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  • Should Pediatric Transplantation Have Separate Fellowship Surgical Requirements?

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

    Low case volume is being associated with worse surgical outcomes, and transplantation is not an exception to this finding (1,2). As programs continue to be scrutinized by regulatory bodies to meet outcome measures, there have been fewer programs in the United States committed to pediatric transplantation.  While the American Society of Transplant Surgeons has established surgical volume requirements for liver, kidney, pancreas, and small bowel for fellowship training program accreditation, there are no fellowship requirements specific to pediatric transplantation. Assuming that each organ requires specific individual training requirements—because of complexity of the underlying disease and technical variation—it can be argued that pediatric solid organ transplantation calls for vastly different medical and surgical approaches from those of the adult counterparts and, therefore, should have its own fellowship requirements per solid organ.

    In addition, the UNOS Pediatric Transplant Committee has recently gained momentum on a motion to improve the quality and safety of pediatric transplantation. By the current OPTN Bylaws, the primary surgeon and primary physician in a pediatric transplant program are not required to have pediatric training or experience. The Pediatric Transplant Committee identified that OPTN data from 1995-2010 showed significantly better unadjusted Kaplan-Meier graft and patient survival for kidney, liver, and heart recipients from 1995-2010 at higher volume centers. Higher volume centers were defined differently for each organ:  12 for kidney, 18 for livers, 8 for hearts, and 4 for lungs, respectively. Over the period from 1/1/05-7/31/14, 65.5% of kidney and 58.0% of liver programs performing pediatric transplants met these criteria. The proposal by the UNOS Pediatric Transplant Committee requires that each transplant center have a primary pediatric transplant surgeon who meets the current Bylaws for a Primary Surgeon in addition to having performed 12 pediatric kidneys or 18 pediatric livers and participated for at least 2 years in organ-specific pediatric transplantation care. This proposal was presented to the Membership and Professional Standards Committee (MPSC) in September 2015. The MPSC is supportive of the proposal overall with the caveat that there be at least one qualifying program in each region by the time the requirements take effect.

    If pediatric requirements are accepted, mandating similar volume criteria for surgical fellowship (performing 12 kidneys and 18 livers for pediatric certification) would convey the technical and management differences that exist in pediatric transplantation. Currently in the 119 modules the transplant fellows are required to complete in the ASTS Academic Universe, only 2 are specific to pediatric transplantation.

    With certification targets in place, applicants interested in pediatric transplantation can seek out programs that will satisfy the requirements.  Graduates of these programs may pave the way to a better understanding of these pediatric differences following completion of their training. They can embark on job opportunities that reflect their strengths or look to continue training with their deficits more clearly defined. That is not to say that someone with no pediatric fellowship training could not consider pediatrics as a job career, but like many graduates without pancreatic or intestine training, the understanding is that they will not lead a program without senior expertise and further exposure.

    What continues to set transplant surgeons apart from other surgical fields is their lifelong commitment to patients, the reason that many of us chose the field. Setting fellowship requirements in pediatric transplantation might emphasize to trainees that performing a transplant on children means understanding and commanding issues unique to this patient population, such as the impact of psychomotor development as well as psychosocial issues, bone disease, inherited and sporadic syndromes, metabolic diseases, urologic anomalies, the effects of life-long immunosuppression, non-adherence particularly amongst adolescents, post-transplant lymphoproliferative disorders, and anatomic considerations (3,4). Embracing this knowledge allows us to advance the field of pediatric transplantation and reinforce our commitment to take care of such a fragile patient population.

    Bibliography

    1: Rana A, Pallister Z, Halazun K, Cotton R, Guiteau J, Nalty CC, O'Mahony CA, Goss JA. Pediatric Liver Transplant Center Volume and the Likelihood of Transplantation. Pediatrics. 2015 Jul;136(1):e99-e107. doi:10.1542/peds.2014-3016. Epub 2015 Jun 15. PubMed PMID: 26077479.

    2: Schold JD, Buccini LD, Goldfarb DA, Flechner SM, Poggio ED, Sehgal AR. Association between kidney transplant center performance and the survival benefit of transplantation versus dialysis. Clin J Am Soc Nephrol. 2014 Oct 7;9(10):1773-80. doi: 10.2215/CJN.02380314. Epub 2014 Sep 18. PubMed PMID:25237071; PubMed Central PMCID: PMC4186511.

    3. Davis ID, Bunchman TE, Grimm PC, Benfield MR, Briscoe DM, Harmon WE, Alexander SR, Avner ED. Pediatric renal transplantation: indications and special considerations. A position paper from the Pediatric Committee of the American Society of Transplant Physicians. Pediatr Transplant. 1998 May;2(2):117-29.Review. PubMed PMID: 10082443.

    4.  McDiarmid SV. Liver transplantation. The pediatric challenge. Clin Liver Dis. 2000 Nov;4(4):879-927. Review. PubMed PMID: 11232362.

    Have a different perspective? The ASTS Communications Committee would love to hear it. Log in to comment below or send your thoughts to asts@asts.org!

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  • Uncompensated Work in Transplantation

    Dr. Christine Hwang Christine Hwang, MD
    Assistant Professor, Surgery
    UT Southwestern Medical Center

    In most specialties of general surgery, surgeons have a set schedule and patients are seen at regular intervals in clinic and scheduled for elective cases. Relative value units (RVUs) are generated in a predictable fashion, both in clinic and in the operating room.

    Transplant surgery is quite the opposite. We see our patients in evaluation, but the procurements and transplants occur at unpredictable times, and transplant activity waxes and wanes. When we do receive organ offers, it is not uncommon for multiple recipients to be evaluated for the same organ offer. This translates into going through several potential recipients’ charts, then admitting potential recipients, with only the possibility of transplantation.

    In the ideal situation, one of those potential recipients will receive the organ, which will allow for RVU generation, but there are times where nobody will receive the organ, and the work of evaluating each potential recipient is wasted. This work will not generate any RVUs except for at best reimbursement for seeing a patient to perform a history and physical.

    There are models in surgery where one is reimbursed for being on call, and in addition to that, any activity and RVU generation when being on call is compensated. This model extends into the call schedule for ancillary staff, such as OR staff, who are paid to take call and receive additional compensation if called in. Unfortunately, there is no such model in transplant surgery.

    In our field, we perform many other activities without any or minimal RVU compensation. Procurement activity is a perfect example of work without RVU compensation.  There is no RVU value associated with procurement activity. In general, most procurements take about 3 hours. There is also the travel time to the donor hospital and back to the transplant center, which is usually a couple of hours each way. Delays are not uncommon, where the procurement may be bumped for an undisclosed amount of time for an emergency at the donor hospital or waiting for other teams to arrive. These delays can add several hours to the process. All the time associated with a procurement can easily take 8 hours, or the time one puts in a “regular” working day. Finally, if the organ is procured and ultimately not used, there is no fee paid for the procurement.  It is interesting to note that some institutions have assigned an RVU value to procurement activity1.

    Likewise, backtable preparation of the organ, despite having a charge, also does not generate any RVU activity, unless a complex vascular reconstruction is involved. Some backtable activity can be simple enough, but the activity takes time and skill to perform and in some instances is critical in performing the transplant. A backtable reconstruction of the arterial system of a liver can be quite complex and can significantly simplify the arterial anastomosis in the recipient; the CPT code for arterial reconstruction, 47147, will generate only 7 RVUs. To put that into perspective, a laparoscopic appendectomy, 44970, will generate 9.45 RVUs.

    In an era where RVUs are increasingly viewed and equated to productivity, lack of recognition of work performed by transplant surgeons in the form of RVUs can become troublesome. As noted above, much of our work as transplant surgeons is not accounted for in work RVU activity. Some centers have adopted the strategy to have co-surgeons be involved in a liver transplant, which would allow for 125% of charges to be generated, rather than an assistant fee, which would be 110%. A virtual RVU system has been suggested2 by Abouljoud et al.

    It is again reasonable to have such a system account for this discrepancy in work performance; the other option is that transplant surgeons should work toward having their activities and work accounted for properly. This is not to ask for higher pay, but simply to receive credit for the work that we perform.

    1. https://www.aamc.org/download/105928/data/
    2. Abouljoud M, Whitehouse S, Langnas A et al. Compensating the transplant professional: time for a model change. Am J Transplant 2015 Mar; 15(3):601-5.
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  • Hepatobiliary Surgery Training: A Transplant Surgeon’s Perspective

    Dr. Srinath ChinnakotlaSrinath Chinnakotla, MD
    Transplant Surgeon
    Director of Living Liver Donor Program
    University of Minnesota

    Medicine, the technological application of scientific knowledge to the treatment of human patients with diseases or injuries, is practiced within the confines of cultural biases and financial constraints. As scientific knowledge and technology change, medicine constantly evolves.

    The surgical sciences are particularly influenced by technology. Over the last two decades, advances in optics and radiologic imaging have revolutionized the practice of surgery. It continues to migrate to progressively less invasive approaches: minimally invasive surgery and interventional radiology have redefined treatment for many common diseases. As an example, the treatment of choice for malignant liver tumors was, for decades, open surgical resection, which conferred a 40% chance of five-year survival and a 20% chance of cure for patients with primary hepatocellular carcinoma or metastatic colorectal cancer. But in the last decade, many improvements, including laparoscopic liver resection, have been developed. At first, only superficial and peripheral lesions in anterolateral segments were selected for the laparoscopic approach. More recently, however, centers with extensive experience in laparoscopy and hepatic surgery have also performed major hepatic resections laparoscopically—with satisfactory outcomes. Importantly, no evidence of compromised oncologic clearance has been found in patients who undergo laparoscopic liver resection.

    Other new surgical strategies for safer resection include two-stage hepatectomies with portal vein embolization. For patients with unresectable liver metastases, thermal ablation is an option. The percentage of patients who can now be considered for liver resection has jumped to almost 30%. In recent years, better survival rates for patients with primary or metastatic liver cancer have been reported.

    Of course, with the development of all these new therapies, academic surgeons face a number of challenges. First and foremost is how to train future surgeons to perform advanced hepatobiliary procedures with competence.

    In the last decade, the number of general surgery residents seeking fellowship training has markedly increased. More than 80% of them now pursue subspecialty training after their general surgery residency.1 In particular, interest in complex general surgery has risen, because residents often do not feel prepared for independent practice after graduation. In fact, in the field of hepatobiliary surgery, the typical graduating general surgery resident in the United States in 2012 had performed a mean of only 11.3 ± 4.3 pancreas procedures, 9.4 ± 3.4 liver procedures, and 3.8 ± 2.1 biliary procedures, excluding cholecystectomy.2 Moreover, the Surgical Council on Resident Education (SCORE) curriculum has identified essentially all hepatobiliary procedures as complex, except for cholecystectomy, common bile duct exploration, liver biopsy, and liver abscess drainage. The SCORE curriculum’s definition of complex denotes procedures that are not consistently performed by general surgeons in training and that are not typically performed in general surgery practice. Thus, exposure—but not proficiency—is required; consequently, additional hepatobiliary training after the general surgery residency has become the norm.

    In the United States, that additional hepatobiliary training is primarily accredited by the fellowship council of the Americas Hepato-Pancreato-Biliary Association (AHPBA). More than 21 AHPBA-accredited, standalone fellowship programs now offer hepatobiliary surgery training; half are one-year programs, and half are two-year programs. Program requirements include performing, per year, 100 hepatobiliary procedures (including at least 25 liver, 25 pancreas, and 15 biliary procedures). The fellow is expected to be a primary surgeon in at least 70 of those procedures; no more than 20% of them can be transplants.

    Other societies accrediting hepatobiliary fellows include the Society of Surgical Oncology (SSO) and the American Society of Transplant Surgeons (ASTS). The SSO offers certification in complex general surgical oncology. Typically, SSO trainees perform more than 150 surgical oncology procedures (including at least 15 complex upper gastrointestinal procedures). According to SSO data, graduates have participated in a median of 35 hepatic procedures, 20 Whipple operations, and 17 pancreatectomies. The SSO also requires its trainees to facilitate multidisciplinary cancer care and to enroll patients in clinical trials.

    ASTS requirements for hepatobiliary certification include 35 hepatobiliary procedures (at least 12 hemihepatectomies and 15 biliary procedures); for hepatopancreatobiliary certification, an additional 15 nontransplant major pancreas procedures are required.

    As transplant surgeons, we have several skill sets that are required for hepatobiliary procedures. About 20% to 30% of liver transplants are in patients with hepatocellular carcinoma. Pretransplant, we are very involved in the management of those tumors and regularly attend multidisciplinary tumor conferences. We actively collaborate with medical oncologists in delivering chemo-embolization and adjuvant therapies. We are engaged in providing ablation and liver resections. We perform split-liver transplants and living donor liver transplants. Our experience with implanting and explanting livers translates well to ex vivo resections. Our adroitness with various vascular anastomoses (which are necessary during transplants) also translates well to such hepatobiliary procedures as portal vein resections for pancreatic cancer during Whipple operations. And we are deeply familiar with the management of liver failure and portal hypertension, closely collaborating with medical hepatologists to care for such patients.

    Obviously, transplant surgery can and should be included as a core element of hepatobiliary surgery training programs (such as those accredited by the AHPBA and SSO). The two main implications of this approach are far-reaching. First, it will provide core transplant experience to future surgeons. Second, it will foster more collaboration between hepatobiliary surgeons and transplant surgeons, so that we can learn from each other and ultimately provide better care to our patients. A key step in the right direction was the recent joint conference (conducted at San Francisco on October 27, 2014, by the AHPBA, SSO, and ASTS) to develop a consensus on hepatobiliary surgery training guidelines.

    In conclusion, every academic transplant program should have a hepatobiliary surgery portfolio and needs to understand the critical need for hepatobiliary surgery training, both during and especially after the general surgery residency. We must collaborate even more closely with our AHPBA and SSO colleagues to have the greatest impact on patient care and on the next generation of surgeon-scientists.

    1. Borman KR, Vick LR, Biester TW et al. changing demographics of residents choosing fellowships: longterm data from the American Board of Surgery. J Am Coll Surg.2008; 206:782-788; discussion 788-789
    2. Sachs TE, Ejaz A, Weiss M et al. Assessing the experience in complex hepatopancreatobiliary surgery among graduating chief residents: is the operative experience enough? Surgery 2014;156:385-393.
    Have a different perspective? The ASTS Communications Committee would love to hear it and share it with your fellow members in an upcoming issue of the Chimera. Comment below or send your thoughts to asts@asts.org!
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