Correspondence

Postoperative urinary retention Sir Postoperative urinary retention is a common complication after surgery but is rarely reported upon in the literature. The paper ‘An algorithm for the management of postoperative urinary retention’ by A. G. S . Tulloch (Br J Surg 1984; 71: 638-9) is therefore an important contribution. It has, however, a single defect. Transurethral catheterization is unpleasant for the patient and a potent cause of urinary tract infection. A superior and much neglected alternative is percutaneous suprapubic bladder drainage. In a prospective, randomized trial comparing transurethral with suprapubic catheterization for postoperative urinary retention in general surgical patients’, the urinary infection rate was 70 per cent with transurethral catheters and only 8 per cent with suprapubic drainage. Patients with suprapubic catheters were more comfortable than those catheterized via the urethra. Suprapubic catheters were more easily managed by the nursing staff. A great advantage of suprapubic catheterization is that the patient’s ability to void can be assessed without removing the catheter thus avoiding unpleasant, time-consum- ing and infection-provoking recatheterizations.

Suprapubic catheterization is recommended in all cases of post- operative urinary retention which do not respond to treatment with cholinergic or a-adrenergic blocking agents.

J. Hoffmann

Kommunehospitalet (her Farimagsgade 5 DK-1399 Copenhagen K Denmark

1. Shapiro I , Hoffmann J, Jersky J. A comparison of suprapubic and transurethral drainage for postoperative urinary retention in general surgical patients. Acta Chir Scand 1982; 148: 323-7.

Author’s response: reply from M r A Tulloch

Sir Dr Hoffmann’s letter is fair comment. However, it should be remem- bered that most patients with postoperative urinary retention require only a single catheterization. A urethral catheter can be passed by a nurse and will only cost a few pence. A suprapubic catheter costs ten pounds and needs a doctor to insert it.

None the less, the point Dr Hoffmann raises is a good one, and for patients who have failed to void within 24 h I sometimes modify the algorithm and use a suprapubic catheter releasing it every 6 h.

A. G. S. Tulloch

Wellington Clinical School of Medicine Department of Surgery Wellington Hospital Wellington New Zealand

Sir Two points need to be made about Mr Tulloch’s article.

Firstly, it is often difficult to exclude an element of mechanical obstruction in these patients without urodynamic tests. Secondly, the discomfort of repeated catheterization and the attendant risks of urethral trauma can be avoided by the use ofa suprapubic catheter. This can be spigoted to see if the patient is able to void and released if he or she is unable to do so. Residual volumes can be measured just as easily. The emotional crisis associated with each trial of a urethral catheter is also avoided.

M. C. Ormiston

Department of Surgical Studies The Middlesex Hospital London WIN 8AA, V K

Pre-operative biliary drainage Sir We read with interest the report of McPherson and colleagues (Br J Surg 1984; 71 : 371-5) on pre-operative percutaneous transhepatic biliary drainage. This report showed that in patients with malignant bile duct obstruction pre-operative drainage reduced serum bilirubin but did not improve either nutritional status or postoperative mortality. We have recently identified three independent factors which are related to postoperative mortality and morbidity after surgery for obstructive jaundice’. These were an initial haematocrit of 30 or less, which probably reflects a poor nutritional status, a bilirubin of over 200 pmol/l and a malignant obstructing lesion. Pre-operative drainage attacks only one of these factors and it is then not surprising in view of its own associated complications that the mortality after operation is not improved by this technique.

It is of interest, however, in the group undergoing pre-operative drainage, that postoperative gastrointestinal bleeding was not seen, whereas in the immediate laparotomy group three patients developed this complication (9.7 per cent). We have recently emphasized the importance of gastrointestinal bleeding after surgery for obstructive

The bleeding arises most commonly from gastric erosions, which occur due to a combination of endotoxaemia and reflux of bile into the stomach following the large choleresis after relief of obstructive jaundice4. Pre-operative drainage allows the increased output of bile following relief of the obstruction to be drained externally and possiply also reduces systemic endotoxaemia and appears one method of preventing these erosions.

This latter observation suggests that if its complications are ameliorated then pre-operative drainage may be of use in the selected group of patients at high risk of developing postoperative gastro- intestinal bleeding’.

* J. M. Dixon t C. P. Armstrong

* G. C. Davies

* University Department of Clinical Surgery Royal Infirmary Edinburgh U K

t Department of Surgical Gastroenterology Manchester Royal Injrmary Oxford Road Manchester UK

1. Dixon JM, Armstrong CP, Duffy SW, Davies GC. Factors affecting morbidity and mortality after surgery for obstructive jaundice: a review of 373 patients. Gut 1983; 24: 845-52. Dixon JM, Armstrong CP, Duffy SW, Elton RA, Davies GC. Upper gastrointestinal bleeding. A significant complication after relief of obstructive jaundice. Ann Surg 1984; 199: 271-5. Armstrong CP, Dixon JM, Taylor TV, Davies GC. Surgical experience of deeply jaundiced patients with bile duct obstruction. Br J Surg 1984; 71 : 2344. OConnor MJ, Schwartz ML, McQuarrie DG, Summer HW. Cholangitis due to malignant obstruction of biliary outflow. Ann Surg 1981; 193: 341-5.

2.

3.

4.

Exclusion of the oesophagus. Is this a dangerous manoeuvre? Sir I read with interest the article by Aylwyn Mannell and B. Epstein (Br J Surg 1984; 71: 422-5). My impression based on the experience’ in 11 cases of unresectable carcinoma of the oesophagus and one case of a benign stricture is in agreement that suture closure of both ends of excluded oesophagus is a safe procedure. None of the seven cases who survived for 3-10 months after operation and the case of benign stricture who is alive and well 5 years after bypass have had complications attributable to the closure of oesophageal ends. However, in my cases, CT scan was not used for follow-up evaluation and autopsy was not

Br. J. Surg., Vol. 71, No. 12, December 1984 1007