Organ Transplantation

Length: 1-4 months of PGY-1 through PGY-5 year Location: Hawaii Medical Center East Primary Supervisor: Alan Cheung, M.D. Contact Telephone #: 547-6499

Organ transplantation is an exciting field dealing with the surgical treatment of patients with end-stage organ failures. Residency Review Requirements state that General Surgery Residents shall be exposed to the basic principles of, and have a personal clinical experience in, transplant surgery. During this rotation - concurrent with your duties at Hawaii Medical Center East - you will learn the overall principles of organ transplantation, including organ donation and procurement, transplant immunology and immunosuppression, treatment of rejections, and intraoperative approaches to organ transplantation.

Goals

Upon completion of the transplant rotation, Residents will:

1. Understand the basic principles of organ transplantation

2. Recognize the various components of organ transplantation that fall within the purview of general surgery.

Objectives

Medical Knowledge

1. Achieve a basic understanding of transplant immunology as it relates to candidate selection and matching of organs to recipients, as well as its relationship to immunosuppressive management. 2. Demonstrate a basic understanding of post-transplantation immunosuppressive therapy, both in the immediate post-transplantation period as well as during periods of acute rejection and for long term chronic immunosuppressive therapy. 3. Develop an understanding of donor selection criteria, clinical evaluation of potential organ donors, donor management and multi-organ surgical recovery of organs for transplantation. 4. Develop an understanding of the legal and Institutional requirements for brain death and informed consent for organ donation. 5. Demonstrate an understanding of the anatomy of liver transplantation, kidney transplantation, pancreas transplantation, and heart transplantation.

Patient Care

1. Demonstrate familiarity with all aspects of care of the transplantation candidate to include pre- operative evaluation, peri-operative care, and post-operative management. 2. Demonstrate technical proficiency by performing transplantation procedures, either as an assistant to the Transplant Surgeon, or under direct teaching supervision of the Transplant Surgeon perform aspects of these procedures as directed. 3. Recognize and describe the diagnosis and management of surgical complications, including infection in immunosuppressed patients. 4. Demonstrate understanding of the differential diagnosis of organ rejection, including hyperacute, acute, and chronic rejections. 5. Participate in multiorgan donor surgery.

Professionalism

1. Interact with patients and their families in a respectful, sensitive, and ethical manner. 2. Interact with other members of the Multidisciplinary Transplant Team in a respectful, responsible, and professional manner.

Systems-based Practice

1. Understand the multidisciplinary role of the Transplant Surgeon, Subspecialty Physicians and Consultants, Transplant Nurse Coordinator, ICU, Nurses, Clinical Laboratory, the Operating Room Team, and ancillary staff in the provision of safe, efficient, coordinated, and high quality care for the transplantation patient. 2. Demonstrate an understanding of the importance of delivery of cost-effective health care (diagnostic evaluation, therapy) and the importance of coordination in rehabilitation and discharge planning.

Practice-based Learning and Improvement

1. Demonstrate ability to utilize scientific studies to provide high quality transplant care. 2. Appropriately utilize Hospital information technology systems to manage patient care, and to access on-line medical information to deliver high quality care. 3. Facilitate and support the education of Medical Students, other Residents, and other healthcare team members.

Interpersonal and Communication Skills

1. Demonstrate skill in effective information exchange with patients, their families, and other members of the Multidisciplinary Transplant Team. 2. Demonstrate ability for accurate and timely information exchange between other members of the Transplant Team, both verbally and in writing, with appropriate use of the medical record.

Implementation

During the rotation, you will attend a weekly Transplant Teaching Conference held on Thursday or Friday mornings. The hour-long didactic session will cover topics including organ donation, ethics, transplant immunology, and kidney, pancreas, liver, and heart transplantation. These didactic sessions will cover the basics and principles of transplantation as listed in the objectives. Bedside rounds will also be conducted when feasible.

You will assist in the evaluation of any potential organ donors and participate in the organ procurement, including multi-organ procurements by the Hawaii Medical Center East Transplant Team. You will participate in any living-related donor and cadaver kidney procurements, and will participate in any living- related donor and cadaver kidney transplant operations as appropriate for your level of training and experience (e.g., first assistant or surgeon). You will also participate in the performance of liver, pancreas, and heart donor recipient operations.

You will assist in the management of immunosuppressive drug therapy for transplant recipients. You will evaluate patients for possible transplanted organ rejection and assist in the evaluation with appropriate laboratory or other diagnostic tests for organ rejection. In addition, you will help manage the definitive treatment of hyperacute, acute, and chronic organ rejections, as well as manage the surgical complications, including infection in the immunosuppressed patient.

Required Readings

You are to read the appropriate chapters in the general surgery textbooks available on transplantation. Suggested readings include Transplantation in the Principles of Surgery, edited by Schwartz, Shires, and Spencer. The chapters on transplantation in the Textbook of Surgery, edited by Sabiston are also recommended. This textbook goes into much more detail, and includes topics such as Historical Aspects of Transplantation, The Transplantation Antigens and Immunomechanisms, Allograft Destruction and Immunologic Testing, Renal Transplantation, Vascular Access Procedures for Renal Dialysis, Principles of Immunosuppression, Preservation of the Kidney, Liver Transplantation, Pancreas and Pancreatic Islet Transplantation, Cardiac and Cardiopulmonary Transplants, and Auto Transplantation. Residents will be expected to supplement their textbook reading with current peer reviewed publications.

Performance Measures and Competency Assessment

1. Daily interactions with Transplantation Attending Faculty and Senior/Chief Residents on patient wards, in the Clinic, and in the Operating Room, with Focused Review. 2. Conference participation. 3. Global Evaluation at the end of the rotation. 4. Nursing and Medical Student evaluations (360 degree evaluation)