Transplant Surgeons Research Articles

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.

S1307 Provider Perceptions of Code Status for Patients With End-Stage Liver Disease

Introduction: Liver transplantation (LT) is the only curative option for patients with end-stage liver disease (ESLD). Patients with ESLD have high rates of in-hospital mortality and low rates of survival to hospital discharge after in-hospital CPR. As ESLD is one of the few diseases where patients are close to death but also to a total cure, some studies suggest that LT listing and hospice referral should not be mutually exclusive. While many centers require that a patient be “full code” for LT listing or evaluation, this is not a United Network for Organ Sharing (UNOS) mandate. This study aims to assess LT providers’ awareness of organizational policies and their perspectives on code status requirement, with the eventual goal of providing patients with goal-concordant care while balancing the need of ethical solid organ allocation for transplant. Methods: Healthcare providers involved in the LT evaluation process at a high-volume transplant center anonymously completed a 13-question survey. Provider specialties are shown in Table. Answers were displayed using descriptive statistics. Results: Out of 83 providers who filled out the survey, 40% reported that they either often or always discussed code status with patients, often in a hospital setting. 62% were unaware of the institutional protocol that patients had to be full code for LT evaluation or listing, and 95% were unaware that UNOS did not have a full code requirement for the LT process. 93% of participants felt that patients undergoing LT evaluation should discuss code status. 15% felt that patients should remain full code throughout, 54% felt that patient should have their choice of code status during LT evaluation and listing, and 31% felt that patients should have their choice during evaluation but become full code once listed. Conclusion: These results show a need for increased educational initiatives among providers involved in the LT process, as there is a lack of knowledge among providers regarding policy on code status. Among the subset who was aware of a protocol, knowledge of the actual requirements varied. While most providers believe that a discussion regarding code status is necessary for patients who wish to undergo LT, there was a diverse range of opinions on code status requirement throughout the LT evaluation and listing process. Initiatives to further the dialogue of code status and advanced care planning in a high mortality patient population are needed. Table 1. - Description of Survey Respondents Role on LT team Number of Respondents Gastroenterology/Hepatology Attending 6 Critical Care Attending 5 Transplant Surgeon 3 Palliative Medicine Attending 3 Gastroenterology Fellow 9 Internal Medicine Resident 32 Advanced Practice Provider 14 Transplant Coordinator 6 Transplant Selection Committee 1 Social Worker 1 Other 3

Challenges in implementing antimicrobial stewardship (AMS) in organ transplant centers in India.

We, in India, have unique challenges in implementing antimicrobial stewardship (AMS) in our institutions, especially the transplant settings. Identifying challenges, addressing them, and finding innovative solutions to these are the need of the hour. Several challenges in India exists, which hamper implementation of effective AMS like lack of adequately trained personnel (infectious diseases [ID] physicians and clinical pharmacists), missing opportunities of AMS during the timeline, and lack of India-specific outcome measures for AMS programme. Finding local solutions can make our AMS implementation more effective. Numbers of ID physicians are increasing (24 in 2011 to>300 in 2020), and we expect the specialty to grow more and make rapid progress in AMS. We propose that cost savings and overall improvement in clinical outcome to be included in outcomes measures, rather than rates of C. difficle infection. Effective implementations of National Medical Commission mandatory AMS training regulation are few such steps that can fill the gaps. Antimicrobial stewardship programs is one of the several components of tackling the antimicrobial resistance-related negative consequences in transplant patients. Transplant physicians, surgeons, and institutions should understand the bigger picture and strive hard to convince the policymakers to act for the benefit of the transplant recipients and the transplant programs across the country.

Preparing for Transplant - Screening and Prophylaxis of Donor and Recipients before Solid Organ Transplantation

Infections are major cause of morbidity and mortality after transplantation. Although many infections are common worldwide, there are differences in various geographic locations. South Asia and India, in particular, has a very active transplant program for kidney and liver transplantation, however, there are no guidelines as how to screen and provide prophylaxis to solid organ transplant (SOT) recipients and donors for both specific infections prevalent in this region along with usual infections. Keeping this in mind, a working group was created comprising transplant physicians, surgeons, and infectious disease specialists from South Asia as well as experts from other countries. This working group developed guidelines based on published evidence, unpublished data from large centers in this region, along with expert opinion. This section of the guidelines deals with pretransplant screening of donors and recipients, which should be useful in dealing with transplants performed in this region for patients belonging to these countries, for those coming for transplantation from other countries, and for programs outside of South Asia who are screening donors and recipients from this region or who have spent significant time in this region.

Genetic factors underlying tacrolimus intolerance after liver transplantation.

BackgroundTacrolimus (FK506) is the cornerstone of immunosuppression after liver transplantation (LT), however, clinically, switching from FK506 to cyclosporine (SFTC) is common in LT patients with tacrolimus intolerance. The aim of this study was to investigate the genetic risk of patients with tacrolimus intolerance.MethodsA total of 114 LT patients were enrolled in this retrospective study. SNPs were genotyped using Infinium Human Exome-12 v1.2 BeadChip, and genome-wide gene expression levels were profiled using Agilent G4112F array.ResultsSFTC was a potential risk factor of dyslipidemia (OR=4.774[1.122-20.311], p = 0.034) and insulin resistance (IR) (OR=6.25[1.451-26.916], p = 0.014), but did not affect the survival of LT patients. Differential expression analysis showed donor CYP3A5, CYP2C9, CFTR, and GSTP1, four important pharmacogenetic genes were significantly up-regulated in the tacrolimus intolerance group. Twelve SNPs of these four genes were screened to investigate the effects on tacrolimus intolerance. Regression analysis showed donor rs4646450 (OR=3.23 [1.22-8.60] per each A allele, p = 0.01), donor rs6977165 (OR=6.44 [1.09-37.87] per each C allele, p = 0.02), and donor rs776746 (OR=3.31 [1.25-8.81] per each A allele, p = 0.01) were independent risk factors of tacrolimus intolerance.ConclusionsThese results suggested that SFTC was a potential risk factor for dyslipidemia and IR after LT. Besides, rs4646450, rs6977165, and rs776746 of CYP3A5 might be the underlying genetic risks of tacrolimus intolerance. This might help transplant surgeons make earlier clinical decisions about the use of immunosuppression.

Incidence of attrition among early-career abdominal transplant surgeons

BackgroundThe prevalence of burnout and depression among abdominal transplant surgeons has been well described. However, the incidence of early-career transplant surgeons leaving the field is unknown. The objective of this study was to quantify the incidence of attrition among early-career abdominal transplant surgeons. MethodsA custom database from the Organ Procurement and Transplantation Network with encrypted surgeon-specific identifiers was queried for transplant surgeons who entered the field between 2008 and 2019. Surgeons who experienced attrition, defined as not completing a subsequent transplant after a minimum of 5, were identified. Surgeon-specific case volumes, case mix, and recipient outcomes were modeled to describe their association with attrition. ResultsBetween 2008 and 2018, 496 abdominal transplant surgeons entered the field and performed 76,465 transplant procedures. A total of 24.4% (n = 121) experienced attrition, with a median time to attrition of 2.75 years. Attrition surgeons completed fewer kidney (7 vs 21, P < .01), pancreas (0.52 vs 1.43, P < .01), and liver transplants (1 vs 4, P < .01) in their first year of practice. Attrition surgeons completed a smaller proportion of their transplant center’s volume (9% vs 18%, P < .01) and were less likely to participate in pediatric transplants (26.5% vs 52.5%, P < .01) and living donor kidney transplants (64.5% vs 84.5%, P < .01). On multivariable analysis, performing fewer kidney (odds ratio: 0.98, 95% confidence interval: 0.98–0.99) and liver transplants (odds ratio: 0.98, 95% confidence interval: 0.97–0.98) by year 5 and completing a smaller proportion of their centers’ volume (odds ratio: 0.96, 95% confidence interval: 0.94–0.98) were associated with attrition. Furthermore, attrition surgeons had worse allograft and patient survival for liver transplant recipients (both log-rank P < .01). ConclusionThis investigation was the first to quantify the high incidence of attrition experienced by early-career abdominal transplant surgeons and its association with surgeon-specific case volumes, case mix, and worse recipient outcomes. These findings suggested the abdominal transplant workforce is struggling to retain their fellowship-trained surgeons.

The San Antonio kidney transplant model: validity evidence and proficiency benchmarks

Simulation has become an increasingly important tool in training complex and high-stake surgical techniques, including kidney transplantation. While several kidney transplant models have been described, there remains a need for a low-cost model with established proficiency targets. We developed a low-cost kidney transplant model to simulate a renal vein to iliac vein end-to-side anastomosis, and a proficiency-based curriculum to prepare and evaluate trainees. This low-fidelity model utilizes a constrained space and adjustable depth to simulate the iliac fossa, with replaceable Penrose drains as vascular conduits. 18 novices (PGY1), 19 junior intermediates (PGY 2–3), 7 senior intermediates (PGY 4–5) and 6 experts (faculty transplant surgeons) each performed anastomoses on the model. Three metrics were used to rate each performance—completion time, a scoring rubric, and a composite technical score (CTS) formula. Messick’s validity framework was used to evaluate the model and scoring rubric to provide evidence for content alignment, response process validity, internal structure validity, and construct validity. Resident participants reported the model was easy to set up (8.6/10) and added value to their surgical education (9.8/10). Transplant surgery faculty reported the model realistically simulated an end-to-side renal vein anastomosis (8.3/10), supporting content alignment. One-way ANOVAs for each of the three metrics was statistically significant across all skill levels (p < 0.001), supporting construct validity. Response process validity was achieved using blinded raters to review the video performances. Finally, inter-rater reliability was obtained with an intraclass correlation coefficient of 0.896 (< 0.001), supporting internal structure validity. We utilized Messick’s validity framework to provide validity evidence for a low-cost, low-fidelity kidney transplant model and a scoring rubric. Furthermore, we provided proficiency benchmarks for trainees to train towards. This model is well suited for preparing surgical trainees to perform in vivo kidney transplants.

233.9: The Sun Is Still Shining: Nature of Industry Payments to Transplant Surgeons From 2014-2019

Introduction: This study aims to characterize the nature of these payments made to transplant surgeons over the past six years of Open Payments Program (OPP) data, to better understand the nature of physician-industry relationships within transplant surgery. Methods: The study sample included all physicians (categorized under Urology, Surgery, Pediatric Urology, and Pediatric Surgery) who received at least one non-research payment as transplant surgeons to the OPP. To capture transplant surgeons who may be listed under their pipeline specialty, the American Society of Transplant Surgeons member directory as of January 2021 was queried. Physicians identified as residents in the ASTS member directory were excluded from analysis. Data was analyzed between 2014 and 2019. Results: Total number of transplant surgeons receiving payment 1335. Total amount in dollars paid, $15,661,536. The mean payment was $416.58 (SD $1684.60) and the median payment was $50.00 (IQR $17.44-$151.0). The top three categories include $3,910,288 (26.2%) paid for consulting fees, $4,668,147 (31.3%) paid for non-consulting fees (speaker and vendor fees), and $3,035,045 (20.3%) paid for travel and lodging. OPTN Region 5 received the most payment at 19.3%, and Region 1 received the least payment at 1.5%. The top five companies making payments include Intuitive Surgical Inc, Gilead, Norvartis, Astellas, Genzyme. Conclusions: There is a considerable financial relationship between medical device and pharmaceutical manufacturers and transplant surgeons. The majority of non-research payments to transplant surgeons by industry sponsors were for non-consulting services. There exist regional differences in the amount paid by industry to transplant surgeons in regards to median and total industry payment amounts.

400.4: Deceased Kidney Donor Acceptance Criteria: A Survey of Canadian Transplant Nephrologists, Surgeons and Urologists

Introduction: Kidney transplantation provides a quality of life and survival advantage for patients with end-stage kidney disease (ESKD) relative to remaining on dialysis. However, the number of patients on the transplant waitlist is steadily increasing relative to the number of available kidney donors. Despite this, while Canadian organ discard rates are not available, the proportion of discarded kidneys in the United States has paradoxically increased over time. While there is an abundance of literature regarding predictors of organ decline in the United States, to date, there are no data regarding the rate or rationale for deceased donor decline in Canada. Methods: We performed an online survey (July 22-Oct 4, 2021) to assess deceased donor acceptance practices of Canadian transplant nephrologists, surgeons and urologists. Surveys were distributed by email to members of the Canadian Transplant Society. Surveys consisted of 3 sections of increasing donor complexity and respondents were asked whether they would accept or decline a hypothetical donor presented in the question stem, assuming there was a suitable recipient. The proportion of respondents completing the survey was determined, as were overall and donor scenario-specific acceptance rates amongst those providing responses. Results: A total of 81 respondents accessed the survey from 19 centers and seven provinces across Canada (all provinces with at least one transplant center). A total of 72 respondents (88.9%) answered at least one question and 16 respondents (22.2%) did not complete the survey. Donor acceptance rates for Sections 1 and 2 are demonstrated in Figure 2. Overall acceptance rates were highest for the younger (40 years) donor scenarios and when the donor was NDD vs. DCD. The most pronounced drop in acceptance rates for all donor scenarios was between a non-dialysis dependent donor with recovering AKI (92% acceptance) and a donor with AKI requiring dialysis and a biopsy demonstrating ATN but no coagulative necrosis (20% acceptance). Acceptance rates for Section 3 are demonstrated in Figure 3. The most pronounced drop in acceptance rates for all donor scenarios was between a deceased donor with comorbidities but no CKD (85% acceptance) and a donor with CKD and a biopsy demonstrating 3 out of 12 glomeruli sclerosed, but no arterial hyalinosis (25% acceptance). Overall, advanced donor age, DCD donor status, AKI, CKD and comorbidity burden were all associated with an increased risk of deceased donor non-acceptance. Conclusions: Given relatively high rates of donor decline and apparent heterogeneity in acceptance decisions, Canadian transplant specialists may benefit from additional education regarding the benefits achieved from even medically complex or “marginal” kidney donors for appropriate candidates relative to remaining on dialysis on the transplant waitlist.

P9.12: The Impact of the Multiple Bile Ducts on Postoperative Biliary Complications in Living Donor Liver Transplantation: Single Center Experience

Introduction: The multiple bile ducts in a living donor graft are a long standing troublesome. All transplant surgeons try to avoid this problem due to technical difficulty and relation with biliary complications. However, there have been many mixed reviews about the impact of multiple bile ducts on biliary complications. This study aimed to investigate correlations between the number of bile duct and biliary complications in patients undergoing living donor liver transplantation (LDLT). Methods: We reviewed all LDLT patients in our hospital between July 2008 and December 2020. The patients were divided into 2 groups according to the number of bile duct in living donor graft (single duct=SD, multiple duct=MD). Biliary complications were defined by endoscopic, interventional or surgical treatment. Collected data included demographics of donors and recipients, surgical data about to biliary anastomosis (duct-to-duct, hepaticojejunostomy, and conjoined), perioperative and postoperative outcomes. Results: All 70 patients were represented SD (n=48) and MD (n=22). Biliary complications occurred in 27(38.6%) patient and were more common in MD group (54.5% vs 31.3%). Although there were no statistic differences between 2 groups, multiple bile ducts was positively correlated with biliary complications (HR=2.4). MD patients revealed longer operation time (1052 ± 251 vs 910 ± 215 p=0.019) and higher percentage of hepaticojejunostomy (31.8% vs 8.3%, p=0.012). Donor age, graft-recipient weight ratio, cold ischemic time and amount of transfusion were not different between 2 groups. Twenty-one (77.7%) were fully recovered from biliary complications but 3(4.3%) resulted in graft failure. Conclusion: Biliary complications were common problems in LDLT despite overall good result. Multiple bile ducts can be a potent risk factor of biliary complications among other predisposing factors.

P10.01: How Did the War Affect Organ Transplantation in Syria?

Since 2011, the Syrian conflict has destroyed much of the country’s infrastructure. The deteriorating humanitarian situation has involved health workers and facilities. In 2010, before the war, 385 kidney transplants were performed in Syria. This number declined to 154 in 2013 (60% less) before increasing to 251 transplants in 2018, which is still 35% less than the number of transplants performed before the war. In addition, the number of operational kidney transplant centers has decreased from 8 in 2010, distributed over 3 cities, to only 4 in 2013, all located in Damascus, which increased to 6 centers in 2019. Interestingly, with regard to type of living donor, the percentage of unrelated kidney donors has decreased by 20% for unclear reasons. Another alarming statistic is that more than 50% of kidney transplant physicians and surgeons are no longer practicing transplant medicine in their centers, either because they have left the country or because their centers had become nonoperational. Since the war, free and timely provision of immunosuppressive drugs for all patients in all provinces has been a leading challenge for health authorities and transplant patients. This difficulty has led to adverse medical consequences for patients. A project to initiate liver transplant came to a halt because of complex reasons but mainly because foreign trainers could not visit Syria. Although the autologous bone marrow transplant program had slowed until recently, it has become more active, involving both autologous and allogeneic transplants. The deceased-donor program is still not available in Syria; the war has just reinforced the many reasons that prevented the start of this program before the conflict. The commitment of transplant teams despite these large challenges continues to be extraordinary. The Syrian conflict has affected all aspects of organ transplant, paralyzing new projects and negatively affecting existing programs.

P9.09: Peri-Hepatic Gauze Packing for the Control of Haemorrhage During Liver Transplantation: Experience of a High-Volume Center

Introduction: The use of peri-hepatic gauze packing (PHGP) has been rarely reported during liver transplantation (LT). The objective of this technique is to achieve fast control of bleeding while haemodynamic stability is restored and coagulation disorders are fixed. Conditions like baseline cirrhosis-related coagulopathy, intraoperative blood loss, prolonged surgery, anhepatic phase and initial allograft dysfunction may all contribute to persistent bleeding. In some cases, usual means of haemostasis can be ineffective and reiterate attempts at controlling bleeding can be frustrating or even detrimental. Although, PHGP use during LT raises concerns for a potentially increased risk of infection and graft related complications. The aim of our study was to assess the value of PHGP during LT. Method: We conducted a retrospective and descriptive study. We reviewed the clinical records of 13 orthotopic liver transplantation (OLT) patients undergoing PHGP between a total of 407 patients at the HPB surgery and liver transplant department of the Hospital de Alta Complejidad “El Cruce” between January 2013 and February 2022. Patients and donor’s demographics and intra/postoperative features were analyzed. Continuous data are presented as medians and means and standard deviations. Discrete data are given as counts and percentages. Chi-square test, Fisher exact test, Mann–Whitney U test and Student’s T-test were used when appropriate (for categorical and continuous data respectively). Two-sided p value equal or less than 0.05 was considered to indicate statistical significance with a confidence interval of 95%. All analyses were conducted using MedCalc version 20.027 (https://www.medcalc.org/). Results: Of 407 recipients, 13 were treated with packing for peri-hepatic bleeding (3.19%). One of them required urgent reoperation for ongoing haemorrhage after PHGP. After that, correction of haemodynamic and coagulation parameters was constantly achieved (table 1). 6 patients died (46.15%), none of them related to the PHGP. Patient survival (table 2) was associated with recipient age (p≤0.001) and intraoperative plasma transfusions (p=0.02). Conclusion: Peri-hepatic gauze packing it’s highly effective in achieving adequate haemostasis, allowing the correction of haemodynamic parameters and underlying disorders. However, it’s associated with relevant morbidity and high mortality. We believe that PHGP is a valuable strategy in the armamentarium of the liver transplant surgeon facing a life-threatening situation like the persistent bleeding during the operation.

427.10: A New Era in Transplantation: Artificial Intelligence, Augmented Reality, Virtual Reality and Metaverse

Introduction: Big data in healthcare and surgical sciences, combined with advances in computer technology and software, has brought healthcare and medical applications into the age of Artificial intelligence (AI), Virtual Reality (VR) and Augmented Reality (AR). These technologies have started to come to the fore even more with the metaverse era. The main purpose of this review is to discuss the advances and challenges of these methods in transplantation. Method: In this systematic review study, we systematically searched for studies on MEDLINE, Scopus, Web of Science and Google Scholar. The concepts of AI, Machine Learning (ML), Deep Learning (DL), AR, VR and Metaverse which opened a new era in transplantation, were discussed and their application areas in transplantation in the literature were examined. Along with the benefits it will provide limitations and possible risky situations, disadvantages and especially the ethical dimension have been examined. Results: AI is a scientific approach that uses theories and mathematical algorithms to give computer systems the ability to perform tasks that would normally require human intelligence. ML and DL algorithms in particular AI models will create a decision support system for the clinician at every stage related to the patient in transplantation. Some basic applications of AI in transplantation are seen in evaluations such as listing for transplantation, organ allocation algorithms, determining whether to accept the organ for a particular recipient, creating a clinical prediction and decision support system that will guide the physician, estimating mortality and morbidity in the waiting list, and post-transplant survival analysis. There are also examples of AI in image processing, organ allocation, donor and recipient matching, pathology, real-time immunosuppression, transplant oncology, and predictive analysis. VR and AR are areas of robotic surgery innovation in the coming years. VR is generally defined as an experience where a user stays physically in their real world while entering a virtual world using a computer or mobile device. AR is a technology that overlays digital information on real-world objects or places to enhance the user experience. Applications of AR in the field of transplantation include its use in the training of transplant surgeons, in promoting organ donations, in graft retrieval and allocation, and in the microscopic diagnosis of organ rejection, in the treatment of complications and post-transplant neoplasms. Conclusion: In the digital age we live in, these methods should be used in the clinical decision-making process in the field of transplantation. In the coming years, clinical transplant professionals will increasingly use these models to support their decisions. With the use of these applications in transplantation, organ use can be optimized, complications can be predicted and pre-transplant management can be optimized, which can reduce the need for transplantation.

P5.16: Learning From the Learning Curve: The Personal Database of an Entry-Level Transplant Surgeon as a Tool to Improve Outcomes

P5.16: Learning From the Learning Curve: The Personal Database of an Entry-Level Transplant Surgeon as a Tool to Improve Outcomes

A Conceptual Model for Sources of Differential Selection in Lung Transplant Allocation.

Rationale: In the United States, donor lungs are allocated to transplant candidates on the basis of lung allocation scores (LAS). However, additional factors beyond the LAS can impact who is transplanted, including listing and donor-organ acceptance practices. These factors can result in differential selection, undermining the objectivity of lung allocation. Yet their impact on the lung transplant pathway has been underexplored. Objectives: We sought to systematically examine sources of differential selection in lung transplantation via qualitative methods. Methods: We conducted semistructured qualitative interviews with lung transplant surgeons and pulmonologists in the United States between June 2019 and June 2020 to understand clinician perspectives on differential selection in lung transplantation and the LAS. Results: A total of 51 respondents (30 surgeons and 21 pulmonologists) identified many sources of differential selection arising throughout the pathway from referral to transplantation. We synthesized these sources into a conceptual model with fivethemes: 1) transplant center's degree of risk tolerance andaccountability; 2) successfulness and fairness of the LAS; 3)donor-organ availability and regional competition; 4)patient health versus program health; and 5) access to care versus responsible stewardship of organs. Conclusions: Our conceptual model demonstrates how differential selection can arise throughout lung transplantation and facilitates the further study of such selection. As new organ allocation models are developed, differential selection should be considered carefully to ensure that these models are more equitable.

Expert consensus on liver transplantation perioperative evaluation and rehabilitation for acute-on-chronic liver failure

Acute-on-chronic liver failure (ACLF) can be cured by liver transplantation; however, perioperative complications still affect posttransplant outcomes. In recent years, early rehabilitation for critical illness, liver disease, and surgery have significantly improved organ reserve function, surgery tolerance, and postoperative quality of life. They could also be applied in the perioperative period of liver transplantation in patients with ACLF. Therefore, the Transplantation Immunology Committee of Branch of Organ Transplantation Physician of Chinese Medical Doctor Association, the Organ Transplant Committee of China Association Rehabilitation Medicine, and the Guangdong Medical Doctor Association of Organ Transplantation conducted a comprehensive review of rehabilitation in end-stage liver disease, critical illness and surgical patients by summarizing current evidence and best clinical practices and proposed a practice consensus on evaluation of cardiopulmonary and physical function, rehabilitation or physiotherapies, as well as the safety concerns in perioperative liver transplant recipients. It will be a valuable resource for hepatologists, transplant surgeons, and intensivists as they care for ACLF patients during transplantation.

Inflammatory complications after hair transplantation: Report of 10 cases.

Androgenetic alopecia (AGA) is a pathology involving the aesthetic prognosis. Hair transplantation is among best treatments. The principle of hair micro-grafts during AGA consists in taking hair from the non-androgen-dependent occipital area to transplant them with their root in the sparse androgen-dependent areas. Herein, we report 10 cases of the different types of post-transplant inflammatory complications. We included patients referred to our center by their dermatologists or hair transplant surgeons for inflammatory cicatricial alopecia or hair loss observed after the hair transplant. Ten patients (eight men and two women) were included. These patients represented 0.08% of all consultations in our center. The indication for hair transplantation was AGA in all of our patients. The technique used for the transplant was follicular unit extraction (FUE) in seven cases and follicular unit transplantation (FUT) strip in three cases. None of the patients had pathology of the scalp or an inflammatory dermatosis before the operation. The inflammatory complications found were lichen planopilaris (LPP) in seven cases, erosive pustulosis of the scalp (EPS) in two cases, and superficial folliculitis (SF) in 1 case. Our series highlight the rarity of inflammatory complications that occur after a hair transplant. We demonstrate through this work that a hair transplant can trigger inflammatory pathology a few months after the act. We show also, the importance of detecting the rough forms of lichen before an intervention, hence the interest of the systematic dermatoscopic examination during the preoperative consultation.

Ex situ arterial reconstruction prior normothermic machine perfusion of liver grafts

PurposeAtypical variants of the hepatic artery are common and pose a technical challenge for normothermic machine perfusion (NMP). The transplant surgeon has three options when confronted with hepatic arterial variation in a liver graft to be subjected to NMP: to perform arterial reconstruction (i) prior, (ii) during, or (iii) following NMP.MethodsHerein, we report our experience and technical considerations with pre-NMP reconstruction. Out of 52 livers, 9 had an atypical hepatic artery (HA): 3 replaced right HA, 3 replaced left HA, 1 accessory left HA, 1 accessory left and right HA, and 1 replaced left and right HA.ResultsReconstruction was conducted during back-table preparation. A single vascular conduit was created in all grafts to allow single arterial cannulation for NMP, necessitating only one arterial anastomosis within the recipient. All grafts were subjected to NMP and subsequently successfully transplanted.ConclusionOur approach is being advocated for as it preserves the ability to alter the reconstruction in case of problems resulting from the reconstruction itself, thereby allowing functional evaluation of the reconstruction prior transplantation, permitting simultaneous reperfusion in the recipient, and providing the shortest possible duration for vascular reconstruction once the graft is rewarming non-perfused within the recipient. In addition, in light of the frequency of technically demanding reconstructions with very small vessels, we consider our technique beneficial as the procedure can be performed under ideal conditions at the back-table.

If You Catch the Ball, We Win the Game. If You Drop It, We Lose

As a transplant surgeon at California Pacific Medical Center in San Francisco, I cannot forget those cases where I faced forks in the road and had to decide whether the right direction lay in the well-charted direction of objective metrics or immeasurable feelings of intuition. I carry those cases with me still.

Liver transplantation in patients with post-hepatectomy liver failure - A Northern European multicenter cohort study.

Liver transplantation (LTX) has been described as a rescue treatment option in severe, intractable post-hepatectomy liver failure (PHLF), but is not considered to be indicated for this condition by many hepatobiliary and transplant surgeons. In this article we describe the clinical experience of five northern European tertiary centers in using LTX to treat selected patients with severe PHLF. All patients subjected to LTX due to PHLF at the participating centers were identified from prospective clinical databases. Preoperative variables, surgical outcome (both resection surgery and LTX) and follow-up data were assessed. A total of 10 patients treated with LTX due to severe PHLF from September 2008 to May 2020 were identified and included in the study. All patients but one were male and the median age was 70 years (range 49-72). In all patients the indication for liver resection was suspected malignancy, but in six patients post-resection pathology revealed benign or pre-malignant disease. There was no 90-day mortality after LTX. Patients were followed for a median of 49 months (13-153) and eight patients were alive without recurrence at last follow-up. In selected patients with PHLF LTX can be a life-saving procedure with low short-term risk.