What's Your Perspective?

  • Growing the Pipeline of Future Transplant Surgeons

    Dageforde Photo JPGLeigh Anne Dageforde, MD, MPH
    Massachusetts General Hospital

    Transplant Surgery is an amazing field so let’s get students and residents involved early!

    From my perspective, transplant surgeons have one of the most exciting careers in medicine. We have a unique role in turning the devastating experience of death into a life-giving opportunity for multiple patients. Our practices are a combination of time spent in the clinic and the operating room. We do day surgeries and large complex operations. Our patients require equal parts medical knowledge and surgical skill. Some of our patients are rescued from the brink of death after lingering in the MICU with a high MELD awaiting their liver transplant. Others come from home for their preemptive living donor kidney transplant. We treat patients of all ages with diverse social situations and backgrounds. Our role in the field can be customized by organ-type and interest. Many of us follow our patients for years building lasting relationships with them and their families reminiscent of a relationship with a primary care physician. Transplant research is novel and cutting edge, and more work needs to be done. What a great field!

    If all this is true, then why is the demand for an abdominal organ transplant fellowship so low?

    Transplant surgery is one of the least competitive fellowships for US trained general surgery residents, and the number of applications for transplant surgery fellowship has been decreasing in recent years 1,2. The reasons for this are felt to be multifactorial. Fewer students rotate on transplant surgery with the new curriculums mixing clinical care with educational lectures, and some students may not even be at a center with transplant surgery.   Also, students can now match directly into surgical subspecialty residencies thus bypassing the opportunity to “recruit” general surgery residents to the field. Some general surgery residency programs see the “service-education” balance fall too heavily towards service and have reduced the resident time on transplant rotations. NPs and PAs are utilized to organize the complex care required of transplant patients both in- and out-patient.  For trainees there are work-life balance concerns 3 as well as questions about available jobs after training 4. Innovations in transplant surgery such as normothermic perfusion and organ procurement centers may improve the transplant operative schedule and address surgeon burnout 5. Still, it should be a priority of us as transplant surgeons to recruit highly qualified, excellent future surgeons to be our partners and eventual replacements!

    To recruit an ongoing stream of future transplant surgeons, Dorry Segev, MD, PhD and Jean Emond, MD organized the ASTS Pipeline Taskforce. Our Taskforce is working to reach students and residents very early in their career to improve their exposure to transplantation. We have developed the Pipeline Award to recognize surgeons committed to sharing their love of the field and are conducting research to better understand career choices by general surgery residents. We are partnering with the Behind the Knife podcast to provide listeners with pertinent clinical information about solid organ transplantation. Listeners also have the opportunity to hear 13 diverse transplant surgeons share about both their career and life outside the hospital.

    Behind The Knife/ASTS Podcast Series

    Access the Podcast at: http://behindtheknife.libsyn.com/. The BTK/ASTS Miniseries was published in October 2019, but the podcasts are still available. Please promote among students and residents by encouraging them to listen to high-yield transplant information for the ABSITE and Boards.

    Behind The Knife/ASTS Podcast Miniseries Session Guide


    Session 1

    We explore a vascular access case and the pre-transplant evaluation for both liver and kidney transplant. We also explore the most common indications for transplantation.

    Dr. Arika Hoffman, a kidney transplant and vascular access surgeon, talks about her practice at University of Nebraska medical center. She also shares about balancing life with her kids with her busy clinical schedule.

    Dr. Vincent Casingal is Chief of the Division of Abdominal Transplant and the surgical director of the kidney transplant program at Atrium Health’s Carolinas Medical Center in Charlotte, North Carolina. He talks about life as a transplant surgeon without a transplant fellow.

    Session 2
    In this session we explore what to look for when patients are called in for the liver or kidney transplant operation. The induction immunosuppression medications and their mechanisms of action are discussed.

    Dr. Joshua Mezrich, transplant surgeon at the University of Wisconsin Hospital and author of recently published book, When Death Becomes Life, shares about memorable patients and what drew him to transplant surgery.

    Dr. Majella Doyle is a Professor of Surgery at Washington University in St. Louis where her practice includes pediatric liver transplant surgery, adult liver/pancreas/kidney transplants, HPB surgery, and living donor nephrectomies.  She was born and trained in Ireland and discusses advice for young residents interested in a career in transplant surgery.

    Session 3
    This session highlights some of the most common post-transplant complications that residents and students caring for liver and kidney transplant patients may encounter.

    Dr. Lisa McElroy just completed her fellowship at University of Michigan Summer 2019 and is now on faculty at Duke. She discusses finding a job and the transition from fellowship to practice.

    Dr. Adeel Khan had a circuitous route to his current position at Washington University in St. Louis due to visa issues.  He gives advice to others interested in transplant surgery who may also encounter difficulty with their visas. He is busy building his robotic HPB practice in addition to his job as a multi-organ transplant surgeon.

    Session 4
    Session 4 examines long-term outcomes after transplant and immunosuppression medications. Also, we discuss post-transplant complications including infection, PTLD and rejection.

    Dr. Satish Nadig works at the Medical Un South Carolina and is an NIH funded basic science researcher who shares his advice for future transplant surgeons.

    Dr.Daniela Ladner is an Associate Professor of Surgery at Northwestern University where she Director of the Northwestern University Transplant Outcomes Research Collaborative. She is an R01 funded health services researcher.

    Session 5
    This unique episode discusses organ donation – both living and deceased donors.

    Dr. Robert Montgomery is the director of the NYU Langone Transplant Center. He was a recipient of an HCV+ heart transplant and discusses his own experience as a patient and the research opportunities for future transplant surgeons.

    Dr. Charles Rickert is a PGY-4 general surgery resident at MGH. He is currently applying for solid organ transplant fellowships after having completed his research time studying immunology and zenotransplant. He was a non-designated altruistic living kidney donor during medical school.

    Session 6
    In this transplant “Grab Bag” session we talk with transplant surgeons about the intersection of transplant and global/international surgery as well as transplant surgery and medical student/resident education. We also hear about multivisceral organ transplant and uterine transplant.

    Dr. Jeffrey Punch at University of Michigan started the living donor kidney transplant program in Ethiopia.

    Dr. Peter Liou is a resident at Columbia where he is pursuing a career in multivisceral organ transplantation.

    Dr. Liza Johannesson at Baylor in Dallas, Texas shares about her experiences as a Uterine transplant surgeon.

    ASTS Pipeline Taskforce members:
    Dorry Segev, MD, PhD; Kelly Collins, MD; Leigh Anne Dageforde, MD, MPH; Mike Englesbe, MD; Jacqueline Garonzik Wang, MD, PhD; Jaime Glorioso, MD; Cutler Quillin, MD; Amit Tevar, MD; Anthony Watkins, MD

    References

    1. Quillin RC, Cortez A, Bongu A, et al. The Transplant Surgery Pipeline. ASTS Winter Symposium. https://onlinelibrary-wiley-com.ezp-prod1.hul.harvard.edu/doi/epdf/10.1111/ajt.14572.

    2. Schlottmann F, Gerber DA, Patti MG. International medical graduates and unfilled positions in abdominal transplant surgery fellowships in the United States. Transpl Int. 2018;31(5):566-567. doi:10.1111/tri.13120.

    3. Balch CM, Shanafelt TD, Sloan JA, Satele DV, Freischlag JA. Distress and career satisfaction among 14 surgical specialties, comparing academic and private practice settings. Ann Surg. 2011;254(4):558-568. doi:10.1097/SLA.0b013e318230097e.

    4. Reich DJ, Magee JC, Gifford K, et al. Transplant surgery fellow perceptions about training and the ensuing job market-are the right number of surgeons being trained? Am J Transplant. 2011;11(2):253-260. doi:10.1111/j.1600-6143.2010.03308.x.

    5. Lindemann J, Dageforde LA, Brockmeier D, et al. Organ procurement center allows for daytime liver transplantation with less resource utilization: May address burnout, pipeline, and safety for field of transplantation. Am J Transplant. 2018;11(4):1109. doi:10.1111/ajt.15129.

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  • The Value of Upper Extremity, Face, and Uterus Transplantation: A Workshop with the Leading Programs in the U.S. and Funding Institutions

    Andreas TzakisAndreas Tzakis, MD
    Cleveland Clinic

    ASTS, in collaboration with AST, the American Society for Reproductive Medicine (ASRM), and the American Society for Reconstructive Transplantation (ASRT), is organizing a workshop on face, hand, and uterus transplants to take place at the Uniformed Services University on November 8, 2019. Invited are leaders of private and public funding and regulatory organizations. Presentations will be made by the leading active programs in the United States.

    This workshop is a continuum of a symposium convened in Baltimore in 2017. It aims to update our guests on the current state of VCA. Indeed, significant progress has been made since then toward:

    • Establishing the indications
    • Standardizing the procedures
    • Quantifying and presenting the results using common functional dashboards
    • Accumulating more data on cost benefit analysis
    • Collaborating with third party payers to develop reimbursement plans

    VCAs differ in regard to the clinical problems they address, the organs transplanted, and the qualifications and background of the caregivers. Face and hand transplants have a longer history and slow buildup of the experience. Possible candidates nationwide are numbered in the hundreds. Uterus is the most recent. Experience is building more rapidly, and possible candidates are numbered in the thousands.

    Although spotty, coverage of the medical cost has been provided for exceptional cases. These include military service-related injuries as well as with Local Coverage Determinations (LCDs). In general, reimbursement has been an extremely difficult problem.

    One serious obstacle has been the small number of clinical cases performed. Historically, data is sparse and not standardized. Collaboration among centers is highly desirable.

    Abdominal wall transplants, although VCAs, will not be discussed in this workshop because they have been packaged with intestinal or multivisceral transplants.

    The latest addition, uterus transplants, are also very different. They have been segregated from VCAs and are now included with the other solid organs.

    Indeed, the uterus is a solid organ rather than a composite tissue graft. Whereas transplant surgeons play a consulting role in VCAs, in uterus transplants transplant surgeons and gynecologists play a vital role in the development and performance of these procedures.

    The active clinical programs (Baylor Hospital, University of Pennsylvania, and Cleveland Clinic) already share clinical information through regular meetings and conference calls. They have agreed to form a consortium. Sharing will include a database and tissue repositories in order to expedite learning and research as well as training of new staff.

    Pursuing Current Procedural Terminology (CPT) codes for VCAs to enable tracking has been a priority but is a very elaborate process. It has now been reinvigorated thanks to the personal interest of ASTS President Dr. Lloyd Ratner.

    We hope that this workshop will bring face, hand, and uterus transplants closer to acceptance in clinical practice.

    Uterus Transplant: A personal perspective on the occasion of the International State of the Art International meeting in Cleveland (September 6-7, 2019)

    The 2nd Congress of the International Society of Uterus Transplantation is planned to take place in Cleveland on September 6th and 7th, 2019. More than 100 participants are expected to attend. More than 50 uterus transplants and more than 15 babies born as a result worldwide. Lively and informative discussions are eagerly expected.

    My introduction to uterus transplants started when I was a junior staff surgeon at the University of Pittsburgh. A novelist approached me at the direction of Dr T. E. Starzl; his heroine, a renowned transplant surgeon, had to perform a uterus transplant. He did not disclose the plot. The question was: how would she do it?

    I went to my anatomy books and conceived the operation for him. The book was published successfully. I was included in the credits and did not give it a second thought for several years.

    Then, a young woman in her 20’s presented to me at the University of Miami in need of a multivisceral transplant, a transplant which would include all abdominal organs. She had a prior hysterectomy and no children. Would it not be nice to restore everything back to normal?

    A seminal event had just occurred in my own life and made me sensitive: my wife gave birth to our daughter… I will never forget the day our daughter was born. It was a pivotal event, the happiest day of my life, and had an everlasting effect!

    Indeed, I don’t know anything more valuable to my wife and I than our daughter. The thought of adding a uterus to my patient’s multivisceral transplant was insistent. Prudence prevailed and I abandoned the thought for this particular patient. It would be too much risk for an unknown procedure. But what about doing a uterus transplant for patients who could not have children because of lack of a functioning uterus?

    I had to study it.

    Having resolved the anatomical considerations, at least in theory, I had to study the immunology of the uterus, particularly because of its role in the tolerance of the offspring by the mother.

    There were 3 volunteers on the team, eager to participate in the studies: Werviston (Tom) DeFaria, Akin Tekin, and Takis Tryfonopoulos, all surgeons with passion for research. We obtained mini swines, which Dr. David Sachs was kind enough to provide. We designed a heterotopic variant of the operation in order to study the uterus, rejection, its treatment, and the longevity of the graft. The feasibility, at least in animals, was demonstrated.

    By good fortune, while working on the mini swine model, I received an Honorary Degree from the University of Gothenburg in Sweden, home of my good friend Michael Olausson and also Mats Brannstrom, the Chairman of Gynecology who was working diligently with his team, including Michael, on uterus transplants. They were ahead of us!

    It was the beginning of a collaboration that took us to Nairobi, Kenya, and Homestead, Florida, for experiments on primates and then to Gothenburg for the first clinical trial at the Sahlgrenska University Hospital.

    This was a great inspiration, particularly because at that time I was relocating to the Cleveland Clinic, an institution with an excellent record in transplant research and an exceptionally good gynecological program led by Dr. Tommaso Falcone.

    Dr. Falcone expressed some skepticism in the beginning. It took a visit to Gothenburg and meeting the recipients of the transplants to persuade him. It was clear that this was an operation that these women really wanted in their quest to have their own children. Once persuaded, Falcone and his team were perfect partners.

    Contrary to most other programs, our preference for these transplants has been that they should be performed with uteri from deceased donors in order to avoid any risk to a living donor.

    We performed our first uterus transplant on February 24, 2016. It was the first attempt in the U.S., which unfortunately failed due to a fungal infection which caused a rupture of one of the arterial anastomoses.

    As a result, there was a very elaborate review of our trial.

    In the meantime, the excellent team at Baylor Hospital in Dallas, Texas, led by Drs. Testa and Klintmalm, with the assistance of Drs. Michael Olausson and Liza Johannesson of the Gothenburg team, performed the first successful uterus transplants in the U.S., which resulted in the births of 2 healthy babies. These were the first babies in the U.S. born from transplanted uteruses.

    We resumed our program as soon as all necessary precautions were taken to avoid another infection. We have now performed an additional 6 transplants, 5 of them successful. One of them resulted in the delivery of a beautiful, healthy baby this July.

    That baby was the first born from a deceased donor in the U.S. and second in the world, confirming the efficacy of this approach.

    Uterus transplantation is evolving rapidly, even in today’s heavily regulated environment. We hope it will be a valuable option to the many women who cannot have children simply because one non-vital part of their body is missing.

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  • Searching for What Defines a Good Outcome After Transplantation

    robert montgomeryRobert A. Montgomery, MD, DPhil, FACS
    NYU Langone Transplant Institute, NYU Langone Health

    Three weeks before my heart transplant in September 2018, I was lecturing at a transplant meeting in Matera, Italy. It was there that I suffered 4 ventricular tachycardic arrests, one after the other.  The next morning, I signed myself out of the tiny hospital in Matera against medical advice with an IV in my arm and boarded a commercial flight back to the U.S. accompanied by a friend who carried a fist full of pre-loaded resuscitation syringes, compliments of the worried Italian doctors. I was rapidly evaluated and admitted to the NYU intensive care unit to wait for a new heart. I had an RO1 grant due the day after my transplant. My first call after my surgeon offered me a new heart at 4 a.m. on September 20th was to my co-PI letting him know he and our staff would have to get the grant across the finish line.

    Within days of my transplant, I began making decisions and doing academic and administrative work from my hospital bed. I would meet with my assistant each day and we would go over essential items that needed to be acted upon. I was 10 days in the hospital and upon discharge began a routine that would continue for the next 2 months: blood draws, heart biopsies, doctors’ appointments, and cardiac rehabilitation were scheduled early in the morning, followed by meetings, rounds, writing, emails, administrative and academic work until about 2 p.m. I was privileged to be able to get my blood draws in my office, avoiding having to line up at the phlebotomy lab door at 7 a.m. next to my patients. The transplant clinic and cardiac catheterization suite were a few floors above my office and the rehab gym was a few blocks down the road. Mid-afternoon I would go home and rest. Just before Thanksgiving I began working full days. A month later, I was seeing patients in clinic. My nurse practitioners and doctors stopped by my office to check on me and answered my texts at all hours of the day and night.

    This is hardly the typical story of a transplant patient, with one exception. I am now 8 months out from my transplant and I am still unable to operate, the part of my job that, in my mind, defines my career. This is not because I am debilitated; on the contrary, I am stronger and more fit than I have been in 20 years. It is not because I have had rejection episodes or complications.  My post-transplant course has been relatively smooth. I am not doing an essential part of my job because I am experiencing a side effect that almost all of our patients have to deal with but rarely talk about: a tacrolimus tremor.

    My administration and colleagues have been very understanding, certainly far more so than our typical patient’s bosses and co-workers. Well, actually, the inconvenient truth is that most transplant patients do not have bosses or co-workers because only a minority of them actually return to work after their transplant. For kidney transplant patients who were not working before their transplant, there is a 92-94% certainty that they will not return to the work force, and yet I used to smile at them at a follow up visit and say, “now, go back to a normal life.”1 They will go back to life and that is an immeasurable gift, but only for a minority of patients will that life be “normal.”

    I remember doing a second kidney transplant for a woman in her 20’s who was highly sensitized. She had been ill most of her life, in and out of hospitals and on dialysis. With a lot of help she had managed to finish high school. After her successful transplant, which involved a complex desensitization protocol, I triumphantly asked her what she was going to do with her new life. She told me she was going to enroll in college in the fall and become a nurse. Just before Thanksgiving, I saw her at a follow-up appointment and asked how it was going. She cast her gaze downward and said, “Not so good, Dr. Montgomery. I had to withdraw from school.” She began to cry, “No one ever expected anything from me and now everyone thinks I should be able to do anything. I have been so depressed.” Upon further discussion, it became clear that her dialysis days had been largely replaced by doctors’ appointments and blood draws, and although she felt better, she had never really needed to develop good time management skills. Many of our patients have been developmentally stunted by chronic disease and have somewhat chaotic lives as a result, and when their transplant happens they are ill-equipped to jump back in.

    For the purpose of measuring the quality of a transplant center, the Centers for Medicare and Medicaid (CMS) define a successful transplant as one in which the patient is alive with a functioning graft at 1 year. The United Network for Organ Sharing (UNOS) and the payers have adopted CMS metrics. Before the CMS final rule, I think transplant physicians and surgeons felt that “saving a patient’s life” by finding them a suitable allograft and getting them out of the hospital was success. We did liver transplants for patients who had a predicted one-year survival rate of < 70%. We took risks on organs and patients’ diseases that we would not consider doing now that our actions can put programs and hospitals at risk of decertification. We spend a lot of time adjusting the risk needle to satisfy CMS’s definition of success. We have all done the fireman’s carry of a patient with a failing allograft or a flickering life force across the one-year finish line. I think most of us could agree that this type of effort does not feel very satisfying and is not the success that we had hoped for.

    What do your patients think? Until I started asking them this question a few months ago, I had no idea. I assumed they had the same definition as I did, being alive and free of the pain and perils of debilitating end stage organ disease. I knew quality of life measurements showed that the patients were better off than before the transplant, but for most patients things could hardly have gotten worse. I think we need to begin to explore this question beyond what can be discovered with quality of life indices. To do this we need a better understanding of the burden of disease and of transplantation. The restoration of health, happiness, and productivity should be the goal, but not just for one year. We need to get insurers and regulators more interested in outcomes that patients consider to be important. It is going to take resources and buy-in from all the stake holders.  

    And what about innovative therapy like desensitization or xenotransplantation? The more desperate patients feel, the more risk they are willing to take. What are the limits of risk?  Based on primate studies, the best we can expect from xenograft survival in the early human trials will be about 1-2 years and much of that time could be spent in the hospital. Which groups of patients might consider a one- or two-year dialysis hiatus a meaningful outcome that they would be willing to put their lives on the line for? These are questions we need to find out.

    I spoke to a woman the other day at a kidney event who donated to her 60-year-old father five years ago. I asked how he was doing. She smiled and said his creatinine was 1.0. I said, “That’s great. You must be very proud and happy.” She replied that she was, but that he shook so much that he could no longer take care of himself and she had had to move in with him. I asked if they had discussed this with his doctor. “Yes, but he said it was just a side effect of the medication and not Parkinson’s,” was her reply. “I don’t want to complain. I am just glad he is alive.”

    With all the resources and knowledge I have at my disposal – my brightest colleagues ready to discuss my problem with me at meetings or on the phone and my ability to read and process key studies in the literature, travel to centers using innovative immunosuppression protocols, and weigh the risks of trying them – I have no doubt that I will be back in the operating room soon.  Barring a lightning strike, I will return to the life I had hoped for. I am an exception and my story in no way mirrors most — in fact, it acts as an important contrast to the journey of many of our patients. This awareness compels me to ask them questions I never did before and the answers I get are pretty shocking. Everyone who has a stake in transplantation should want their patients to more fully actualize the potential of the miracles we enable. Being awestruck that these folks are still alive and walking around is no longer an acceptable metric for success. We can do better. 

    References:

    1. Tzvetanov I, D'Amico G, Walczak D, Jeon H, Garcia-Roca R, Oberholzer J, Benedetti E.High rate of unemployment after kidney transplantation: analysis of the United network for organ sharing database.Transplant Proc. 2014 Jun;46(5):1290-4.
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