Prevalence of pancreatic exocrine insufficiency after pancreatic surgery measured by 13C mixed triglyceride breath test: A prospective cohort study.

BACKGROUND: Patients undergoing pancreatic surgery are at risk of pancreatic exocrine insufficiency (PEI) and needing pancreatic enzyme replacement therapy (PERT). METHODS: This study included 254 patients undergoing pancreatic surgery for oncologic indications. A13C mixed triglyceride breath test was performed immediately preoperative and postoperative. This test analyzes the pancreatic remnant lipase activity measuring 13CO2 in breath samples after a test meal with 1.3-distearyl-(13C-Carboxyl)octanol-glycerol. Cumulative percent dose recovery after 6 h of less than 23% confirms PEI. In addition, PEI was compared between pathology subgroups. RESULTS: In 197 patients undergoing pancreaticoduodenectomy, cPDR-6h decreased significantly from a median of 32.84% before to 15.80% after surgery (p < 0.0001). This decrease in exocrine function was significant in all pathology subgroups except in pancreatic neuroendocrine tumors. Exocrine function decreased most in pancreatic ductal adenocarcinoma (PDAC). In addition, the percentage of patients needing PERT because of PEI increased from 25.9% to 68.0% postoperative (p < 0.001). Overall, patients with an MPD diameter of more than 3 mm had a higher risk of developing postoperative PEI: 62.7% compared to 37.3% (p = 0.009), OR = 3.11. In contrast, the majority of the 57 patients undergoing a distal pancreatectomy did not experience any significant change in exocrine function. CONCLUSIONS: The vast majority of patients undergoing pancreaticoduodenectomy for oncologic indications experience a significant drop in exocrine function, are at high risk of developing pancreatic exocrine insufficiency and consequently need to be treated with pancreatic enzyme replacement therapy. Therefore, systematic screening for pancreatic exocrine insufficiency is needed after pancreaticoduodenectomy.

Liver transplantation during the COVID-19 epidemic : recommendations from the Belgian Liver Intestine Transplant Committee (BeLIAC).

Since January 2020, the Novel Coronavirus Disease 2019 (COVID-19) pandemic has dramatically impacted the world. In March 2020, the COVID-19 epidemic reached Belgium creating uncertainty towards all aspects of life. There has been an impressive capacity and solidarity of all healthcare professionals to acutely reconvert facilities to treat these patients. In the context of liver transplantation (LTx), concerns are raised about organ donation shortage and safety, the ethics of using limited healthcare resources for LTx, selection criteria for LTx during the epidemic and the risk of de novo COVID-19 infection on the waiting list and after LTx. BeLIAC makes several recommendations to try to mitigate the deleterious effect that this epidemic has/will have on donation and LTx, taking into account the available resources, and trying to maximize patients and healthcare professionals' safety.

Bilateral adrenal haemorrhage after a high energetic trauma: a case report and review of current literature.

Most adrenal injuries are asymptomatic. In traumatic events, adrenal haemorrhage is very likely to be accompanied by injuries to other organs. Isolated adrenal injury after trauma is very rare and mostly unilateral. We report a case of a 44-year-old male who suffered a major traffic accident with multiple trauma, including a bilateral adrenal haemorrhage. This caused a primary adrenal insufficiency, as proven with a cortisol stimulation test with synthetic corticotrophin. Bilateral adrenal haemorrhage is a very rare but potentially fatal disorder and should not be missed. This case illustrates that early diagnosis and prompt treatment with hydrocortisone may contribute to a beneficial outcome.

Prediction of exocrine and endocrine insufficiency after pancreaticoduodenectomy using volumetry.

Objectives: The aim of this study is to evaluate the use of pancreatic volumetric assessment to predict exocrine and endocrine insufficiency after pancreaticoduodenectomy.Methods: Thirty-seven patients who underwent pancreaticoduodenectomy were included in the study. Endocrine function was assessed in all patients without a history of diabetes using an oral glucose tolerance test. A 13C-labeled mixed triglyceride (MTG) breath test evaluated exocrine function before and after resection. Volumetric measurements were performed on CT or MRI.Results: The volumetric measurements could not predict pre- or postoperative diabetes. Moreover, the resected volume was significantly lower in patients who developed diabetes after resection. Comparing patients with a normal and disturbed postoperative MTG, postoperative volumes and parenchymal thickness were significantly different. The parenchymal thickness on postoperative imaging is withheld as a predictive factor (OR = .85 [95% CI .71-1.01], p = .049). The best cutoff value to predict exocrine insufficiency is a parenchymal thickness of less than 11.4 mm (AUC = .76, p = .025, sensitivity = 88.9%, specificity = 70.0%).Conclusions: Pancreatic remnant volumetry and parenchymal thickness measurement after pancreaticoduodenectomy are correlated with exocrine insufficiency, but with limited predictive value. None of the preoperative measurements are withheld to predict postoperative exocrine function. Pre- and postoperative volumetry appear to have no use in predicting postoperative diabetes.

Estimation of the future remnant liver function is a better tool to predict post-hepatectomy liver failure than platelet-based liver scores.

INTRODUCTION: Recently, there has been increasing interest in the preoperative prediction and prevention of post-hepatectomy liver failure (PHLF). This is a particular concern in colorectal liver metastases (CRLM), when surgery follows potentially hepatotoxic chemotherapy. Platelet-based liver scores (PBLS) such as APRI and FIB-4 are predictive of chemotherapy-associated liver injury (CALI) and PHLF. Estimation of the future liver remnant function (eFLRF) by combining 99mTc-Mebrofenin Hepatobiliary Scintigraphy (HBSBSA) with future liver remnant volume ratio (FLRV%), is predictive of PHLF and related mortality. We hypothesized that a HBSBSA based formula was a better predictor for PHLF than PBLS in chemotherapy-pretreated CRLM. METHODS: Between 2012 and 2016, 140 patients underwent liver resection for CRLM following systemic therapy. HBSBSA, FLRV%, eFLRF and PBLS were calculated and compared for their value in predicting PHLF. RESULTS: eFLRF and FLRV% had a better predictive value for PHLF than HBSBSA alone and APRI and FIB-4 (AUC = 0.800, 0.843 versus 0.652, 0.635 and 0.658 respectively). In a subgroup analysis (Oxaliplatin all, Oxaliplatin ≥ 6 cycles, Irinotecan all and Irinotecan ≥ 6 cycles), eFLRF was the only factor predictive for PHLF in all subgroups (all: p ≤ 0.05). Prediction of HBSBSA for chemotherapy associated steato-hepatitis (CASH) reached almost significance (p = 0.06). FIB-4 was predictive for sinusoidal obstruction syndrome (SOS) (p = 0.011). Only weak correlation was found between HBSBSA and PBLS. CONCLUSION: eFLRF is a better predictor of PHLF than PBLS or HBSBSA alone. PBLS seem to measure other aspects of liver function or damage than HBSBSA.

Single-Center Case Series of Donor-Related Malignancies: Rare Cases With Tremendous Impact.

BACKGROUND: Donor-related malignancy is a rare complication of organ transplantation. METHODS: In this case series, we discuss three cases of donor-related cancers in kidney transplant recipients who were registered in our center between 1979 and 2015. They account for an incidence of 0.29% of donor-related malignancies of a total of 1015 transplanted kidney grafts (deceased and living donors). The three cases that we describe presented in different ways and with different severity, although the response to the initiated treatment was comparable. RESULTS: All three patients not only survived their cancer episode but also had a complete oncological remission and underwent successful second kidney transplantation, accounting for a 100% survival rate in our small cohort. CONCLUSIONS: Despite the very low incidence of this complication, transplant clinicians must be aware of the occurrence of donor-related malignancies when selecting a donor and should be able to diagnose and treat a case of donor-related cancer.

Organ Donation After Euthanasia: A Dutch Practical Manual.

Many physicians and patients do not realize that it is legally and medically possible to donate organs after euthanasia. The combination of euthanasia and organ donation is not a common practice, often limited by the patient's underlying pathology, but nevertheless has been performed >40 times in Belgium and the Netherlands since 2005. In anticipation of patients' requests for organ donation after euthanasia and contributing to awareness of the possibility of this combination among general practitioners and medical specialists, the Maastricht University Medical Center and the Erasmus University Medical Center Rotterdam have developed a multidisciplinary practical manual in which the organizational steps regarding this combined procedure are described and explained. This practical manual lists the various criteria to fulfill and the rules and regulations the different stakeholders involved need to comply with to meet all due diligence requirements. Although an ethicist was involved in writing this paper, this report is not specifically meant to comprehensively address the ethical issues surrounding the topic. This paper is focused on the operational aspects of the protocol.

The Risk of Malnutrition in Community-Living Elderly on Admission to Hospital for Major Surgery.

BACKGROUND: With prevalence rates varying from 10 to 60%, malnutrition in acute hospitals has been acknowledged as a persistent problem in older adults worldwide. This publication is to describe the nutritional condition and associated risk factors of malnutrition in free living elderly on admission to the hospital for major elective surgery. METHODS: A cross sectional, multi-center study in eight surgical wards in three Belgian hospitals. A total of 204 free living elderly, aged 74.8 ± 6.6 years (Mean ± SD), on admission to the hospital for major elective surgery and requiring at least 3 days of hospitalization, were consecutively recruited to the study. The nutritional status was assessed on admission and before surgery using the recommended NRS-2002. Data on possible associated factors were collected during post-operative stay using a structured questionnaire. RESULTS: A total of 107 patients (51.4%) were at high risk of malnutrition. In patients older than 70 years (n 150) the risk of malnutrition increased up to 66%. None of the included patients reported preoperative referral to a dietician or nutritional advice nor any prescribed preoperative nutritional supplement. In a multivariate regression analysis it appeared that none of the possible associated factors were significantly associated with malnutrition. CONCLUSIONS: This study confirms the high risk of malnutrition in community living elderly on admission to hospital for elective surgery. According to the NRS-2002 these patients might benefit from nutritional support. However, it appears that nutritional support is not yet commonly implemented in preoperative care for this population at risk.

Pooled analysis of the surgical treatment for colorectal cancer liver metastases.

Liver metastases in colorectal cancer patients decreases the expected 5 year survival rates by a factor close to nine. It is generally accepted that resection of liver metastases should be attempted whenever feasible. This manuscript addresses the optimal therapeutic plan regarding timing of resection of synchronous liver metastases and the use of chemotherapy in combination with resection of synchronous metachronous liver metastases. The aim is to pool all published results in order to attribute a level of evidence to outcomes and identify lacking evidence areas. A systematic search of guidelines, reviews, randomised controlled, observational studies and updating a meta-analysis was performed. Data were extracted and analysed. Data failed to demonstrate an effect of timing of surgery or use of chemotherapy on overall survival. Concomitant resection of liver metastases and the primary tumour may result in lower postoperative morbidity. Systemic peri-operative chemotherapy may improve progression free survival compared to surgery alone.

Identification of quality indicators for the nutritional management of adult hospitalized patients by a modified Delphi process.

BACKGROUND AND OBJECTIVE: The aim of this study was to identify quality indicators (QI) that measure or evaluate the quality of nutritional management of the adult hospitalized patient irrespective of the primary disease or surgical condition. METHODS: During a modified Delphi procedure consisting of three rounds a 48 member expert panel selected quality indicators applicable to the subject focusing on validity and feasibility from a list of 89 candidate indicators, retrieved from the literature and completed by expert opinion. RESULTS: The following top ten of QIs were selected (weight between brackets): (1) Priority use of enteral route in the absence of contra indications (.95); (2) Patients with malnutrition (risk) receive a nutrition care plan or Nutritional Support (NS) (.935); (3) The hospital has a formulary on enteral formulas, parenteral nutrition (PN) solutions and nutritional supplements (.93); (4) The hospital has a designated nutrition support service (or team) (.922); (5) The hospital has written policies and procedures for the provision of nutrition support therapy (.9); (6) In hospitalized patients on PN the plasma triglycerides are checked weekly (.894); (7) Presence of a protocol for enteral drug administration through a feeding tube (.885); (8) Frequency of periodic reassessment of patients on NS (.883); (9) Enteral and PN orders are regularly revised and adjusted (daily/weekly/twice a week)(.88); (10) There is a hospital wide consensus on the screening method(s) for malnutrition (.88). CONCLUSIONS: Using a three round modified Delphi approach a list of ten best scoring QIs for the management of the adult hospitalized patient was established.

The influence of laboratory-induced MELD score differences on liver allocation: more reality than myth.

BACKGROUND: Liver allocation in Eurotransplant (ET) is based on the MELD score. Interlaboratory MELD score differences in INR and creatinine determination have been reported. The clinical implication of this observation has not been demonstrated. METHODS: MELD scores were calculated in 66 patients with liver cirrhosis using bilirubin, creatinine, and INR analyzed in six liver transplant centers. Based on allocation results of ET, patients transplanted from December 2006 to June 2007 were divided according to MELD score in four groups. For each group, the influence of the match MELD on the probability of receiving a transplant was studied (Cox proportional hazards model). RESULTS: Laboratory-dependent significant differences in MELD score were demonstrated. Cox proportional hazards model showed a significant association between MELD score and the probability of organ allocation. The unadjusted hazard ratio for receiving a liver transplant was significantly different between group 2 and group 4 (group 2: MELD 19-24; group 4: MELD > 30). CONCLUSION: Laboratory-dependent significant differences in MELD score were observed between the six transplant centers. We demonstrated a significant association between the MELD score and the probability of organ allocation. The observed interlaboratory variation might yield a significant difference in organ allocation in patients with high MELD scores.

The role of surgery and transplantation in neuroendocrine tumours.

Surgery represents the only chance of cure for a patient with a neuroendocrine tumour (NET). The main indications for surgery lie in the risk of developing metastatic disease with increasing tumour diameter and for a functioning NET also in control of the hormonal syndrome. However, only a small minority of patients presents with a potentially resectable primary NET without metastatic disease. An R0-resection is mandatory, which may be achieved in selected cases by tissue sparing surgical techniques. Most patients unfortunately present with a locally advanced or metastatic disease. For patients with an advanced functioning NET, control of the hormonal syndrome may also represent a surgical indication. Various cytoreductive techniques or, in highly selected cases, liver transplantation can be applied. For locally advanced non-functioning tumours, there is an indication for surgery in large tumours which tend to create local complications because of bleeding or bowel obstruction. Especially in ileal NETs aggressive surgical therapy is recommended because of prevention of long-term complications, which may improve survival.

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.

Simultaneous kidney-parathyroid allotransplantation from a single donor after 20 years of tetany: a case report.

Persistent hypocalcemia after total parathyroidectomy and autotransplantation is rare and occasionally has been treated using allotransplantation of parathyroid tissue. We present the case of a 32-year-old woman with terminal renal failure who at age 5 years underwent a first renal transplantation from a brain-dead donor. The graft was lost as a result of acute rejection. Tertiary hypoparathyroidism developed, which was treated with total parathyroidectomy and implantation in the forearm of a standardized amount of parathyroid tissue. The graft failed, and hypoparathyroidism developed. Despite a second implantation of cryopreserved autologous tissue, severe hypocalcemia persisted with a tendency for tetany. Although the patient was highly dependent on high-dose vitamin D(3) (tacalcitol) and calcium supplements, regular paresthesias and tetany developed. At age 9 years, the patient underwent a second renal transplant from a living related donor (her mother). After 18 years, the graft was lost as a result of chronic cyclosporine toxicity and angiosclerosis. Four years later, the patient underwent combined kidney and parathyroid transplantation from a local brain-dead donor. Preservation of the parathyroid glands was in University of Wisconsin solution, with cold ischemia time of 14 hours. Directly after the renal transplantation, parathyroid transplantation was performed, with implantation in the forearm of the total amount of donor parathyroid tissue. Postoperatively, there was recovery of parathyroid function, and the patient was able to discontinue vitamin D and calcium supplements after more than 20 years.

Addition of somatostatin-14 to a standard total parenteral nutrition-mixture in the treatment of fistulae: a clinical, double-blind, randomised, cross-over study.

UNLABELLED: BACKGROUND/STUDY AIMS: Somatostatin and total parenteral nutrition (TPN) are routinely used in the treatment of pancreatic and enterocutaneous fistulae. The objective of this clinical randomised cross-over study was to investigate the serum levels of somatostatin infused alongside TPN by a separate intravenous line, and when it had been added to the TPN mixture. PATIENTS/METHODS: The subjects were recruited by the treating physicians and the nutrition nurses. From the patients who started the study, no one dropped out. Ten patients were treated with a standard TPN mixture and somatostatin 6 mg/day. Patients were randomised to two possible regimens: 'somatostatin plus TPN--somatostatin separately--somatostatin plus TPN' or 'somatostatin separately--somatostatin plus TPN--somatostatin separately'. Each regimen consisted of 3 x 3 days of therapy, during which, serum levels of somatostatin were measured daily. Pre- and posttreatment samples were also analysed. RESULTS: When somatostatin was infused separately, the mean serum level was 884.8 pg/ml (SD: 557.3; range: 54-1900). When added to TPN, the mean serum level was 807.5 pg/ml (SD: 505.8; range 162-2279) (p value of difference = 0,473). The mean pretreatment level was 17.1 pg/ml (SD: 7.5; range: 8-33), and posttreatment was 32.8 pg/ml (SD: 26.5; range: 16-97). CONCLUSIONS: These results demonstrate that serum levels of somatostatin are similar in both treatment regimens and therefore may be added to a TPN mixture.

Necrotizing pancreatitis due to poisoning with organophosphate pesticides.

Several complications have been reported in relation to organophosphate poisoning. Pancreatitis due to cholinergic hypersecretion related to this type of poisoning, is however rare and has usually a subclinical course. Necrotizing pancreatitis has only been reported in 3 patients. We present a case of a young man who deliberately ingested the organophosphate dichlorvos and developed a necrotizing pancreatitis. A distal spleen and vessel preserving pancreatectomy was performed already 36 hours after ingestion. We believe that due to this very early surgery, this patient could be discharged as early as 12 days after surgery.

Liver transplantation using non-heart-beating donors: Belgian experience.

UNLABELLED: Mortality on liver transplantation (OLT) waiting lists has increased dramatically. Until recently, non-heart-beating donors (NHBD) were not considered suitable for OLT, because of a higher risk of primary graft nonfunction (PNF) and biliary strictures. However, recent experimental/clinical evidence has indicated that NHBD-OLT is feasible when the period of warm ischemia is short. PURPOSE: To characterize the results of NHBD-OLT in Belgium, a survey was sent to all Belgian OLT centers. RESULTS: Between January 2003 and November 2005, 16 livers originating from NHBD were procured and transplanted. The mean donor age was 48.8 years, including 9 males and 7 females with mean time of stop-therapy to cardiac arrest being 18 minutes and from cardiac arrest to liver cold perfusion, 10.5 minutes. Mean recipient age was 52.2 years including 12 males and 4 females. Mean cold ischemia time was 7 hours 15 minutes. No PNF requiring re-OLT was observed. Mean post-OLT peak transaminase was 2209 IU/L, which was higher among imported versus locally procured grafts. Biliary complications occurred in 6 patients requiring re-OLT (n = 2), endoscopic treatment (n = 2), surgical treatment (n = 1), or left untreated (n = 1). These tended to be more frequent after prolonged warm ischemia. Graft and patient survivals were 62.5% and 81.3%, respectively, with a follow-up of 3 to 36 months. CONCLUSION: This survey showed acceptable graft/patient survivals after NHBD-LT. The NHBD-liver grafts suffered a high rate of ischemic injury and biliary complications and therefore should be used carefully, namely with no additional donor risk factors, lower risk recipients, and short cold/warm ischemia.

Portal vein thrombosis in a patient with HIV treated with a protease inhibitor-containing regimen.

We report a case of an HIV seropositive female patient treated with a protease inhibitor-containing regimen who developed recurrent severe life-threathening episodes of haematemesis over time, caused by ruptured oesophageal varices as a consequence of a portal vein thrombosis. Coagulation tests revealed a protein S deficiency, an elevated homocysteinemia and a constitutional elevated plasma factor VIII coagulant activity. These coagulopathies and the HIV infection are independent risk factors for developing venous thromboembolic events. The protease inhibitor treatment may have played a role in increasing the thromboembolic risk. The recurrent bleedings only stopped after invasive surgery. The invasive splenorenal shunt operation was in this case a life-saving procedure.

Robot-assisted choledochotomy: feasibility.

Because clearing stones from the common bile duct is demanding with conventional laparoscopic techniques, the "da Vinci" robotic system can be of additional value in inserting a kehr drain and suturing the common bile duct. As far as we could ascertain, we report the first case of a laparoscopic choledochotomy with the assistance of this robotic system. Thanks to it, we were able to suture the common bile duct meticulously.