'
In this Section:
More:
In This Section:

What's Your Perspective?

  • Transplant Department over Transplant Division of General Surgery?

    Dr. Amy GalloAmy E. Gallo, MD
    Assistant Professor of Surgery (Abdominal Transplantation)
    Stanford University Medical Center

    As the field of abdominal transplant surgery evolved, transplant surgeons fell under a number of hospital departments, including vascular surgery, general surgery, and urology. Financial and academic considerations dictate the reasoning for particular placement; however, what makes the most clinical sense is a multifactorial discussion and might be worth reconsideration in the changing medical environment. For large volume centers, perhaps a Transplant department is the future.

    Currently, even for large centers there is no uniform departmental configuration for transplant physicians. The majority of programs have abdominal transplant surgeons under general surgery. Some kidney programs have surgeons solely in the urology department for both recipient operations and donor nephrectomies. Some surgeons, double boarded in pediatric surgery, remain in the division of pediatric surgery. The medical counterparts, hepatologists and nephrologists, are hired through the medical and pediatric departments, where transplant surgeons may or may not have hiring influence. These physicians may have a special interest in transplant or may be designated to transplant based on other staffing considerations. Fewer centers have transplant hepatologists and nephrologists as dually appointed in medicine and in surgery. Additional individuals vital to transplant success, namely intensivists, cardiologists, radiologists, anesthesiologists, psychiatrics, and oncologists, often have interest in transplantation but are hired based on their individual departmental needs and not the needs of the transplant program.

    There is no doubt that in recent years, quality scrutiny of transplant programs has increased (1). Flagging by MPSC or CMS is a reality, to the extent that a program can be at jeopardy of closing based on outcomes. However, many of the transplant quality measures are unknown to participants outside the transplant community, while their involvement often directly affects patient outcomes.

    A dedicated transplant department could control the flow of personnel in alignment with transplant recipient needs, list volume and management, and oversight of detailed quality measures. Research within the department across disciplines would be more accessible. The ability to collaborate could be more extensive, and the requirement to attend departmental activities outside the interest of transplantation could be curtailed.

    A major consideration for continuing general surgery involvement is for residency training. Within the department of surgery, transplantation may have more clinical exposure to residents and in turn enhance recruitment into the field. I would argue, however, that in the current general surgery environment, transplantation is a low priority. It is no longer mandated as a formal rotation and is required only as a “transplant experience” (2). Exposure is often in the first and second years where the surgical experience, which often entices interest, is limited. The details of immunosuppression management is lost on short rotations.

    If medical students alternatively could be exposed to a transplant science department, potentially it could then attract the best and the brightest early on in training like plastic surgery, ENT, and neurosurgery have over the years. With a bigger presence as a department with emphasis on medicine, research, and surgery, perhaps it will look more appealing to medical students as its own field instead of being buried within general surgery.

     Bibliography

    1: Snyder JJ, Salkowski N, Zaun D, Leppke SN, Leighton T, Israni AK, Kasiske BL. New quality monitoring tools provided by the Scientific Registry of Transplant Recipients: CUSUM. Am J Transplant. 2014 Mar;14(3):515-23. doi:10.1111/ajt.12628. PubMed PMID: 24502435.

    2: Egle JP, Mittal VK. Program directors' perspective of transplant training during general surgery residency. Am Surg. 2014 Aug;80(8):796-800. PubMed PMID: 25105401.

    Go comment!
  • How Do I Get on an ASTS Committee?

    The American Society of Transplant Surgeons is our organization. It exists because of the dedication of transplant surgeons, physicians, and other transplant professionals, who work together with the highly skilled staff of the ASTS to support our primary goal: to advance the field of transplant surgery through leadership, advocacy, education, and training. While there are several organizations working on issues related to organ transplantation, the surgical perspective, particularly as it relates to training and advocacy, is uniquely represented by the ASTS.

    If we did not have members who wanted to be involved, the organization would cease to exist. Maintaining your membership in the ASTS and attending the Winter Meeting (January 26-29, 2017) are essential to being engaged. However, many of you may be ready to increase your participation in the ASTS by joining one of the many committees responsible for the carrying out the Society’s mission. However, you may not be entirely clear on how the ASTS committee process works. Below is a list of common questions you may have as well as a description of the main duties of the various committees. If you have additional questions, please don’t hesitate to contact us.

    Dr. Julie Heimbach 
     Ellie Proffitt  Diane Mossholder
    Julie Heimbach, chair, Communications Committee Heimbach.julie@mayo.edu Ellie Proffitt, staff liaison, Nominating Committee ellie.proffitt@asts.org Diane Mossholder, staff liaison, Communications Committee diane.mossholder@asts.org


    Q: When does the committee nominations process take place?

    A: The committee nominations period varies from year to year, depending on when ATC takes place. Nominations will open several months prior to ATC. All ASTS members will receive notification via email when nominations open.  In 2017, nominations will open in early January.

    Q: How does the nominations process work?

    A: Once nominations are open, members can nominate either themselves or one of their peers for a committee position. Nominations are made through Survey Monkey. Nominations stay open for several weeks, then close to allow time for appointments to be made prior to ATC. All nominees are notified either way via email a few weeks later, and new committee members begin their appointments during the Business Meeting at ATC.

    Q: How are committee appointments made?

    A: Committee appointments are made at the discretion of the current ASTS president. The president considers all nominations before making appointments. The top 6 committee choices are indicated on the nomination form, and a great deal of effort is made to place nominees in their first choice; however, this is not always possible, and the president tries to place each person in a committee where their strengths can be put to the best possible use.  Typically, there are more nominees than committee slots, so you may not be selected when you are initially nominated. Last year, there were 146 people nominated for 73 open positions.

    Q: How are committee chair and co-chair appointments made?

    A: Committee co-chairs (similar to vice-chair) are usually selected from current members of the committee. If a person currently on a committee would like to be considered for the co-chair position, there is space to indicate this in the nomination form. Committee co-chairs usually move into the chair position when the chair slot is open.

    Q: How long do committee appointments last?

    A: Committee chairs and members all serve 3-year terms. Co-chairs are appointed for one-year terms but may be reappointed for up to 3 years.

    Q: Does it help if there multiple nominations for the same person, and does it matter who nominates you?

    A: It is not necessary for multiple people to nominate the same person for a committee appointment. Only one nomination is necessary for the president to consider someone for a position, and typically the qualifications of the nominee and the needs of the committee are the most important factors.

    ASTS Committees

    Advanced Transplant Provider: To decrease the geographical barriers between providers and allow for a close, strong, supportive community to exist. Monthly conference calls.

    ATC Planning: Charged with ensuring that the meeting provides exceptional educational objectives and provides a forum for exchange of new scientific and clinical information.

    Business Practice Services: Assists ASTS members in understanding the business aspect of transplantation and helps them keep up with national trends in transplant practice management. Monthly calls (sometimes more frequent) and in-person meeting at ATC.

    Bylaws: To maintain and update the bylaws of the ASTS to accurately reflect the purpose, structure and function of the organization. Calls as needed and in-person meeting at ATC.

    Cellular Transplant: To promote the advancement of research and clinical applications in cellular transplantation and regenerative medicine, while serving as an advisory expert panel for the ASTS Council in cell transplant-related issues. Monthly conference calls and in-person meeting at ATC.

    CME: To provide support to members of ASTS to allow for their educational growth and development in service to patients, the public, and the ASTS. Monthly conference calls with in-person meeting at ATC and sometimes the Winter Symposium.

    Communications:  To act as an avenue by which the Society conveys information to the membership and transplant community on issues regarding transplantation science and medicine through the ASTS website, the ASTS newsletter (the Chimera), scientific journals, and e-mail communications. Monthly conference calls with in-person meeting at ATC.  

    Curriculum: To develop and implement the National Transplant Surgery Fellowship Curriculum to provide a structured educational and training framework for abdominal transplant surgery fellowship. Monthly conference calls.

    Diversity Issues: To ensure balanced representation among under-represented and underserved minorities specific to organ donation and transplantation. Monthly conference calls and in-person meeting at ATC.

    Ethics: Charged with considering ethical issues related to transplantation and organ donation. Conference calls as needed and in-person meeting at ATC.

    Fellowship Training: To ensure that the highest standards of clinical, professional, and scientific excellence are passed to future generations of transplant surgeons.  The FTC governs accreditation and oversight of surgical training programs in abdominal transplantation, and strives to provide benchmarks and guidance in order to facilitate high quality training across the United States and Canada. Monthly conference calls and in-person meeting at ATC.

    Grants Review: To support basic, clinical, and translational research performed in transplantation. The Committee will review and award applications for ASTS grants that support research performed by ASTS members, their trainees and collaborators. The Committee is responsible for providing advice, education and resources to trainees and members who are applying for funding from the broad range of granting organizations. . Conference calls as needed and in-person meeting at ATC.

    Legislative: To advise Congress and related federal agencies on decisions that influence the practice and science of transplantation by educating Members of Congress and advocating for new legislation, appropriations matters, and changes to existing laws and regulations for the benefit of patients, transplant surgeons, and society. Monthly conference calls and in-person meeting at ATC.

    Living Donation: Outline best practices to improve the safety and long-term care of the living donor, as well as develop informational materials to better inform potential donors and recipients on living donation. Conference calls as needed and in-person meeting at ATC.

    Membership and Workforce: Charged with the monthly review process for all new member applications and a focus on workforce needs, IMG experiences, and other issues impacting the membership. Calls as needed and in-person meeting at ATC.

    Reimbursement and Regulatory Compliance: Charged with helping the ASTS membership optimize professional reimbursement by understanding the issues and being part of the solution, reviewing all new and pending regulations relevant to physician reimbursement, and drafting comments that can be submitted to specific organizations or government agencies on behalf of ASTS. Monthly conference calls and in-person meeting at ATC.

    Scientific Studies: Explores basic science and clinical issues in the field of transplantation and aims to facilitate the dissemination of information regarding opportunities for collaboration in clinical studies. Monthly calls and in-person meetings at ATC and other ASTS events.

    Standards and Quality: To educate the membership about quality, standards, policies, and regulations, and to promote the development of high standards and quality in organ procurement, transplantation, patient safety, and performance improvement. Monthly calls (sometimes more frequent) and in-person meeting at ATC.

    Thoracic Organ Transplant: To propose and/or facilitate clinical and research initiatives aimed at increasing the number of thoracic organ transplants performed annually in the U.S. and improving the quality of life following heart/lung transplantation. Monthly conference calls and in-person meeting at ATC.

    Vanguard: To encourage involvement in the activities and initiatives of the ASTS by its junior members by providing opportunities for interactions between the Society’s leadership and its newer members, thus increasing the cohesive nature of the society. Conference calls as needed and in-person meeting at the Winter Symposium.

    Vascularized Composite Allograft (VCA): To maintain position papers to advise funding and regulatory agencies on the proper development of this complex field: To promote balanced scientifically sound investigation and career development in VCA, educate the membership about regulations and policies as they are being developed for VCA, and foster a place for professionals interested in VCA. Conference calls every other month and in-person meeting at ATC.

    Go comment!
  • Waste Not, Want Not: Determining the Fate of the Marginal Liver Allograft

    Dr. John SealJohn Seal, MD
    Transplant Surgeon
    Ochsner Health System

    The primary goal of liver transplantation is to reduce mortality and significant morbidity associated with end stage liver disease and hepatocellular carcinoma. To that end, the current allocation system in the United States is designed to prioritize patients with the highest risk of death as estimated by the MELD scoring system. However, significant variability in the quality of donor organs complicates this process. The presence of extended criteria donor (ECD) features such as advanced age, abnormal liver function tests, steatosis, and donation-after-circulatory death can negatively impact early allograft function and overall graft survival. Many transplant surgeons avoid or very selectively use these grafts in the highest MELD patients out of concern for early organ dysfunction not well tolerated by sicker patients. In the environment of severe organ shortage, transplant centers are left with the onerous task of balancing the risk of death on the waitlist versus the potential risks associated with expanded criteria allografts.  Each organ offer prompts the questions: Will this liver work in my sickest patient? If not, will it work in any of my listed patients? And, if it will only work in my lowest MELD patients, am I really offering a survival benefit?

    For the past several years, our center has adopted an aggressive approach to organ utilization based on the hypothesis that the potentially deleterious effects of marginal features can be minimized through careful patient selection and minimization of cold ischemia time. Recipient selection is focused on limiting surgical complexity to facilitate a rapid hepatectomy with minimal blood loss. We carefully consider the patient’s overall functional status and co-morbidities to help predict an adequate physiologic reserve to support hemodynamic stability during clamp and reperfusion periods. During the transplant evaluation process, patients are assigned a score of surgical risk to facilitate recipient selection when an ECD offer is received. The second key principle, minimization of cold ischemia time, is more complex—it requires robust logistics and communications with procurement coordinators as well as an OR staff and anesthesia team able to mobilize quickly and on short notice. We also have a routine practice of having two attending surgeons available for every case. By executing these details well, we can avoid the cumulative effects of even small delays in the process that can add hours to cold ischemia time.

    While the upper limit of recipient selection for ECD is easier to define (high MELD, ICU, frail, etc.), the lower limit is less clear. In keeping with the priorities of the allocation system, we approach each offer systematically working our way down the list of potential recipients from high MELD score to low. Our goal is to transplant the graft into the most appropriate patient with the highest MELD on the list. A majority of the recipients of imported grafts at our center have MELD scores between 18-25, a range where the survival benefit from transplantation is clear. For the lowest MELD patients (<18), we focus on patients with a disease burden that is not reflected in their MELD score such as marked ascites, debilitating encephalopathy, or early stage HCC tumors waiting to accrue exception points. Also, it is important to consider the MELD history of the patient, including prior episodes of increased MELD suggesting instability in the degree of compensation and likelihood of progressive liver disease in the future.

    What does it mean for a graft to “work”? Defining the terms of early allograft dysfunction is critical to evaluating the performance of ECD grafts. Since 2012, we have observed no significant difference in graft or patient survival comparing imported ECD grafts with standard donors, with both categories at or above expected. Certainly we have seen higher rates of elevated AST/ALT (>2000) in the ECD grafts, but typically it is transient and normalizes by the time of discharge from the hospital. At our center we put more weight on the markers of synthetic and metabolic function of the graft, namely INR, bilirubin, and lactate in the early post-transplant period. Using post-transplant MELD as a marker of graft function1, we see no difference in early graft function with ECD grafts.

    We believe nearly every donor liver offers a potential survival benefit for some listed patient. Accordingly, we have invested resources and experience to optimize outcomes using ECD grafts and to identify suitable recipients to achieve a survival benefit.  Currently in the United States, the distribution of aggressive centers and donor liver utilization varies significantly between regions.2,3 As we strive for parity in organ allocation across regions, some emphasis should be placed on the lack of uniformity in utilization. We should also continue to invest in the development of better diagnostics for graft assessment, including normothermic machine perfusion systems4 and metabolomic/proteomic approaches to biomarker discovery5. But in the meantime, the challenge is to employ donor-recipient matching strategies to optimize utilization of the non-perfect graft within an allocation system that prioritizes our sickest patients.

    References

    1. Wagener G, Raffel B, Young AT, Minhaz M, Emond J. Predicting early allograft failure and mortality after liver transplantation: the role of the postoperative model for end-stage liver disease score. Liver Transplant Off Publ Am Assoc Study Liver Dis Int Liver Transplant Soc. 2013 May;19(5):534–42.

    2. Garonzik-Wang JM, James NT, Van Arendonk KJ, Gupta N, Orandi BJ, Hall EC, et al. The aggressive phenotype revisited: utilization of higher-risk liver allografts. Am J Transplant Off J Am Soc Transplant Am Soc Transpl Surg. 2013 Apr;13(4):936–42.

    3. Goldberg DS, French B, Lewis JD, Scott FI, Mamtani R, Gilroy R, et al. Liver transplant center variability in accepting organ offers and its impact on patient survival. J Hepatol. 2015 Nov 25;

    4. Ravikumar R, Jassem W, Mergental H, Heaton N, Mirza D, Perera MTPR, et al. Liver transplantation after ex vivo normothermic machine preservation: a Phase 1 (first-in-man) clinical trial. Am J Transplant Off J Am Soc Transplant Am Soc Transpl Surg. 2016 Jan 11;

    5. Cortes M, Pareja E, García-Cañaveras JC, Donato MT, Montero S, Mir J, et al. Metabolomics discloses donor liver biomarkers associated with early allograft dysfunction. J Hepatol. 2014 Sep;61(3):564–74.

    Go comment!