515 How Has ‘Montgomery’ Changed the Way We Document Risks on Consent Forms for Deceased Donor Kidney Transplantation? A Single-Centre Audit and Re-Audit

Introduction

The 2015 Montgomery case changed the remit of risk discussions required during the consent process. This audit reviewed single kidney transplant (SKT) consent forms to establish which risks are documented, and whether this legal case affected discussions. Following the audit, we introduced a pre-printed consent form and closed the audit loop by assessing its uptake.

Method

Trust paper consent forms for all patients aged 50+ who received a deceased donor SKT in our centre in 2014 (n = 58; pre-Montgomery) and 2017 (n = 70; post-Montgomery) were reviewed to see if 20 perceived ‘gold standard’ risks were documented. A pre-printed procedure-specific consent form including all gold standard risks was then introduced in July 2019. A re-audit reviewed the case-notes of every alternate recipient aged 50+ of a deceased donor SKT from 01/08/19 to 29/02/20 to check if the pre-printed form was used.

Results

Overall, 53% of the 20 ‘gold standard’ risks were documented in 2014 versus 59% in 2017 (p = 0.55). There was a 91% uptake of the pre-printed consent form.

Discussion

This audit established the importance of using a pre-printed consent form to standardise risk discussions We propose that pre-printed procedure-specific forms should be encouraged throughout the NHS to support ‘Montgomery-appropriate’ consent discussions.

Successful transplantation of kidneys from elderly circulatory death donors by using microscopic and macroscopic characteristics to guide single or dual implantation

Most kidneys from potential elderly circulatory death (DCD) donors are declined. We report single center outcomes for kidneys transplanted from DCD donors over 70 years old, using preimplantation biopsy Remuzzi grading to inform implantation as single or dual transplants. Between 2009 and 2012, 43 single transplants and 12 dual transplants were performed from elderly DCD donors. Remuzzi scores were higher for dual than single implants (4.4 vs. 3.4, p < 0.001), indicating more severe baseline injury. Donor and recipient characteristics for both groups were otherwise similar. Early graft loss from renal vein thrombosis occurred in two singly implanted kidneys, and in one dual-implanted kidney; its pair continued to function satisfactorily. Death-censored graft survival at 3 years was comparable for the two groups (single 94%; dual 100%), as was 1 year eGFR. Delayed graft function occurred less frequently in the dual-implant group (25% vs. 65%, p = 0.010). Using this approach, we performed proportionally more kidney transplants from elderly DCD donors (23.4%) than the rest of the United Kingdom (7.3%, p < 0.001), with graft outcomes comparable to those achieved nationally for all deceased-donor kidney transplants. Preimplantation biopsy analysis is associated with acceptable transplant outcomes for elderly DCD kidneys and may increase transplant numbers from an underutilized donor pool.

A registry analysis of damage to the deceased donor pancreas during procurement

Surgical injury to the pancreas is thought to occur commonly during procurement. The UK Transplant Registry was analyzed to determine the frequency of pancreatic injuries, identify factors associated with damage, and assess the impact of injuries on graft survival. Twelve hundred ninety-six pancreata were procured from donation after brain death donors, with 314 (19.5%) from donation after circulatory death donors. More than 50% of recovered pancreata had at least one injury, most commonly a short portal vein (21.5%). Liver donation, procurement team origin, hepatic artery (HA) arising from the superior mesenteric artery (SMA), and increasing donor BMI were associated with increased rates of pancreas damage on univariate analyses; on multivariate analysis only the presence of an HA from the SMA remained significant (p = 0.02). Six hundred forty solid organ pancreas transplants were performed; 238 had some form of damage. Overall, there was no difference in graft survival between damaged and undamaged organs (p = 0.28); however, graft loss was significantly more frequent in pancreata with arterial damage (p = 0.04) and in those with parenchymal damage (p = 0.05). Damage to the pancreas during organ recovery is more common than other organs, and meticulous surgical technique and awareness of damage risk factors are essential to reduce rates of procurement-related injuries.

Comparison of liver transplantation outcomes from adult split liver and circulatory death donors

BACKGROUND

Adult whole-organ donation after circulatory death (DCD) and 'split' extended right lobe donation after brain death (ERL-DBD) liver transplants are considered marginal, but direct comparison of outcomes has rarely been performed. Such a comparison may rationalize the use of DCD livers, which varies widely between UK centres.

METHODS

Outcomes for adult ERL-DBD livers and 'controlled' DCD liver transplantations performed at the Cambridge Transplant Centre between January 2004 and December 2010 were compared retrospectively.

RESULTS

None of the 32 patients in the DCD cohort suffered early graft failure, compared with five of 17 in the ERL-DBD cohort. Reasons for graft failure were hepatic artery thrombosis (3), progressive cholestasis (1) and small-for-size syndrome (1). Early allograft dysfunction occurred in a further five patients in each group. In the DCD group, ischaemic cholangiopathy developed in six patients, resulting in graft failure within the first year in two; the others remained stable. The incidence of biliary anastomotic complications was similar in both groups. Kaplan-Meier survival analysis confirmed superior graft survival in the DCD liver group (93 per cent at 3 years versus 71 per cent in the ERL-DBD cohort; P = 0·047), comparable to that of contemporaneous whole DBD liver transplants (93 per cent at 3 years). Patient survival was similar in all groups.

CONCLUSION

Graft outcomes of DCD liver transplants were better than those of ERL-DBD liver transplants. Redefining DCD liver criteria and refining donor-recipient selection for ERL-DBD transplants should be further explored.

Outcomes of simultaneous pancreas-kidney transplantation from brain-dead and controlled circulatory death donors

BACKGROUND

Organ scarcity has prompted increased use of organs from donation after circulatory death (DCD) donors. An early single-centre experience of simultaneous pancreas-kidney (SPK) transplantation from controlled DCD donors is described here.

METHODS

Outcomes of SPK transplants from DCD and donation after brain death (DBD) donors between August 2008 and January 2011 were reviewed retrospectively.

RESULTS

SPK transplants from 20 DCD and 40 DBD donors were carried out. Donor and recipient characteristics were similar for both groups, although pancreas cold ischaemia times were shorter in DCD recipients: median (range) 8·2 (5·9-10·5) versus 9·5 (3·8-12·5) h respectively (P = 0·004). Median time from treatment withdrawal to cold perfusion was 24 (range 16-110) min for DCD donors. There were no episodes of delayed pancreatic graft function in either group; the graft thrombosis rates were both 5 per cent. Similarly, there were no differences in haemoglobin A1c level at 12 months: median (range) 5·4 (4·9-7·7) per cent in DCD group versus 5·4 (4·1-6·2) per cent in DBD group (P = 0·910). Pancreas graft survival rates were not significantly different, with Kaplan-Meier 1-year survival estimates of 84 and 95 per cent respectively (P = 0·181).

CONCLUSION

DCD SPK grafts had comparable short-term outcomes to DBD grafts, even when procured from selected donors with a prolonged agonal phase.

Acute cytomegalovirus cholecystitis following renal transplantation

Solid organ transplant recipients are at risk of infection from cytomegalovirus (CMV). A wide range of disease is associated with CMV infection and we report two cases of CMV cholecystitis in patients following renal transplantation. Both patients presented with severe hemorrhagic cholecystitis, which required immediate resuscitation and emergency cholecystectomy. The diagnosis of CMV infection was confirmed in both cases using CMV-specific staining of the gallbladder. The diagnosis of CMV cholecystitis must be considered in all patients with upper abdominal pain after renal transplantation.

The double-spouted loop ileostomy

OBJECTIVE

A functional improvement to a conventional loop ileostomy is described with both proximal and distal limbs spouted reducing the number of patients with problematic ileostomies.

METHOD

The results of the National Prospective Audit of Stoma Complications for the hospital showed 14/15 of the traditional single loop ileostomies were identified as problematic. 21 patients were then studied prospectively, who underwent formation of a new type of loop stoma, in which both the proximal and distal limbs were spouted.

RESULTS

In the group of 21 patients with a double spouted loop ileostomy 3/21 had a problematic stoma. The number of appliances needed was significantly less than the single spouted group. The number of home visits by the stoma nurse and outpatient visits to the stoma therapy team at the hospital were also significantly less in the double spouted group.

CONCLUSION

This modification of the loop ileostomy, with both the proximal and distal ends of the bowel spouted has several advantages. The danger of spouting the wrong limb is eliminated, it can be created very easily via a trephine technique and spouting the distal limb reduces the leakage of mucus under the flange of the stoma bag, reducing the problems of poor appliance adhesion.

Predicting response to recombinant factor VIIa in non-haemophiliac patients with severe haemorrhage

BACKGROUND

Despite increasing use of recombinant factor VIIa (rFVIIa) in non-haemophiliac patients, it is unclear when rFVIIa might be effective.

METHODS

A single centre review of consecutive non-haemophiliac patients receiving rFVIIa for the management of severe haemorrhage. Treatments with rFVIIa were at a dose of 90 mug kg(-1) repeated at three hourly intervals at the clinicians' discretion.

RESULTS

Eighteen patients received rFVIIa. Six patients survived to discharge and 12 patients died in hospital. The median (range) Sequential Organ Failure Assessment (SOFA) score at the time of administration of rFVIIa for the group that survived was 8.0 (5-12) compared with the group that died 12.0 (7.0-14.0) (P=0.03). One of the patients who survived (17%) had organ failure at the time of rFVIIa administration compared with 11 of those who died (92%) (P=0.004). Fifteen patients survived long enough to consider a second dose of rFVIIa, one patient who survived to discharge needed more than one dose (1/6, 17%), compared with seven of those who later died in hospital (7/9, 78%) (P=0.04). The survivors had a significant reduction in blood product requirements after rFVIIa, while patients who died did not. Neither the prothrombin time nor the activated partial thromboplastin time before or after rFVIIa predicted survival.

CONCLUSIONS

High SOFA score and failure to respond to one adequate dose of rFVIIa appear to identify patients with poor prognosis. These observations may help in determining when rFVIIa treatment is likely to be futile.

Overnight Intensive Recovery: Elective Open Aortic Surgery Without a Routine ICU Bed

OBJECTIVES

Most patients are managed on the intensive care unit (ICU) after elective open aortic surgery. We preoperatively identify patients suitable for extubation in theatre with overnight management in theatre recovery before discharge back to the ward (overnight intensive recovery (OIR)). The safety of this was investigated.

DESIGN

Retrospective case note analysis of all patients who underwent EOAS from 1998 to 2002, recording in-hospital morbidity and mortality. Physiological and operative severity score for the enUmeration of mortality and morbidity (POSSUM) data were collected prospectively.

METHODS

Patients were divided into those selected for OIR and those booked for elective ICU admission. Observed morbidity and mortality data were compared with predicted outcomes generated by Portsmouth-POSSUM and POSSUM equations.

RESULTS

Hundred and fifty-two out of 178 patients used OIR; 155 patients had abdominal aortic aneurysm (AAA) repair. The elective ICU group had significantly higher anaesthetic risk scores (ASA grade), larger AAA, greater intraoperative blood loss and longer operations. In the OIR group, ten patients (7%) needed ICU admission within 48h postoperatively. Complications occurred in 85/152, with two deaths. There was no excess morbidity or mortality in the OIR group (predicted 95% CI 83-105 and 5-17, respectively).

CONCLUSION

Most patients having elective open aortic surgery can be managed safely using OIR.

Obturator canal fat plug: a pre-hernial condition?

Although obturator hernias are rare, they are associated with a high mortality, as diagnosis is often delayed and the condition tends to occur in the elderly. Previous researchers have postulated that obturator hernias begin with invagination of pre-peritoneal fat through the pelvic orifice of the obturator canal, forming a fat plug. With chronically raised intra-abdominal pressure, or sudden weight loss, this can progress to a clinical obturator hernia. We dissected 95 Caucasian cadaveric hemi-pelvises (47 males; 48 females) in order to investigate the frequency of fat plugs and examine the validity of the current hypothesis regarding obturator hernia pathogenesis. The mean age (SD) of the specimens was 83 (9) years, with 48 (24 male; 24 female) from the left side and 47 (23 male; 24 female) from the right side. A fat plug was found in 21 canals (22%); the majority were female (71%, P = 0.03), and right sided (62%, P = 0.20). The mean (SD) length was 20.0 mm (6.3 mm), with mean diameter 5.9 mm (1.8 mm). A shallow peritoneal dimple was also found overlying fat plugs in two specimens. No visceral herniations were found. The sex and side distribution of the obturator canal fat plugs we found are similar to those of obturator hernias reported in the literature, supporting the hypothesis that fat plugs are pre-hernial. It is unlikely that fat plugs are a high-risk condition, but dimples over these plugs may be a marker of potential hernia formation.

Breast reconstruction in the United Kingdom and Ireland

BACKGROUND

Although it is becoming more common, previous surveys have identified concerns regarding the safety of immediate reconstruction following mastectomy. The aims of this study were to define current practice of breast reconstruction in the UK and Ireland, and to identify the characteristics of surgeons who use immediate breast reconstruction.

METHODS

: A postal questionnaire survey of 498 consultant breast surgeons in the UK and Ireland was performed in January 2000.

RESULTS

There were 376 responses (response rate 76 per cent). Eighty-eight per cent of surgeons 'always' or 'usually' discuss reconstruction with patients due to undergo mastectomy; clinicians with a heavy caseload were significantly more likely to discuss it (odds ratio (OR) 18.45 (95 per cent confidence interval 1.99 to 171.07)). The majority of respondents (57 per cent) preferred delayed to immediate breast reconstruction; 70 per cent believed that immediate reconstruction has disadvantages, most commonly that it interferes with adjuvant therapy (56 per cent). Older surgeons were significantly less likely to perform immediate reconstruction (OR 5.18 (2.21 to 12.11)), and were significantly more likely to believe that immediate breast reconstruction has disadvantages (OR 2.02 (1.01 to 4.05)). Surgeons from Ireland were less likely to discuss and perform breast reconstruction (OR 0.20 (0.10 to 0.43) and 0.27 (0.12 to 0.60) respectively), or to have access to a plastic surgeon (OR 0.22 (0.11 to 0.44)).

CONCLUSION

: Significant variation exists in the delivery of breast reconstruction after mastectomy in the UK and Ireland. The age, workload and personal characteristics of the surgeon are important in determining reconstructive practice.

The control of heartwater on large-scale commercial and smallholder farms in Zimbabwe

As part of a series of studies associated with the development of improved vaccines for heartwater (a tick-borne disease of ruminant livestock caused by Cowdria ruminantium), field surveys were carried out to assess losses associated with the disease and the costs associated with controlling it in the two main agro-ecological zones of Zimbabwe (lowveld and highveld) where heartwater is believed to be endemic and epidemic, respectively. In each zone, a cross-sectional study was performed in the main farming systems (smallholder (SH) and large-scale commercial (LSC) beef and dairy), followed by longitudinal studies in the same sectors to improve data accuracy for some parameters. Suspected heartwater-specific mortality in cattle was similar in all LSC sectors (p = 0.72) accounting for a median 1% mortality risk. Heartwater-specific mortality in SH areas was not assessed due to poor diagnostic ability of the farmers. Few LSC farms and SH households kept sheep; suspected heartwater-specific mortality in LSC sheep was 0.8% in the lowveld and 2.4% in the highveld. Goats were a major enterprise in SH areas but not on LSC farms. Suspected heartwater mortality in LSC goats was 0.8% at one site in the highveld and 17.5% on a farm in the lowveld. Application of acaricides was the major control method for heartwater and other tick-borne diseases on both SH and LSC farms. On LSC farms, plunge dipping was used most frequently and the number of acaricide applications ranged widely between 3 and 52 per year. The total cost of acaricides per head per annum was higher in highveld dairies than in highveld and lowveld beef enterprises (p = 0.03). In SH areas, cattle plunge dipping was conducted by the government with an average frequency of 8 +/- 2 (sd) immersions per annum in both the lowveld and highveld. The type of tick control on sheep and goats in all production systems was highly variable (ranging from none to hand removal or intensive acaricide treatment). Suspected heartwater cases on LSC farms were treated with tetracyclines; treatment was not reported in SH areas. Reported treatment costs were high (median Z$ 120) and highly variable (range Z$-833). Vaccination against heartwater with the live, blood-based vaccine was reported on only one LSC farm. LSC farms applying acaricide 30 or more times per year reported higher morbidity (p < 0.0001) and mortality (p < 0.0001) than farms applying acaricides less than 30 times a year. This finding supports the use of reduced tick control in the management of heartwater in Zimbabwe.