Cs Rutter

Junior doctor‐led practical prescribing course

Several authors have studied the transition from medical student to junior doctor. There have been several problems identified, one being prescribing. Junior doctors have been found to be the cause of most of the prescription errors in hospitals. These authors suggest improvements in prescribing teaching, and several describe their own innovations seeking to correct these problems.

Urgent Multivisceral Transplantation for Widespread Splanchnic Ischemia

BACKGROUND Multivisceral transplantation (transplantation of the stomach, intestine, liver, and pancreas) is usually undertaken as a semi-elective procedure after thorough assessment in patients who have intestinal failure with cirrhosis, cirrhosis with portomesenteric venous thrombosis, or tumors such as desmoids involving the liver and mesentery. STUDY DESIGN Data were collected prospectively from the time of referral and held in a central database. We used it to report the first cases of urgent multivisceral transplantation (MVT) in patients with widespread splanchnic ischemia (occlusion of the celiac axis and superior mesenteric artery) resulting in small bowel infarction and hepatic failure. RESULTS Three women (ages 33, 48, and 50 years) were referred to our center with superior mesenteric artery and celiac axis occlusion. All other modes of treatment had been considered and/or attempted. After transfer to our institution, all patients were assessed, urgently listed, and underwent transplantation in 10, 7, and 5 days. Two patients are still alive after 2 years and 1 died at 8 months from multiorgan failure due to infections and graft vs host disease. CONCLUSIONS Treatment options for patients presenting with widespread splanchnic ischemia with hepatic and intestinal failure/infarction were previously limited to salvage surgery and attempted revascularization. In situations in which these failed, the only previous option would have been palliation. In selected cases, we propose that urgent multivisceral transplantation should be considered as a life-saving treatment. This represents a previously unreported indication for MVT.

Simultaneous Intestinal and Kidney Transplantation in Adults

ABSTRACT Aim of the study: Intestinal transplantation (IT) is a life-saving procedure for carefully selected patients with intestinal failure. We evaluated patients who had undergone simultaneous intestinal and kidney transplantation (SIKT) to determine whether UK guidelines for inclusion of a renal allograft (dialysis dependent or estimated glomerular filtration rate ((eGFR)) < 45 ml/min/1.73 m2) are justified. Methods: A single centre analysis was undertaken of adults undergoing IT at the Cambridge Transplant Centre between December 2007 and January 2016. A prospectively maintained database was used to identify SIKT recipients and determine outcomes. Results: Over this period, 63 intestinal transplants were performed. Seven (11.1%) recipients received a SIKT. Five were pre-dialysis (median eGFR 29 ml/min/1.73 m2, range 16–36 ml/min/1.73 m2). One recipient was on dialysis, and one needed bilateral nephrectomy at transplant. There were no primary kidney allograft failures and at three months, the median eGFR (55 ml/min/1.73 m2 range 39–124) was similar to recipients of IT alone (median eGFR 56 ml/min/1.73 m2 range 17–143 ml/min/1.73 m2). Two recipients required dialysis due to sepsis related kidney injury and died from multi-organ failure (20 and 63 months). Two died with a functioning renal transplant (10 and 15 months). The remaining three patients are alive at follow up (12–96 months) with an eGFR of 20–45 ml/min/1.73 m2. Conclusion: Patients with significant renal impairment (eGFR <45 ml/min/1.73 m2), and receiving dialysis may benefit from SIKT. Patient survival and renal function are broadly comparable to those undergoing IT alone. Further studies are required to justify allocation of a kidney to this complex high risk group.

PWE-232 Indications for intestinal and multivisceral transplantation at addenbrooke–s hospital, cambridge

Introduction Small intestinal transplantation was first undertaken in Cambridge in 1991. All patients are discussed at the National Adult Intestinal Transplantation Forum (NASIT) and indications for transplantation agreed prior to listing. We present the indications for intestinal and multivisceral transplantation in patients referred to our unit over the last 8 years. Method A prospectively maintained database records the indications for all patients listed for intestinal and multivisceral transplantation. This database was used to identify indications for patients transplanted between January 2006 and December 2014. NASIT and International Transplant Registry indications were reviewed. Results 56 transplant procedures were performed on 50 patients - 27 (48%) multivisceral (MV); 6 (11%) liver/small intestine (LSB); 8 (14%) modified multivisceral and 15 (27%) small intestine. 6 patients were re-transplanted due to acute cellular rejection not amenable to medical therapy (n = 3), intestinal graft ischaemia (n = 2) and primary non-functioning liver graft (n = 1). The predominant NASIT indications for transplantation were intestinal failure associated liver disease (IFALD) (29%); need for multi-organ transplant (liver with portomesenteric venous thrombosis) (20%); loss of venous access for HPN (14%); widespread mesenteric arterial insufficiency (11%); FAP/desmoids (5%); catheter-related blood stream infections (5%) and acute cellular rejection (5%). 54% of patients had short bowel, the causes of which were ischaemia (57%), Crohn’s disease (27%), volvulus (3%), trauma (3%) and other (10%). Conclusion Cambridge is the only UK centre performing adult multivisceral transplants. IFALD remains the predominant indication for multivisceral transplantation but the number of referrals for this indication is not increasing year on year. This may reflect improved management of patients with Type 3 intestinal failure on home parenteral nutrition, with a focus on quality outcomes and reducing complications. We have observed an increase in patients referred with portomesenteric venous thrombosis which precludes an isolated liver graft. Subsequently we have performed more MV or LSB transplants over the last 2 years in a group of patients with multiple co-morbidities, whose management is more complex. Another emerging indication is widespread mesenteric arterial insufficiency, resulting in 5 urgent transplants during the last 2 years (6 in total). Treatment options for these patients have been very limited in the past and MV transplantation offers a potential new management strategy. Disclosure of interest None Declared.

OC-033 Outcomes following small intestinal and multivisceral transplantation at addenbrooke’s hospital, cambridge

Introduction Small intestinal transplantation was first undertaken in Cambridge in 1991 and with advances in immunosuppression agents, outcomes have improved. We present our survival figures from 2006 to 2014. Method A prospective database is used to record all patients who undergo small intestine (SB), liver/small intestine (LSB), modified multivisceral (MMVT – intestine and stomach) and multivisceral (MVT – intestine, stomach and liver) transplantation at Addenbrooke’s Hospital. All grafts may also contain pancreas, kidney and colon. The NHS Blood and Transplant service derived Kaplan-Meier survival curves for all patients undergoing their first transplant procedure between January 2006 and December 2014. Results 56 transplant procedures were performed on 50 patients (6 were re-transplanted, all are still alive). 1-year survival in patients transplanted is 92% (SB), 83% (MMVT), 67% (LSB) and 69% (MVT). 5-year survival is 92% (SB), 63% (MMVT) and 27% (MVT) – this data is not available for LSB transplants due to small numbers and follow-up duration of only 14 m. These data compare favourably with international transplant registry 5-year survival figures of 59% (SB) and 22% (MVT).1Overall 1-year survival for all patients transplanted in our unit is 76% and 5-year survival is 46%. Conclusion Cambridge is one of 2 UK centres performing intestinal transplantation in adults and we are undertaking an increasing number of procedures – 16 in 2013 and 10 in 2014. We are particularly encouraged by our 92% 5-year survival in patients undergoing isolated SB transplantation and would advocate early referral for assessment in patients with Type 3 intestinal failure who develop complications from home parenteral nutrition. Colon is routinely included in the graft to aid fluid balance and does not preclude regular endoscopic surveillance for rejection. We have performed continuity surgery in a number of patients post transplant (transplanted colon to native colon anastomosis) with good outcomes and no anastomotic leaks. Due to complications of the oesophagogastric anastomosis, gastroparesis and increased morbidity and mortality of MVT we are moving towards performing more LSB transplants and will monitor outcomes with interest. Detailed pre-operative assessment, individualised procedures, patient optimisation and an emphasis on the multidisciplinary team are essential when managing these complex patients. Disclosure of interest None Declared. Reference Intestinal Transplant Registry (ITR) – http://www.intestinaltransplant.org/itr/(Accessed May 2014)

PWE-233 An organic marine hydrocolloid acts as a stool thickener in patients with diarrhoea and enteric hyperoxaluria due to short bowel syndrome

Introduction Calcium oxalate is the predominant component of most renal stones; they occur in 10% of patients with bile salt and/or fatty acid malabsorption due to enteric hyperoxaluria1. Patients who have undergone extensive ileal resection, jejuno-ileal bypass surgery or a Roux-en-Y gastric bypass, whose colon remains in continuity, are at a greater risk of developing enteric hyperoxaluria. It is managed by dietary restriction of oxalate and fat, a high calcium intake, and increasing water intake to ensure a daily urine volume of more than 3 litres. The latter is difficult to achieve in patients with short bowel syndrome. Ox-Absorb® is an organic marine hydrocolloid derived from plants and seaweed and was first described in the 1980’s as a promising new treatment for enteric hyperoxaluria. It was also noted that it thickened stools and reduced stool frequency. Ox-Absorb®is unlicensed in the UK and imported on a named patient basis from the USA. When it was used by the renal physicians at North Bristol NHS Trust to reduce oxalate stone formation, patients reported beneficial effect on stool frequency and consistency. Method We conducted a retrospective case note review of all patients prescribed Ox-Absorb® in North Bristol NHS Trust. Drug history, weight, change in stool consistency and urinary oxalate levels were documented. Net reduction in tablet burden and a cost analysis of the use of Ox-Absorb®were calculated. Results 8 patients were prescribed Ox-Absorb®. 7/8 patients reported thicker stools and reduced stool frequency and there was a reduction in tablet burden (mean 8.6 tablets; range 2 to 22; median 7). Mean net reduction of tablets was 22% (median 29%). There was a cost reduction in 3/8 patients, all of whom were taking higher doses of loperamide, codeine phosphate and Creon®(£1.09, £0.57 and £0.15 per day). 3/8 patients had to stop the drug due to supply problems and all noted worsening in diarrhoea symptoms which improved on restarting the drug. Urinary oxalate was reduced in only 2/8 patients. Conclusion In this small cohort, patients who were prescribed Ox-Absorb® reported thicker stools and were able to reduce their net anti-diarrhoeal tablet burden. This was cost effective in patients taking higher doses of loperamide, codeine and Creon®. We believe a larger study of this drug relative to standard treatments is justified. Disclosure of interest None Declared.

PTH-125 Survival Following Intestinal And Multivisceral Transplantation At Addenbrooke’s Hospital, Cambridge, Uk

Introduction Small intestinal transplantation (SBT) was first undertaken in the UK in Cambridge in 1991. Since the introduction of new immunosuppressive agents around the millenium, results have improved and we present our experience over the last 10 years. Since 2003, 47 tranplants have been performed on 43 patients. Grafts include small bowel or small bowel/colon (SBT), liver and small bowel (LSBT), modified multivisceral (MMVT – small bowel, stomach, pancreas, no liver) and multivisceral (MVT – intestine, stomach, pancreas and liver) transplantation. Cambridge is the only UK centre offering MVT in adults. Methods A review of all patients who underwent small intestine and multivsiceral transplantation at Addenbrooke’s Hospital between 2003 and 2013. Kaplan-Meier survival data are shown for each group of organs transplanted. Results Five year survival for all patients transplanted is 77%. Survival curves for each organ group transplanted is graphed below: Conclusion Five year survival in our patients transplanted since 2003 is 100% for SBT and LSBT and 65% for MVT, compared with international registry survival figures of 59% (SBT and LSBT combined) and 22% respectively. In recent years we have also experienced an increase in the number of urgent transplants performed and these patients are often critically unwell at the time of surgery. Our centre undertakes a relatively large number of procedures and this, coupled with a particular focus on multidisciplinary team working, may account in part for our favourable survival figures. Abstract PTH-125 Figure 1 Disclosure of Interest None Declared.

PTH-124 Changes In The Indications For Referral Of Adults For Intestinal And Multivisceral Transplantation

Introduction Small bowel transplantation (SBT) was first performed in the UK in Cambridge in 1991. Recipients mow undergo small bowel (SBT), liver and small bowel (LSBT), modified multivisceral (MMVT – small bowel, stomach, pancreas, no liver) and multivisceral (MVT – intestine, stomach, pancreas and liver) transplantation. Cambridge is the only UK centre offering MVT in adults. The main indications for referral to a transplant centre are: Irreversible intestinal failure plus life threatening complications of parenteral nutrition (PN). Extensive surgery requiring partial or complete evisceration. Methods Prospective data was collected from all patients who underwent intestinal and multivisceral transplantation at Addenbrooke’s Hospital between 2003 and 2013. All patients are discussed and indications for transplantation agreed prior to listing at NASIT (National Adult Small Intestinal Transplant forum). Results 47 transplants were performed on 43 patients; 4 procedures (9%) were re-transplantation for a primary non-functioning graft (2/4) or acute rejection (2/4). The indications for transplant are presented below: Abstract PTH-124 Table 1 Short bowel (%) Motility disorder (%) Re-transplant (%) Desmoids (%) Other (%) Total 2006 1 (100) 1 2007 1 (50) 1 (50) 2 2008 1 (30) 2 (70) 3 2009 3 (60) 1 (20) 1 (20) 5 2010 5 (83) 1 (17) 6 2011 6 (75) 2 (25) 8 2012 2 (33) 1 (17) 1 (17) 2 (33) 6 2013 8 (50) 3 (19) 1 (6) 1 (6) 3 (19) 16 Sixteen transplants were performed in 2013 - MVT (57%), SBT (31%), LSB (6%) and MMVT (6%). 50% of these were due to short bowel - arterial ischaemia (50%), Crohn’s (26%), venous ischaemia (12%) and other short bowel (12%). Colon is now routinely included in the graft to aid fluid balance and does not preclude endoscopic surveillance for rejection. Conclusion The number of small bowel and multivisceral transplants performed over the last 10 years has increased, and more than doubled in 2013. Short bowel remains the commonest indication for transplantation. Historically this was mainly due to Crohn’s disease however in 2013, it was mainly due to ischaemia; this trend was reflected worldwide. In our cohort, an increase in acute arterial thromboses causing coeliac/mesenteric ischaemia resulted in 3 recipients being listed urgently for MVT. There has also been an increase in the number of patients referred with portal vein thromboses extending into the superior mesenteric vein, precluding liver transplant alone. Disclosure of Interest None Declared.