Transplant Fellowship Research Articles

Training the Next Generation of Transplant Surgeons With a 3-Dimensional Trainer: A Pilot Study.

In the United States, no published guidelines promote exposure to technical variants (ie, living donor or split liver) during transplant fellowship. Simulation with hands-on liver models may improve training in transplantation. This pilot study addressed 3 overall goals (material and model creation tools, recruitment rates and assessment of workload, and protocol adherence). A patient-specific hands-on liver model was constructed from clinical imaging, and it needed to be resilient and realistic. Multiple types of materials were tested between January 2020 and August 2022. Participants were recruited stepwise. A left lateral segmentectomy simulation was conducted between August 2022 and December 2022 to assess protocol adherence. Digital anatomy 3-dimensional printing was considered the best option for the hands-on liver model. The recruitment rate was 100% and 47% for junior attendings and surgical residents, respectively. Ten participants were included and completed all the required surveys. Seven (70%) and 6 (60%) participants "agreed" that the overall quality of the model and the material were acceptable for surgical simulation. Five participants (50%) "agreed" that the training improved their surgical skills. Nine participants (90%) "strongly agreed" that similar sessions should be included in surgical training programs. Three-dimensional hands-on liver models have the advantage of tactile feedback and were rated favorably as a potential training tool. Study enrollment for further studies is possible with the support of leadership. Rigorous multicenter designs should be developed to measure the actual impact of 3-dimensional hands-on liver models on surgical training.

Examining the Influence of a General Surgery Resident's Transplant Experience on Their Pursuit of Transplant Surgery Fellowship.

Transplant surgery has historically been a less desirable fellowship among general surgery graduates. Limited work has been done to understand factors associated with residents' interest in transplantation. Using a multi-institutional cohort, we examined how the resident experience on transplant surgery may influence their decision to pursue transplant fellowship. Individual demographics, program characteristics, and transplant-specific case logs were collected for graduates from 2010 to 2020 at 20 general surgery residency programs within the US Resident OPerative Experience (ROPE) Consortium. Residents who pursued transplant surgery fellowship were compared to those who went directly into practice or pursued a non-transplant fellowship. Among 1342 general surgery graduates, 52 (3.9%) pursued abdominal transplant fellowship. These residents completed more transplant (22vs. 9), liver (14vs. 9), pancreas (15vs. 11), and vascular access operations (38vs. 30) compared to residents who did not pursue transplant fellowship (all p<0.05). Multivariable logistic regression found that residents underrepresented in medicine were three times more likely (95% CI 1.54-6.58, p<0.01) and residents at a program co-located with a transplant fellowship six times more likely (95% CI 1.95-18.18, p<0.01) to pursue transplant fellowship. Additionally, a resident's increasing total transplant operative volume was associated with an increased likelihood of pursuing a transplant fellowship (OR = 1.12, 95% CI 1.09-1.14, p<0.01). The findings from this multi-institutional study demonstrate that increased exposure to transplant operations and interaction within a transplant training program is associated with a resident's pursuit oftransplant surgery fellowship. Efforts to increase operative exposure, case participation, and mentorship may optimize the resident experience and promote the transplant surgery pipeline.

Point-of-care-ultrasound for the assessment of post-renal transplant recipients.

Postoperative imaging for deceased donor renal transplants is often delayed, as these surgeries occur after-hours. These delays can be critical in identifying immediate complications. To our knowledge, there are no formal training programs for point-of-care ultrasound (POCUS) in this setting; therefore, we aimed to develop and evaluate a feasible and practical POCUS curriculum for the assessment of a renal transplant graft. Urology and nephrology transplant physicians completed a three-hour online course, followed by a five-hour hands-on seminar for sonographic scanning. Simulated patients with transplanted kidneys were used. Course material was developed with licensed ultrasound technologists based on Sonography Canada national competency profiles. Pre- and post-course surveys focused on user confidence, while pre- and post-course multiple-choice questionnaires assessed theoretical knowledge. Twelve participants were included, six of whom were urologists. Theoretical knowledge in POCUS improved significantly (p<0.001). Confidence in manipulation of ultrasound controls, Doppler imaging, and POCUS of the transplant kidney also improved (all p<0.001, d>2.0). Participants indicated an increased likelihood of POCUS use in clinical practice and that training should be integrated into a transplant fellowship. We introduced a novel and guideline-based POCUS curriculum that leveraged local ultrasound educators and found improved theoretical knowledge and skill confidence in our cohort of transplant physicians. This course will serve as the first step toward a validated competency-based training system for POCUS use in the immediate post-renal transplant setting, and likely will be incorporated into the training of the modern transplant physician.

The use of simulation in liver transplantation anesthesiology fellowship training: A survey of fellowship program directors in the United States.

Liver transplantation surgeries are challenging cases for anesthesiologists. While intra-operative teaching is paramount, simulation has emerged as an educational tool to augment clinical training. A variety of simulation modalities have been described in the literature, but no study has aimed to assess the use of simulation in liver transplantation fellowship training. A 20-question survey detailing the use of simulation, including simulation modalities used and barriers to simulation use, was developed and distributed to 22 program directors for liver transplantation anesthesiology fellowships. An exploratory analysis was performed on multiple-choice and free-text responses. Thirteen program directors completed the survey and were included in our analysis. Most programs (61.5%) did not report the use of simulation for liver transplantation fellow training. Of the programs that did use simulation, four required it as a mandatory component of their curriculum. Task trainers and screen-based simulators were more commonly used by these programs. Faculty availability and interest, as well as a lack of an established curriculum, were cited as major limitations to simulation use. Simulation is an important component of anesthesiology trainee education, as evidenced by the requirement for simulation during residency by the American Council for Graduate Medical Education. Our findings suggest that simulation is an underutilized educational tool that we believe could greatly augment the training of liver transplantation anesthesiology fellows by providing exposure to a wide range of clinical challenges.

Editorial introductions

Current Opinion in Organ Transplantation was launched in 1996. It is part of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of organ transplantation is divided into 18 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Editors-in-Chief, Associate Editor and Section Editors for this issue. SECTION EDITORS Paulo CravediPaulo CravediDr. Paolo Cravedi is an Associate Professor and Director of the Translational Transplant Research Center (TTRC) at Icahn School of Medicine at Mount Sinai, New York, NY. He spent his initial clinical research career at the Mario Negri institute, Bergamo, Italy, where he contributed to the identification of a biopsy-based allocation system of older kidneys that is widely used in Europe and South America. In 2011, he joined Icahn School of Medicine at Mount Sinai, where he started working on the immune monitoring of organ transplant recipients and on the effects of complement in adaptive immune response. More recently, his lab has been working on the immune modulating effects of erythropoietin and those of diet. Paulo MartinsPaulo MartinsDr Paulo Martins MD, PhD, FAST, FEBS, FACS is a transplant surgeon (Associate Professor of Surgery) and has a transplant lab focused on liver preservation at University of Massachusetts, USA. He graduated from medical school in Brazil, where he ranked first. He finished his PhD in transplant immunology at the University of Berlin-Germany in 2005 with “Summa cum Laude” and worked clinically in Berlin, Germany (Charite’-Virchow Klinikum) for over a year. He completed a post-doc research fellowship at the Brigham and Women Hospital and Massachusetts General Hospital at Harvard University, in Boston-USA, and later did a clinical hepatobiliary and Transplant Fellowship at the New York Medical School, followed by other clinical transplant fellowship at Massachusetts General Hospital, Harvard University, followed by one year as clinical instructor in the same institution. Since 2013, Dr. Martins has been working as a transplant Surgeon at the University of Massachusetts. During his career he has obtained several research awards (including the ILTS rising star award, ASTS vanguard award, ASTS rising star award, AST basic science award, an AASLD grant, and the Portuguese-American Scientific leadership award) and grants. He is the vice-chair of the ILTS Basic and Translational Science committee, associate editor of the journal "Artificial Organs, an editorial board member/reviewer of 15 scientific journals, and member of several transplant societies including (ILTS, ESOT, AST, ASTS, DTG, AASLD). Dr. Martins has published 107 peer-reviewed articles (with over 3,500 citations), one textbook, 16 book chapters, and over 100 abstracts in scientific meeting and medical journals. He has been part of Diversity committee at his institution, he is co-chair of the ASTS diversity committee, and chair of the UNOS/OPTN Minority Affairs Committee. He has been part of several initiatives to increase equity in transplantation access (e.g. policies to collect socio-economic data and to eliminate the black race coefficient for eGFR calculation, adjustments/provisions in organ allocation policies, guidelines about listing of patients with cognitive impairment among others). He is also part of the bold against racism task-force in the ASTS that aims to increase representation and equity for the transplant workforce, to build inclusive work environments, and provide culturally sensitive training. He published several articles in this field and this year he was nominated by the University of Massachusetts to the Alpha Omega Alpha honor society.

Practical considerations and consensus opinion for children’s hospital–based inpatient hemostasis and thrombosis (HAT) consultative services: Communication from the ISTH SSC Subcommittee on Pediatric/Neonatal Thrombosis and Hemostasis

Caring for children and adolescents with disorders of hemostasis and thrombosis (HAT) has become more specialized and requires a unique skill set that many providers are not able to obtain in standard pediatric hematology/oncology/bone marrow transplant fellowship training programs. The influx of numerous therapeutic advances and increasing medical complexity has expanded the need for experienced HAT providers and subspecialty collaboration in the inpatient setting due to the nuances in the management of patients with HAT complications and concerns. While there are data highlighting the benefits of an inpatient hemostasis, thrombosis, and anticoagulation management service in adult hospitals, there are limited pediatric data supporting such programs. In this article, we summarize the current practices of various pediatric institutions in the inpatient management of HAT patients and provide a consensus opinion for the development of a pediatric inpatient HAT service at tertiary care referral centers.

Transplant Fellowship and Presenting at a Transplant-Specific Conference.

The ASTS implemented a task force in 2018 to increase residents' interest in careers in organ transplantation. National meetings offer important experiences that can increase interest. The present study examines an association that exists between presenting at a major transplant surgery meeting and a trainee's likelihood of pursuing a career in transplant surgery. All abstracts from the ASTS State of the Art Winter Symposium from 2010 to 2019 were evaluated. Using a combination of internet-based resources, it was determined if the presenter was a resident, what year of residency they were in, and if that individual went into a transplant fellowship. 1544 abstracts were reviewed and 133 were presented by residents. Out of residents that presented, 68.4% (54/79) were senior residents and 31.6% (25/79) were junior residents. Of senior residents, 66.7% (36/54) went into transplant fellowships, while only 20.0% (5/25) of junior residents went into transplant fellowships. Being a senior resident when presenting was statistically significant for pursuing a transplant fellowship (P = .000113). Senior residents who present at ASTS SAWS are likely to pursue a transplant surgery fellowship. Junior residents who present are less likely to pursue transplantation, and this represents an opportunity to improve the engagement of young surgeons in the specialty.

Diversity among transplant surgery fellowship program directors: a call to action.

The diversity among general surgery residency, HPB and other fellowship program directors has been previously analyzed. However, the diversity in abdominal transplant surgery fellowship program directors remains unknown. Abdominal transplant fellowship programs and the corresponding program directors were identified from the American Society of Transplant Surgeons website. Demographic and training information for the members was compiled through internet searches and analyzed. 72 program directors were included. 83.33% were male. 63.9% were non-Hispanic White, 25% were Asian, along with 5.56% Hispanic and Black each. Male program directors were more likely to be Associate Professor (p=0.041), while females were more likely to be Assistant Professor (p=0.021). 66% of female program directors were non-Hispanic White. Transplant surgery fellowship programs are primarily led by male and non-Hispanic White surgeons. Female representation as leaders is on par with their membership in the transplant surgery workforce. There is a deficiency of both male and female underrepresented minorities in program director positions.

Editorial introductions

Editorial introductions

Editorial introductions.

Current Opinion in Organ Transplantation was launched in 1996. It is part of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of organ transplantation is divided into 18 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Section Editors for this issue. SECTION EDITORS Linda S. SherLinda S. SherDr Linda S. Sher is Professor of Clinical Surgery and Director of Clinical Research in the Division of Hepatobiliary Surgery and Abdominal Organ Transplantation at Keck School of Medicine, University of Southern California (USC), USA. After completing her medical school education and surgical residency at Mount Sinai School of Medicine in New York, USA, Dr Sher undertook her fellowship training in Liver and Kidney Transplantation at the University of Pittsburgh, USA. After completing her fellowship in 1988, Dr Sher was involved in the establishment of two liver transplant programs in Los Angeles prior to joining the USC program in 2001. Dr Sher has participated in and overseen over 50 research projects and is currently very active in the development of the clinical and basic science research components of the USC Abdominal Organ Transplantation Program. She has numerous publications on immunosuppression, chronic rejection, disease recurrence, infection, and hepatobiliary surgery. Dr Sher is one of the original editors of Current Opinion in Organ Transplantation and has endeavored over the years to provide the reader with an up to date overview of the entire field of organ transplantation. Paulo N. MartinsPaulo N. MartinsDr Paulo N. Martins MD, PhD, FAST, FEBS, FACS is a transplant surgeon (Associate Professor of Surgery) and has a transplant lab focused on liver preservation at University of Massachusetts, USA. He graduated from medical school in Brazil, where he ranked first. He finished his PhD in transplant immunology at the University of Berlin-Germany in 2005 with “Summa cum Laude” and worked clinically in Berlin, Germany (Charite’-Virchow Klinikum) for over a year. He completed a post-doc research fellowship at the Brigham and Women Hospital and Massachusetts General Hospital at Harvard University, in Boston-USA, and later did a clinical hepatobiliary and Transplant Fellowship at the New York Medical School, followed by other clinical transplant fellowship at Massachusetts General Hospital, Harvard University, followed by one year as clinical instructor in the same institution. Since 2013, Dr. Martins has been working as a transplant Surgeon at the University of Massachusetts. During his career he has obtained several research awards (including the ILTS rising star award, ASTS vanguard award, ASTS rising star award, AST basic science award, an AASLD grant, and the Portuguese-American Scientific leadership award) and grants. He is the vice-chair of the ILTS Basic and Translational Science committee, associate editor of the journal "Artificial Organs, an editorial board member/reviewer of 15 scientific journals, and member of several transplant societies including (ILTS, ESOT, AST, ASTS, DTG, AASLD). Dr. Martins has published 107 peer-reviewed articles (with over 3,500 citations), one textbook, 16 book chapters, and over 100 abstracts in scientific meeting and medical journals. He has been part of Diversity committee at his institution, he is co-chair of the ASTS diversity committee, and chair of the UNOS/OPTN Minority Affairs Committee. He has been part of several initiatives to increase equity in transplantation access (e.g. policies to collect socio-economic data and to eliminate the black race coefficient for eGFR calculation, adjustments/provisions in organ allocation policies, guidelines about listing of patients with cognitive impairment among others). He is also part of the bold against racism task-force in the ASTS that aims to increase representation and equity for the transplant workforce, to build inclusive work environments, and provide culturally sensitive training. He published several articles in this field and this year he was nominated by the University of Massachusetts to the Alpha Omega Alpha honor society.

Transplant administration-A survey of the roles and responsibilities of kidney and pancreas medical directors of US transplant centers.

The current American Society of Transplantation (AST) accredited transplant fellowship programs in the United States provide no structured formal training in leadership and administration which is essential for successfully running a transplant program. We conducted a survey of medical directors of active adult kidney and kidney-pancreas transplant programs in the United States about their demographics, training pathways, and roles and responsibilities. The survey was emailed to 183 medical directors, and 123 (67.2%) completed the survey. A majority of respondents were older than 50years (61%), males (80%), and holding that position for more than 10years (47%). Only 51% of current medical directors had taken that position after completing a one-year transplant fellowship, and 58% took on the role with no prior administrative or leadership experience. The medical directors reported spending a median 50%-75% of time in clinical responsibilities, 25%-50% of time in administration, and 0%-25% time in research. The survey also captured various administrative roles of medical directors vis-à-vis other transplant leaders. The study, designed to be the starting point of an improvement initiative of the AST, provided important insight into the demographics, training pathways, roles and responsibilities, job satisfaction, education needs, and training gaps of current medical directors.

Canadian survey on the rates of use of intraoperative diuretics and justification for their use during renal allograft reperfusion

Mannitol and furosemide have been used as diuretics intraoperatively to facilitate early renal allograft function and reduce delayed graft function. As the evidence of any efficacy of these agents is limited, we sought to characterize the use of diuretics among transplant surgeons. An anonymous online survey was sent to all Canadian transplant programs where kidney transplants are routinely performed. Questions were related to the use and indications for mannitol and furosemide. Responses were collected and analyzed as counts and percentages of respondents. We used χ2 analysis to assess the relationship between demographic factors and survey responses. Thirty-five surgeons completed the survey (response rate 50%). Seventy per cent of respondents reported performing 26 or more transplants per year, 88% had formal transplant fellowship training and 67% indicated that they currently train fellows. Only 24% and 12% reported believing that delayed graft function is reduced by mannitol and furosemide use, respectively. However, 73% routinely gave mannitol to patients and 53% routinely gave furosemide. The most common justification given for mannitol use was to induce diuresis (54%); 37% of respondents reported using mannitol because of training dogma. Likewise, 57% used furosemide for diuresis, with 23% reporting that their use of this agent was based on dogma. No relationship emerged between fellowship training, case volume or training program status and the use of any agent. Interestingly, 71% of respondents indicated that a randomized controlled trial evaluating the utility of intraoperative diuretics is needed and that they were interested in participating in such a trial. Use of intraoperative diuretics and the rationale for their use vary among surgeons. A substantial proportion of surgeons use these medications on the basis of dogma alone. A randomized controlled trial is needed to clarify the role of intraoperative diuretics in kidney transplant surgery.

Securing the future of kidney transplantation by addressing the challenges of transplant nephrology.

Kidney transplant is a life-changing procedure, and transplant nephrologists, as part of a larger transplant team, play an important role in the field by managing the complex medical needs of transplant patients. The subspecialty of transplant nephrology, however, faces structural challenges related to its workforce, reporting structures, compensation, research and innovation, and health care information technology. The position of transplant nephrology at the academic and operational intersection of medicine and surgery may limit its access to critical resources, hinder academic promotion, and contribute to physician burnout. The authors provide an overview of the subspecialty transplant nephrology and propose solutions. Collaborative efforts that fortify the subspecialty of transplant nephrology will ultimately improve the lives of patients suffering from kidney disease.

Prof. Henrik Petrowsky: complex hepatobiliary and pancreatic surgery

Prof. Henrik Petrowsky ( Figure 1 ) is a Professor of Surgery and Vice-Chair of the Department of Surgery and Transplantation at the University of Zurich, Switzerland. He serves as Program Director of the HPB Surgery and Liver Transplant Fellowship at the Swiss HPB and Transplant Center Zurich. Prof. Petrowsky is heading the Liver and Pancreas Tumor Center, which is embedded in the Comprehensive Cancer Center Zurich at the University Hospital Zurich. His current practice consists of liver transplantation and HPB surgery. His research interests have mirrored his clinical work mainly focusing on translational and outcome research in liver transplantation and hepatobiliary surgery.

Editorial introductions

Editorial introductions

Editorial introductions

Editorial introductions

Editorial introductions

Current Opinion in Organ Transplantation was launched in 1996. It is part of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of organ transplantation is divided into 18 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Journal's Section Editors for this issue. SECTION EDITORS Sophoclis P. AlexopoulosSophoclis P. AlexopoulosDr Sophoclis P. Alexopoulos is Chief of the Division of Hepatobiliary Surgery and Liver Transplantation at Vanderbilt University Medical Center, Nashville, Tennessee, USA and the Surgical Director of Pediatric Liver Transplantation at the Monroe Carell Jr. Children's Hospital, Nashville, Tennessee, USA. He obtained his medical degree from Columbia University College of Physicians and Surgeons, New York City, New York, USA and completed a residency in general surgery at the Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA followed by a multi-organ abdominal transplant fellowship at Stanford University, Stanford, California, USA. Benjamin SamsteinBenjamin SamsteinDr Benjamin Samstein, MD is Chief of Liver Transplantation and Hepatobiliary Surgery in the Department of Surgery at New York-Presbyterian/Weill Cornell Medicine and Associate Professor of Surgery at Weill Cornell Medical College, Cornell University, Ithaca, New York, USA. Dr Samstein is the Surgical Director of the Living Donor Liver Transplant Program at New York-Presbyterian, New York, USA. Dr Samstein received his undergraduate degree from Cornell University and his MD at the State University, Stony Brook, New York, USA in 1997. He did his internship and residency in general surgery at New York-Presbyterian/Columbia University Medical Center, New York, USA and completed a research fellowship at the Mayo Clinic in 2001. He completed a fellowship in ASTS multi-organ transplant at New York-Presbyterian/Columbia University Medical Center in 2006. He joined faculty at Columbia University Medical Center where he served as Fellowship Director of the transplant surgery from 2007 to 2015. His research interests focus on minimally invasive liver surgery and live donor liver transplantation. Douglas G. FarmerDouglas G. FarmerDr Douglas G. Farmer, MD is a Professor of Surgery at the David Geffen School of Medicine at the University of California, Los Angeles, USA. He has been involved in intestinal transplantation since 1986. He has performed basic science research focusing on intestinal absorptive function, rejection, and ischemia reperfusion injury. He helped establish the clinical intestinal transplant program at UCLA in 1991 and became the first and only Director of Intestinal Transplantation at that institution. He has performed over 150 intestinal transplant procedures and cared for numerous patients with intestinal failure. He established the first comprehensive program at UCLA caring for patients with intestinal failure including medical, surgical, nutritional, and transplant options. Dr Farmer has published extensively on the subject and has been a prior Guest Editor for Current Opinion in Organ Transplantation. In this edition, the most current issues surrounding intestinal rehabilitation and transplantation are addressed.

Aggressive.

Aggressive Anji Wall "The other faculty members don't think that you are aggressive enough to train with us." This is what my mentor shared with me in confidence when I did not match at my first-choice residency program. I was crushed. I could not understand how aggressive behavior in surgery is considered a positive personality trait. Moreover, as a champion athlete in college and medical school, I knew that I could be aggressive in appropriate settings. I had never considered that a hospital or operating room was a place where I should be aggressive. The term aggressive means ready to attack or confront, and it is synonymous with hostile, belligerent, and antagonistic. How, I wondered, could being aggressive be a desirable trait for a surgical resident? Reflecting on my journey so far, I think that the answer to this question lies in the culture that has been created by—as Joan Cassell states in "Doing Gender, Doing Surgery: Women Surgeons in a Man's Profession"—the 'adrenalized vocation' of surgery that values arrogance, courage and decisiveness. When I rotated at my first-choice hospital, it was everything I'd dreamed of in a surgical training program: intense cases, prestigious research, and teaching rounds with rapid-fire questions that ranged from surgical history to postoperative care. What I didn't notice at the time were the toxicities I'd been conditioned to see as normal. Abrasive, tough surgeons ruled the program. Their hierarchical culture left little room for collegiality. Attending surgeons reigned over the operating rooms, where they had permission to behave how they saw fit: verbally assaulting nurses, scrub technicians, anesthesiologists, and residents. Broken or undesired instruments were thrown to the OR floor for any reason. This behavior was not universal, but far too prevalent and obvious to excuse as one or two bad actors. The operating room culture accepted unprofessional, unkind, and unbelievable behavior as the norm. While my rejection was devastating, not matching at my first-choice program turned out to be the best thing that could have happened to me. The residency program that I did match into valued and promoted attending surgeons and surgical residents who were entirely different. The administrative chief resident's orientation lecture entitled "This is how we roll" outlined the first two rules of surgical residency: Be Nice and Respect Others. We were informed that the annual Emergency Room Consultation Award was a coveted honor for surgical residents. The emergency room residents selected the surgical resident who they determined performed the most timely, respectful, and helpful consultations. Beyond expecting me to become a competent clinical and technical surgeon, my residency taught me that I must also embrace collegiality and kindness. Being confrontational in the OR, ER, and wards was a detriment to patients and not an essential ingredient in excellent care to patients. Such care is best achieved when we work together with respect and lift each other up. When I left residency for transplant fellowship, I had grown accustomed to the collegial teamcentered culture of residency. I thought that I had chosen a place that had a similar culture, and I was so excited to spend two years gathering amazing technical training with staff who would build my surgical career. There were smooth cases, and I made some good relationships, but I can't ignore the fact that parts of the experience were unnecessarily abusive. There was a superficial collegial relationship among the staff and toward the fellows, but in the blink of an eye, attitudes would shift, and normal interactions would turn into confrontations on the wards, in the ER, or in the OR. Artificial or real disasters loomed all around, and an unsuspecting [End Page 209] nurse, circulator, anesthesiologist, or I would become the target of a rampage. If these situations had happened daily, I would have known what to expect. But the whims of any particular surgeon felt random, and, early on, I was entirely unprepared. I had so many positive interactions, but the negative ones were so powerful that I still get chest pain when I think back to my fellowship. By my second year of fellowship, I was getting more accustomed to the culture...

Early experiences in liver resection: lesson learned from liver surgery and transplantation fellowship program and its implementation in daily surgical practice

Introduction: Fellowship program in liver surgery and transplantation provide wide opportunities to learn and experience in all aspects of liver resection and transplantation, including patient selections and perioperative care. With extensive exposures in daily surgical practice of liver surgery, it is expected that fellow will be able to bring such expertise to his or her daily practices. After completion of fellowship, despite several limitations in diagnostic and therapeutic resources, we managed to start liver program and perform a series of liver resections with reasonable outcomes. Methods: From May 2016 to 2017, fourteen liver resections were performed, all of which were reviewed in this study. Results: There were 8 male and 6 female, with median age of 63 (range 17-74) years old. The indication of hepatectomy includes 8 primary liver cancers, 5 liver metastases (3 colorectal cancer, 2 renal cell carcinoma) and 1 liver trauma. There were 6 non anatomical resections and 9 anatomical resections, including Right hemihepatectomy, Left Hemihepatectomy, Left lateral sectionectomy, Right Posterior sectionectomy and Right Anterior sectionectomy. Inflow occlusion technique, either Glissionean approach or selective individual occlusion, together with Kelly crushing technique for parenchymal transection was applied in all cases. Conclusion: In limited resources setting like ours, a safe liver resection can still be done with a proper patient selection and adherent to basic principles such as understanding of individual anatomy with comprehensive imaging, good perioperative care and meticulous surgical technique, as have been learned from the fellowship days.

Accessibility and Content of Abdominal Transplant Fellowship Program Websites in the United States

ObjectivesOrgan transplant volume is at an all-time high. Prospective applicants often utilize individual programs' websites for information when deciding if and where to apply for fellowship training. Accessibility and content from one program's website to the next is highly variable and may contribute to the selection of programs. The aim of this study was to evaluate the accessibility and content of abdominal transplant surgery fellowship websites. Materials and methodsThe American Society of Transplant Surgeons (ASTS) website provides a complete list of abdominal transplant fellowship programs in the United States. A Google search was performed to determine the presence and accessibility of a program's website. Available websites were evaluated on the presence of 20 content criteria. ResultsSixty-five programs in the United States were identified using the ASTS directory. Websites for fifty-one (78%) fellowship programs were identified. Three-fourths of websites contained 50% or less of the 20 evaluated data points, whereas 24% of websites contained 5 or less criteria. The most and least included data points were program description (100%) and on-call expectations (10%), respectively. ConclusionsThe accessibility and content of a program's website is one major factor that can influence a potential applicant's decision on where to pursue transplant surgery fellowship training. This study revealed that a significant percentage of programs fail to provide a functional website. Of the fifty-one programs that did have websites, information deemed important to prospective applicants may be considered inadequate.