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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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  • How Can We Continue to Attract the Best U.S. Surgical Residents into Transplant Surgery?

    Dr. Zoe StewartZoe A. Stewart, MD, PhD, FACS
    Surgical Director Kidney, Pancreas, & Living Donor Transplant
    Assistant Professor of Hepatobiliary and Transplant Surgery

    University of Iowa Organ Transplant Center

    There has been extensive debate in the past few years about the number of transplant surgery fellowship positions. While we may never reach a consensus about the “correct” number of fellowship slots, these discussions have highlighted the challenge to recruit the best U.S. trainees into transplant surgery.

    General surgery training has seen dramatic changes in the past two decades. Implementation of the 80-hour workweek has impacted trainee expectations of work/life balance and potentially reduced resident exposure to transplant surgery. There has also been an explosion in subspecialty training options (breast, endocrine, minimally invasive, bariatric, surgical oncology, colorectal, hepatobiliary, trauma/critical care, burn...to name a few). Further, several specialties (Cardiothoracic, Vascular, Plastics) now enroll some of the most talented medical students directly into “Integrated” residency/fellowship programs, depriving abdominal transplant surgery of the opportunity to recruit these students. Finally, the number of women in surgery continues to rise, from 25 percent in 2003 to almost 40 percent in 2013.

    Numerous factors contribute to the selection of a surgery subspecialty fellowship: intellectual appeal, clinical exposure during residency, an influential mentor, fellowship competitiveness, job opportunities, and lifestyle. While the relative importance of these factors vary between individual trainees, all are vital to the decision-making process. The intellectual appeal of transplant surgery is undeniable. For decades transplant surgery has been perceived as a leader in innovation for all aspects of surgical patient care. However, even liver transplantation is now often considered “old hat” by medical students and residents. Additionally, many subspecialties now outcompete transplant surgery for surgical trainees who desire to be at the forefront of new surgical techniques in robotic, minimally invasive, and endovascular approaches.

    In the past decade, surgical resident exposure to transplant surgery rotations has been in jeopardy of being eliminated. In 2006, the Residency Review Committee (RRC) in Surgery proposed removing the transplant surgery rotation from the core education requirements, citing consistently poor resident evaluations of their transplant educational experience. ASTS developed a corrective action plan to address the RRC concerns and implemented a new resident curriculum. While ASTS won a stay of execution for the resident rotation in transplant surgery at the last hour, the RRC is continuing to closely monitor resident and Residency Program Directors’ feedback. In a 2010 follow-up study, ~60 percent of 648 surgery residents reported favorable self-assessment scores on knowledge of immunosuppression management and transplantation ethics, in addition to the surgical skill set they acquired during their transplant rotation1. A majority of residents also agreed that transplant surgical skills would assist them in their careers and were applicable to other surgical subspecialties.

     Unfortunately, transplant surgery is the least competitive surgical subspecialty for U.S. graduates. The 2014 NRMP Match Data reported 20 U.S. applicants for the 73 Transplant Surgery positions (0.27 applicants/position). In contrast, Pediatric Surgery had 59 U.S. applicants for 38 fellowship positions (1.55 applicants/position)2. While we can debate what the denominator should be for transplant surgery fellowship positions, clearly we need to make transplant fellowship a desirable commodity to attract the very best U.S. trainees.

    Debate on the number of transplant fellowship positions has often focused on the perceived lack of job opportunities for fellowship graduates. However, recent data from several sources has failed to validate this concern. ASTS fellowship exit survey data from 2010-2014 found that annually 80-90 percent of U.S. graduates (24-35 graduates annually) obtained transplant jobs and >80 percent of these graduates got positions transplanting their desired organ(s). Nearly identical results were obtained in a study of an older cohort (2003-2005), with >90 percent of U.S. trainees getting transplant jobs and again over 80 percent getting positions transplanting their preferred organ(s)3.

    There is little question that transplant surgery is globally viewed as having one of the poorest lifestyles of any surgical subspecialty. Resident perceptions about lifestyle are strongly influenced by their mentors. Trainees are unlikely to consider transplant surgery if their mentors are constantly complaining about their call schedule or having to operate at night. We have a tremendous responsibility to impart our passion for what we do on a daily basis to medical students and residents. Finally, I have personally found it very exciting to observe the steady rise in the number of female transplant surgeons. Hopefully this trend will continue and help to foster to the ongoing recruitment of female surgical residents into transplant surgery…from my perspective.

    References

    1 Schwartz J.J., Thiesset H.F., Bohn J.A., et al. (2012) Perceived benefits of a transplant surgery experience to general surgery residency. J Surg Educ 69(3): 371-384.

    2 National Residency Match Program. (2014) Results and Data Specialties Matching Service. www.nrmp.org

    3 Reich D.J., Magee J.C., Gifford K., et al. (2011) Transplant surgery fellow perceptions about training and the ensuing job market--are the right number of surgeons being trained? Am J Transplant 11(2): 253-260.

    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!
    Go comment!
  • HCV Recurrence

    Dr. Caroline Rochon

    Caroline Rochon, MD, FACS
    Transplant and Hepatobiliary Surgeon
    Hartford Hospital
    Hartford, Connecticut

    Because the treatment of HCV recurrence after liver transplantation, a major cause of graft loss, has shown such disappointing results over the years, transplant programs have tried to attack the recurrence problem with prevention strategies first and desperate therapeutic attempts second. Transplant surgeons anticipate HCV recurrence even before the surgery begins. Several donor factors have been identified with higher potential for HCV recurrence post transplantation and most transplant centers will not accept the same organs for HCV positive recipients that they would for recipients with other indications for transplant.

    Many studies have identified multiple donor factors as being associated with higher/earlier HCV recurrence, the most important being increased donor age and higher percentage of steatosis in the graft. The decision to avoid transplanting HCV recipients with older/fatter grafts varies from center to center. How old is too old and how fat is too fat is a matter of preference, but the practice remains universal: prevent recurrence by judicious graft selection. As a consequence, HCV positive candidates can have a longer wait for transplant or a lower transplant rate than candidates without the disease. Other strategies employed in the post-transplant setting involve avoidance of over immunosuppression or episodes of acute rejection (easier said than done).

    In theory, HCV positive liver transplant recipients can be treated with a pre-emptive approach immediately following transplantation or with a recurrence-based approach when liver damage is diagnosed. The advantages of pre-emptive or early post-transplant treatment are that serum HCV-RNA levels are characteristically low and significant histological graft damage is virtually absent. Although these factors predict a favorable response, this therapeutic approach had traditionally been difficult to manage because of poor tolerability and reduced efficacy of the pegylated interferon/ribavirin combination. Thus, the preferred strategy is usually to delay antiviral treatment until histological evidence of recurrent post-transplant HCV-related chronic hepatitis is established. This evidence is sometimes found on biopsies ordered to investigate clinical abnormalities or on protocol biopsies often done at 1 year post transplantation. The algorithms for care vary greatly between institutions but most centers will treat patients with clinical and histological signs of recurrence and at least Grade 3 or 4 inflammation or stage II fibrosis in the liver graft tissue. In this setting, treatment with a combination of Pegylated Interferon plus ribavirin is associated with an overall sustained virological response (SVR) of about 30% (1).

    The recent introduction of direct-acting antivirals, including drugs that inhibit protease, polymerase and other non-structural proteins, heralds a new era in HCV treatment. In the post-transplant phase, triple therapy, with either telaprevir or boceprevir faces multiple challenges. (2) Post-transplant HCV recipients are often “difficult to treat” patients, either because they were prior non responders or they had a high blood HCV RNA. Still, improved outcomes are expected with the new drugs. Triple therapy with these agents is now being investigated. While the data are still very preliminary, reports show that 70 to 90% of patients are virus free at 12 weeks. (3) Infectious and hematologic complications are frequent and drug levels need to be monitored very carefully due to drug-drug interactions between calcineurin inhibitors and protease inhibitors.

     Therefore, from my perspective, the increased risk of HCV recurrence post-transplant with older, more steatotic donor grafts is offset by the better ability we now have to treat recurrent disease, even if recurrence is still considered an off label indication.

    We also have to wonder, in the era of these new drugs, whether it is wise to wait a full year before protocol biopsies and whether it is worth waiting for stage 2 fibrosis on biopsy to treat. Outcomes may be improved with earlier treatment of HCV recurrence; one might even talk of “recurrence prevention.” As we develop expertise with interferon-free direct acting antiviral therapy, like with sofosbuvir for example, lowering the feared risk of rejection while on treatment, we should all discuss how ethical it is to let the virus damage any graft at all and whether all HCV recipients should be treated preemptively post transplantation. (4) Such approaches seem particularly appropriate if the team decided to forfeit the traditional prevention strategies likes avoidance of older donor grafts. In short, the fight against HCV may be won by breaking the barriers to transplantation, being more liberal with graft acceptance and treating preemptively all grafts before the virus begins to damage the new liver…from my perspective.

    References

    1. Roche B, Samuel D. Hepatitis C virus treatment pre- and post-liver transplantation. Liver Int 2012; 32( suppl 1): 120-128.
    2. Werner CR1, Egetemeyr DP, Lauer UM, Nadalin S, Königsrainer A, Malek NP, Berg CP Telaprevir-based triple therapy in liver transplant patients with hepatitis C virus: a 12-week pilot study providing safety and efficacy data. Liver Transpl. 2012 Dec;18(12):1464-70.
    3. Punpapong S, Murphy JL, Henry TM, Ryland K, Satyanaravana R, Rosser B, Yataco ML, Keaveny A. Preliminary experience using Telaprevir with Peginterferon and Ribavirin for treatment of HCV genotype 1 after liver transplantation. Liver Transpl. 2013 2013 Jul;19(7):690-700.
    4. Charlton M, Gane E, Manns MP, Brown RS Jr, Curry MP, Kwo PY, Fontana RJ, Gilroy R, Teperman L, Muir AJ, McHutchison JG, Symonds WT, Brainard D, Kirby B, Dvory-Sobol H, Denning J, Arterburn S Samuel D, Forns X, Terrault NA. Sofosbuvir and Ribavirin for Treatment of Compensated Recurrent Hepatitis C Virus Infection After Liver Transplantation. Gastroenterology. 2014 Oct 7. [Epub ahead of print]

    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!
    Go comment!