Geert Roeyen

Pancreaticojejunostomy versus pancreaticogastrostomy reconstruction after pancreaticoduodenectomy for pancreatic or periampullary tumours: a multicentre randomised trial

BACKGROUND Postoperative pancreatic fistula is the leading cause of death and morbidity after pancreaticoduodenectomy. However, the best reconstruction method to reduce occurrence of fistula is debated. We did a multicentre, randomised superiority trial to compare the outcomes of different reconstructive techniques in patients undergoing pancreaticoduodenectomy for pancreatic or periampullary tumours. METHODS Patients aged 18-85 years with confirmed or suspected neoplasms of the pancreas, distal bile duct, ampulla vateri, duodenum, or periampullary tumours were eligible for inclusion. An internet-based platform was used to randomly assign patients to either pancreaticojejunostomy or pancreaticogastrostomy as reconstruction after pancreaticoduodenectomy, using permuted blocks with six patients per block. Within each centre the randomisation was stratified on the pancreatic duct diameter (≤3 mm vs >3 mm) measured at the time of surgery. The primary endpoint was the occurrence of clinical postoperative pancreatic fistula (grade B or C) as defined by the International Study Group on Pancreatic Fistula. The study was not masked and analyses were done by intention to treat. Patient follow-up was closed 2 months after discharge from the hospital. This study is registered with ClinicalTrials.gov, number NCT00830778. FINDINGS Between June, 2009, and August, 2012, we randomly allocated 167 patients to receive pancreaticojejunostomy and 162 to receive pancreaticogastrostomy. 33 (19.8%) patients in the pancreaticojejunostomy group and 13 (8.0%) in the pancreaticogastrostomy group had clinical postoperative pancreatic fistula (OR 2.86, 95% CI 1.38-6.17; p=0.002). The overall incidence of postoperative complications did not differ significantly between the groups (99 in the pancreaticojejunostomy group vs 100 in the pancreaticogastrostomy group), although more events in the pancreaticojejunostomy group were of grade ≥3a than in the pancreaticogastrostomy group (39 vs 35). INTERPRETATION In patients undergoing pancreaticoduodenectomy for pancreatic head or periampullary tumours, pancreaticogastrostomy is more efficient than pancreaticojejunostomy in reducing the incidence of postoperative pancreatic fistula. FUNDING Funding Johnson & Johnson Medical Devices, Belgium.

Organ Procurement After Euthanasia: Belgian Experience

Euthanasia was legalized in Belgium in 2002 for adults under strict conditions. The patient must be in a medically futile condition and of constant and unbearable physical or mental suffering that cannot be alleviated, resulting from a serious and incurable disorder caused by illness or accident. Between 2005 and 2007, 4 patients (3 in Antwerp and 1 in Liège) expressed their will for organ donation after their request for euthanasia was granted. Patients were aged 43 to 50 years and had a debilitating neurologic disease, either after severe cerebrovascular accident or primary progressive multiple sclerosis. Ethical boards requested complete written scenario with informed consent of donor and relatives, clear separation between euthanasia and organ procurement procedure, and all procedures to be performed by senior staff members and nursing staff on a voluntary basis. The euthanasia procedure was performed by three independent physicians in the operating room. After clinical diagnosis of cardiac death, organ procurement was performed by femoral vessel cannulation or quick laparotomy. In 2 patients, the liver, both kidneys, and pancreatic islets (one case) were procured and transplanted; in the other 2 patients, there was additional lung procurement and transplantation. Transplant centers were informed of the nature of the case and the elements of organ procurement. There was primary function of all organs. The involved physicians and transplant teams had the well-discussed opinion that this strong request for organ donation after euthanasia could not be waived. A clear separation between the euthanasia request, the euthanasia procedure, and the organ procurement procedure is necessary.

Abdominal aortic aneurysm with lumbar vertebral erosion in Behçet's disease. A case report and review of the literature

Although Behqets disease (BD) has been known for 2000 years, it was named after the author who described it properly in 1937.1 Recurrent oral or genital aphtosis and uveitis are the main characteristics, but involvement of other organ systems frequently occurs: i.e. the joints, the gastrointestinal tract, the central nervous system and also the vascular system. A 57-year-old man with known BD was found to have an abdominal aortic aneurysm together with a huge posterior pseudoaneurysm eroding the lumbar vertebrae. Although erosion of the lumbar vertebrae due to an abdominal aortic aneurysm has been reported, 2 the association with Beh~ets disease is unique. Diagnostic and therapeutic aspects of this unusual association are discussed, and a review of the literature presented.

Tacrolimus-related polyneuropathy: Case report and review of the literature

Patients, in particular recipients of orthotopic liver transplants, receiving the immunosuppressant tacrolimus (FK-506), are at risk for developing central neurotoxic adverse events. We report the occurrence of a tacrolimus-induced peripheral neurotoxic event, i.e. pure motor axonal polyneuropathy of the lower limbs in a 44-year-old woman, 9 days after combined orthotopic liver and pancreas transplantation. She was treated for 5 days with intravenous immunoglobulins. Partial recovery followed over months to years. An overview of all 11 reported FK506-associated polyneuropathies is given.

Kidney donation after circulatory death in a country with a high number of brain dead donors: 10-year experience in Belgium

Worldwide shortage of standard brain dead donors (DBD) has revived the use of kidneys donated after circulatory death (DCD). We reviewed the Belgian DCD kidney transplant (KT) experience since its reintroduction in 2000. Risk factors for delayed graft function (DGF) were identified using multivariate analysis. Five‐year patient/graft survival was assessed using Kaplan–Meier curves. The evolution of the kidney donor type and the impact of DCDs on the total KT activity in Belgium were compared with the Netherlands. Between 2000 and 2009, 287 DCD KT were performed. Primary nonfunction occurred in 1% and DGF in 31%. Five‐year patient and death‐censored graft survival were 93% and 95%, respectively. In multivariate analysis, cold storage (versus machine perfusion), cold ischemic time, and histidine‐tryptophan‐ketoglutarate solution were independent risk factors for the development of DGF. Despite an increased number of DCD donations and transplantations, the total number of deceased KT did not increase significantly. This could suggest a shift from DBDs to DCDs. To increase KT activity, Belgium should further expand controlled DCD programs while simultaneously improve the identification of all potential DBDs and avoid their referral for donation as DCDs before brain death occurs. Furthermore, living donation remains underused.

Future remnant liver function estimated by combining liver volumetry on magnetic resonance imaging with total liver function on 99mTc-mebrofenin hepatobiliary scintigraphy: can this tool predict post-hepatectomy liver failure?

INTRODUCTION Posthepatectomy liver failure (PHLF) is a major complication after hepatectomy with a high mortality rate and is likely to happen in insufficient liver remnant. We hypothesize that assessment of the estimated future liver remnant function (eFLRF), combining future remnant liver volume (FLRV) with total liver function (TLF), is an accurate formula for prediction of PHLF. METHODS 88 patients undergoing hepatectomy were included. The ratio of the future liver remnant volume (FLRV%) was measured on MRI. TLF was estimated by liver clearance of (99m)Technetium (Tc)-mebrofenin on hepatobiliary scintigraphy (HBS). eFLRF was calculated by multiplying FLRV% by TLF. Cut-off values of FLRV% and eFLRF predicting PHLF, were defined by receiver-operating-characteristic (ROC) analysis. RESULTS PHLF occurred in 12 patients (13%). Perioperative mortality was 5/12 (41%). Multivariate analysis showed that FLRV% cut off at 40% was not an independent predictive factor. eFLRF cut off at 2.3%/min/m(2) was the only independent predictive factor for PHLF. For FLRV% vs. eFLRF, positive predictive value was 41% vs. 92% and Odds Ratio 26 vs. 836. CONCLUSION FRLF measured by combining FLRV% and TLF is a more valuable tool to predict PHLF than FLRV% alone. The cutoff of eFLRF can be used in clinical decision making.

Diabetes mellitus and pre-diabetes are frequently undiagnosed and underreported in patients referred for pancreatic surgery. A prospective observational study

OBJECTIVE Previous reports on the prevalence of diabetes in pancreatic cancer and chronic pancreatitis patients are based on inconsistent and equivocal criteria. The objective of this study is to prospectively assess with conclusive methods the preoperative glycaemic status of patients undergoing pancreatic surgery. We hypothesise that most of those patients are unaware of these disturbances in glycaemic status and that the prevalence is underestimated. METHODS During the last 2 years, patients referred for pancreatic surgery and without history of diabetes underwent a prospective preoperative screening with an oral glucose tolerance test (OGTT) and determination of the glycated haemoglobin level (HbA1c). The American Diabetes Associations criteria for diabetes and pre-diabetes were used. Beta-cell function and insulin sensitivity were calculated using HOMA2 indices. Impact on surgical policy has been scored. RESULTS 99 patients were screened, 25 had a history of diabetes. The other 74 underwent an OGTT and HbA1c determination. Only 29.7% (22/74) had a normal glucose metabolism, while 8.1% (6/74) had impaired fasting glucose, 21.6% (16/74) had impaired glucose tolerance, 6.7% (5/74) had a combination of both, and 33.8% (25/74) had undiagnosed diabetes. In 15.2% (15/99) of the patients, this preoperative assessment had an impact on surgical policy. CONCLUSIONS 77.7% of patients referred for pancreatic surgery had some degree of (pre-)diabetes. In 70.3% of patients without a history of diabetes, these disturbances in glucose metabolism are a new finding. Physicians involved in pancreatic surgery should be aware of the frequently undiagnosed (pre-)diabetes and actively check for it. This prevalence is underestimated.

Belgian experience of DCD kidney transplantation

O-098 – Table 1. LTx in patients with incidental PPHT Indication labMELD mPAP at induction (mmHg) hospital stay (days) Medical treatment post-LTx Outcome Follow-up (months) m/54yr Post-ethyl cirrhosis 32 44 38 Spontaneous resolution Alive and well 15 f/37yr Post-ethyl cirrhosis 26 26 40.6 42 Epoprostenol IV during 13 months Alive and well 13 f/62yr HBV 31 46.7 92 Sildenafil PO during 9 months Alive and well 12 m/61yr Post-ethyl cirrhosis and HCC 12 36.7 6 Extra-corporeal membrane oxygenation †6d post-LTx – f/67yr Sarcoidosis 36 34.3 – Aborted LTx †1d post-LTx – f/54yr Post-ethyl cirrhosis 24 35.3 22 Spontaneous resolution Alive and well 16 f/53yr Postethyl + HBV cirrhosis 19 37.3 19 Spontaneous resolution Alive and well 55 f/53yr PBC 17 51.7 58 Sildenafil PO Alive and well 6 m/42yr HCV 17 53.3 – Listed for combined heart/lung/LTx Alive and well 120 Eleven (9.9%) patients did not even achieve 65% of the predicted target heart rate, and notably all of them were on β-blockers. Thirty (73.1%) of 41 patients who achieved the target heart rate had MELD score ≤15 compared with 11 (26.9%) patients with MELD score > 15 (p < 0.05). Conclusions: Chronotropic incompetence on DSE is frequent in patients with ESLD. In absence of any cardiac symptoms or/and ECG findings during DSE, a lower cut-off for target heart rate may be acceptable when patients are on βblockers or/and MELD score >25 to avoid unnecessary further investigations. Large prospective studies are needed to support these findings. O-098 INCIDENTAL PORTOPULMONARY HYPERTENSION DISCOVERED AT THE START OF LIVER TRANSPLANTATION, “TO GO AHEAD OR TO LET GO...” Filip Gryspeerdt, Marion Dupont, Wim Laleman, Raymond Aerts, Dieter Mesotten, Geert Meyfroidt, Marleen Verhaegen, Arne Neyrinck, Frederik Nevens, Jacques Pirenne, Diethard Monbaliu. Leuven liver Transplant Team, University Hospitals Leuven, Leuven, Belgium Background: Portopulmonary hypertension (PPHT) is the association of pulmonary hypertension (mean pulmonary artery pressure [mPAP] >25 mmHg) and portal hypertension with or without chronic liver disease. Moderate PPHT (mPAP >35 mmHg) is associated with higher morbidity/mortality and severe PPHT (mPAP> 45mmHg) is generally considered a contra-indication for Liver Transplantation (LTx). Moderate to severe PPHT may develop during the waiting time of LTx period. A retrospective analysis was done to review the shortterm outcome of LTx in patients with incidental PPHT (e.g. diagnosed at the start of LTx and unkown at time of listing). Methods: All medical records of patients with incidental PPHT were reviewed. Lab-MELD at time of LTx, mPAP immediately pre-LTx, post-LTx hospital stay, type/length of post-LTx medical treatment for PPHT and patient survival were analyzed (see Table 1). Results: Between 2000-2011, 9/653 patients were diagnosed with moderate to severe PPHT at time of LTx induction. LTx was pursued in 7 patients. Of those, 6 had uneventful post-LTx recovery with spontaneous or medically assisted (vasodilators) resolution of PPHT; and 1 succumbed to complications of extra-corporeal membrane oxygenation. LTx was started but aborted in 1 due to hemodynamic unstability. LTx was not started in 1 who later received combined heart/lung/LTx. Conclusion: The incidental discovery of a previously unknown moderate to severe PPHT at the start of LTX is a possibility that LTx teams should be aware of. PPHT has usually been seen as a contra-indication for LTx. However, favorable outcome in 6/7 recipients suggests that LTx should not necessarily be aborted in case of incidental PPHT. 28 Oral Sessions Oral Session 13: Liver / intestine miscellaneous O-099 LIVER INMUNOPROTECTIVE EFFECT ON THE KIDNEY ALLOGRAFT IN SIMULTANEOUS LIVER AND KIDNEY TRANSPLANTATION Nuria N. Esforzado 1, Ana Yurena A.Y. Sánchez 1, José Vicente J.V. Torregosa 1, Nuria N. Serra 1, Rafael R. Pascualin 1, Jaume J. Martorell 2 , Federico F. Oppenheimer 1 , Josep Maria J.M. Campistol 1 . 1Renal Transplant Unit, 2Inmunology Unit, Hospital Clinic, Barcelona, Spain Background: Simultaneous liver-kidney transplantation (SLK) has less incidence of renal graft rejection and inmunological graft lost against the receptors of an isolated renal transplantation (RT). In addition, a low rejection incidence and a good renal graft evolution have ben reported in cross-match (CM) positive (+) SLK patients. The low prevalence of immunological complications in high-risk immune (“HRI”) SLK patients, suggests a liver’s inmunoprotective effect on the kidney graft. Material and methods: We present our experience in “HRI” SLK patients, defined as CM by cytotoxicity (CDC) post DTT + and/or “HRI” + pre transplantion (Tx). From May 1993 until December 2010, 58 SLK Tx were made (27 retransplanted patients), and eight patients had CM + pre Tx and other four patients had negative CM but positive “HRI”. Results: Of 12 “HRI” patients, 3 (25%) patients had graft dysfunction related to humoral acute rejection (HAR) during the first month after SLK Tx. Only one of these patients (33%) received Apheresis and Rituximab treatment with a good response. In the other two patients, HAR was resolved without specific treatment. None of 12 patients after 45±40 months follow-up, loss graft related to inmunological etiology. Six of 8 CM + pre Tx patients became negative post Tx. Conclusion: High-risk inmune SLK patients have a low prevalence of immunological complications which suggests an inmunoprotector role of the liver on the kidney allograft in these patients. O-100 EVOLUTION OF KIDNEY FUNCTION AFTER LIVER TRANSPLANTATION FOR ADULT POLYCYSTIC LIVER DISEASE AND INDICATIONS FOR COMBINED LIVER AND KIDNEY TRANSPLANTATION Tom Darius 1, Alexander Patris 1, Ziad Hassoun 1, Diethard Monbaliu 2, Tania Roskams 2, Olga Ciccarelli 1, Yves Pirson 1, Yves Vanrenterghem 2 , Frederik Nevens 2, Jacques Pirenne 2, Jan Lerut 1 . 1Abdominal Transplant Unit, University Hospitals Saint Luc, Brussels, Belgium; 2Liver Transplant programme, University Hospitals Gasthuisberg, Leuven, Belgium Background: Adult polycystic liver disease (PLD) is frequently associated with autosomal dominant polycystic kidney disease (ADPKD). Established indication for combined liver and kidney transplantation (CLKTx) is end stage renal failure. If renal insufficiency is less advanced, indications for combined kidney transplantation (KTx) are controversial. We reviewed our experience with isolated liver transplantation (LTx) and CLKTx in patients with PLD. Methods: Between 1995-2008, 56 patients originating from 2 collaborating centers underwent LTx for PLD. 7 patients with isolated PLD received LTx alone. Of 49 patients with combined PLD and ADPKD, 31 underwent isolated LTx and 18 CLKTx. Among the 18 CLKTx recipients, 11 were dialysisdependent pre-transplant whereas 7 had a creatinine clearance (CrCl) between 15 and 38 mL/min. Results: Median follow up is 34 months (range, 26-167). 1 and 5-year patient and liver graft survival were 96% and 94%, and 96% and 90%, respectively. The 1 and 5-year kidney graft survival (death censored) is 100%. Of the 31 patients who underwent isolated LTx for combined PLD and ADPKD, 29% (n=9) developed terminal renal failure post-LTx. Their mean pre-LTx CrCl was 76 mL/min (range, 48-110). The mean pre-LTx CrCl in the 71% patients who display stable kidney function post-LTx was 78 mL/min (range, 47-153). Pre-LTx CrCl was not a significant factor for the development of renal failure after isolated LTx for combined PLD and ADPKD (p=0,835). Conclusion: This series demonstrates that short& long-term survival after LTx and CLKTx for PLD is excellent. In patients with clearly-proven & evolving renal impairment pre-transplant, CLKTx is the preferred option, anticipating the need for later KTx. In patients with preserved/mildly disturbed renal function, nephron sparing strategies are essential since evolution towards renal failure is seen in 29%, without clear prognosis factors. O-101 LIVER TRANSPLANTATION (LTx) FOR TRANSTHYRETIN SYSTEMIC AMYLOIDOSIS DISORDERS: ANALYSIS FROM THE FAMILIAL AMYLOIDOTIC POLYNEUROPATHY WORLD TRANSPLANT REGISTER (FAPWTR) Bo-Göran Ericzon. Transplantation Surgery, Karolinska Institutet, Stockholm, Sweden Background: Transthyretin (TTR) systemic amyloidosis disorders are treatable with Ltx. The FAPWTR was established in 1993 to assemble data on such patients. Methods/Results: By December 2009, 1798 patients/1953 liver transplantations were reported to the FAPWTR from 72 centers in 19 different countries. Most transplantations were done in Portugal (n=866), France (n=216), Sweden (n=130) and Brazil (n=91). More than 45 different TTR-variants have been reported, the commonest being Val30Met (85%) followed by Ser77Tyr, Thr60Ala and Tyr114Cys. Gastrointestinal, cardiovascular and extraneurological manifestations appear more often in non-Val30Met than in Val30Met patients. 15% of the non-Val30Met patients underwent liver and heart transplantation compared to 0.1% of the Val30Met patients. Different countries show varying age at onset in Val30Met patients, with Brazil having the youngest patients and Sweden the oldest (32 years and 45 years, respectively). After Ltx, 80-90% of the ValMet30 patients reported stable or improved clinical symptoms compared to 60-65% in non-Val30Met patients. The overall 5-, 10and 15-year patient survival is 79%, 70% and 64%, respectively. Most common cause of death is cardiac. Val30Met patients with a disease duration >7 years disclose inferior 5-year survival than patients with a duration ≤7 years (58.2% and 84.7%, respectively p<0.001). Results improve when analyzing patients transplanted in the last 5 years, but the 5-year survival still remains significantly better in patients with less than 7 years disease duration (72.1% and 88.7%, respectively p<0.05). Conclusion: LTx is lifesaving in patients with TTR amyloidosis. Val30Met and non-Val30Met TTR mutations differ clinically. Cardiac related post transplant death i

Does Kidney Donor Risk Index implementation lead to the transplantation of more and higher-quality donor kidneys?

Abstract Background The Kidney Donor Risk Index (KDRI) is a quantitative evaluation of the quality of donor organs and is implemented in the US allocation system. This single-centre study investigates whether the implementation of the KDRI in our decision-making process to accept or decline an offered deceased donor kidney, increases our acceptance rate. Methods From April 2015 until December 2016, we prospectively calculated the KDRI for all deceased donor kidney offers allocated by Eurotransplant to our centre. The number of the transplanted versus declined kidney offers during the study period were compared to a historical set of donor kidney offers. Results After implementation of the KDRI, 26.1% (75/288) of all offered donor kidneys were transplanted, compared with 20.7% (136/657) in the previous period (P < 0.001). The median KDRI of all transplanted donor kidneys during the second period was 0.97 [Kidney Donor Profile Index (KDPI) 47%], a value significantly higher than the median KDRI of 0.85 (KDPI 34%) during the first period (P = 0.047). A total of 68% of patients for whom a first-offered donor kidney was declined during this period were transplanted after a median waiting time of 386 days, mostly with a lower KDRI donor kidney. Conclusions Implementing the KDRI in our decision-making process increased the transplantation rate by 26%. The KDRI can be a supportive tool when considering whether to accept or decline a deceased donor kidney offer. More data are needed to validate this score in other European centres.

Prediction of delayed graft function using different scoring algorithms: A single-center experience

AIM To compare the performance of 3 published delayed graft function (DGF) calculators that compute the theoretical risk of DGF for each patient. METHODS This single-center, retrospective study included 247 consecutive kidney transplants from a deceased donor. These kidney transplantations were performed at our institution between January 2003 and December 2012. We compared the occurrence of observed DGF in our cohort with the predicted DGF according to three different published calculators. The accuracy of the calculators was evaluated by means of the c-index (receiver operating characteristic curve). RESULTS DGF occurred in 15.3% of the transplants under study. The c index of the Irish calculator provided an area under the curve (AUC) of 0.69 indicating an acceptable level of prediction, in contrast to the poor performance of the Jeldres nomogram (AUC = 0.54) and the Chapal nomogram (AUC = 0.51). With the Irish algorithm the predicted DGF risk and the observed DGF probabilities were close. The mean calculated DGF risk was significantly different between DGF-positive and DGF-negative subjects (P < 0.0001). However, at the level of the individual patient the calculated risk of DGF overlapped very widely with ranges from 10% to 51% for recipients with DGF and from 4% to 56% for those without DGF. The sensitivity, specificity and positive predictive value of a calculated DGF risk ≥ 30% with the Irish nomogram were 32%, 91% and 38%. CONCLUSION Predictive models for DGF after kidney transplantation are performant in the population in which they were derived, but less so in external validations.