News - Report of 3 month stay at Erasmus MC Rotterdam

Date of departure from SA: 22 June 2008
Date of departure from Rotterdam: 17 September 2008

Hilda Smith

Thanks to the Gatroenterology Foundation and AstraZeneca, as well as the Donald Gordon Medical Centre who all sponsored my trip and stay in the Netherlands, I was on my way to Erasmus MC to learn more about liver transplantation and liver diseases in general. On arrival at Schiphol Amsterdam, I had to travel via train to Rotterdam, where I was met by Marjolein Boermans, the Liver Transplant unit secretary. She showed me the way to my apartment, close to the Central Station, and introduced me to Professor HJ Metselaar at Erasmus MC hospital. Professor Metselaar was my primary mentor during my stay. I was also lent a bicycle for my stay which would be my main transport method through wind and rain.

I worked primarily in the Liver Transplant unit. My day at hospital usually started at 8am with a hand over round in their seminar room, followed by the transplant team seeing all pre and post transplant patients admitted in both general wards and ICU.

Monday mornings would be occupied further by Sonar and Liver biopsies. The afternoon was occupied by an outpatient clinic specifically for transplanted patients. The afternoon round happened at 15h30 and then there was time allocated for research/reading until 18h00.

Tuesday mornings were dedicated to Liver sonar by one of the Hepatologists. I found this very educational. They are excellent sonographists and look at things with a lot of insight. It is important to know what to look for especially in a patient who was transplanted. Tuesday afternoons was also spent at sonar or with research. The afternoon round also happened at 15h30, and then there was time for reading again until 18h00.

Wednesday mornings were again dedicated to Liver sonar by one of the Hepatologists. This session was also for contrast sonar. This was very interesting. They use an agent called SonoVue. This is very useful, especially in delineating the characters of a nodule in the liver further. This might be very useful in our setting where imaging techniques such as CT/MRI often take a long time or are even unavailable.

There was also an outpatient clinic for Hepatitis C patients follow up and treatment.Wednesday afternoons were occupied by an outpatient clinic for patients being worked up for Liver transplantation and their follow up. The afternoon round also happened at 15h30, again with time for reading until 18h00. Thursday mornings was occupied by their grand ward round, which started off with a discussion of all patients in a

The South African Gastroenterology Review • November 2007

seminar room, and then a bedside round. At 11h00 there was a discussion of all the outpatients seen on the Monday Transplant outpatient clinic and the patients on the waiting list was discussed, with all telephonic queries. Thursday afternoon again was outpatient clinic for transplanted patients. The Combined transplant meeting then happened from 17h00 to approximately 18h00, where all transplanted or waiting list patients admitted at present were discussed, as well as all new patients for the waiting list. Friday mornings was dedicated to research meetings, where they present all current research, all findings up to date, and future intentions. This was followed by another discussion of the outpatient clinics not yet discussed as well as telephonic consults and problematic patients. Friday afternoon was dedicated to research/reading until 18h00.

There were 14 transplants during this 3 month period for 11 patients, 3 of which was high urgency re transplants for primary graft non function. There were also 2 patients that were re transplanted for chronic biliary complications. The underlying liver pathology for which these patients who were transplanted was quite varied. Most patients received standard immunosuppression post surgery, (comprising of an IL2 blocker, prednisone, and Tacrolimus) unless they participated in a study or had significant renal dysfunction.

During my stay I did a Retrospective Cohort study for the Transplant unit looking at the predictors of HCC recurrence in the patients transplanted for HCC at Erasmus MC between 4/10/1989 and 8/08/2008. This was a patient population of 45. We looked at gender, age, compliance with Milan criteria on pre transplant staging and on explants histology, the presence of microvascular invasion, whether pretreatment to down stage had any effect and the level of AFP.We found that the overall recurrence free survival on Kaplan Meyer curve showed that approximately 55% had a recurrence by 3 years.

Findings on Cox’s univariate regression analysis found age, compliance with Milan criteria on explants histology, the presence of microvascular invasion and the level of AFP to be statistically significant in predicting recurrence. On Multivariate analysis only compliance with Milan criteria on explants histology and the level of AFP was found to be statistically significant. It also showed that they were doing quite well with regards to pre transplant staging, with only staging 15.5% incorrectly, while we see in literature that incorrect staging ranges between 21- 43 %. I presented the findings of this study at their Combined Transplant meeting held on the 21/08/2008. This has been an academically enriching experience for me and I trust that my patients will benefit most from this.


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