low chloraemic acidosis have been proposed. The serum potassium concentration. Further cases of first ascribes it to selective absorption by the severe potassium deficiency complicating acidosis colonic mucosa of chloride from the urine in the have been reported by Wilkinson (1952), Parsons colon. The second explanation invokes impair- et al. (I952) and Creevy (I953). Amongst these ment of renal function, particularly that of the patients both the morbidity and mortality rates distal tubules, either by hydronephrosis and back- on September 29, 2021 by guest. are higher; Ieven when the potassium deficiency pressure, especially after the indirect type of is recognized and specially treated, recovery is anastomosis, or by pyelonephritis and ascending slower and complications are more common. infection, especially after the direct type of anasto- Anuria is not a common feature of the chemical mosis. Much conflicting evidence has been distuirbances after ureterosigmoidostomy and is adduced in support of
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