Transplant surgeryBMJ 2004; 329 doi: https://doi.org/10.1136/bmj.329.7458.s23-a (Published 17 July 2004) Cite this as: BMJ 2004;329:s23
For budding surgeons with an interest in complex surgery that is both ethically and technically challenging, transplant surgery may be the ideal career choice. Chris Callaghan, Ayyaz Ali, and Gavin Pettigrew offer a practical guide
More than 2500 solid organ transplant operations are performed each year in the United Kingdom, and with advances in immunosuppression and anaesthetic and surgical techniques, more than 85% of renal, liver, and heart transplants are functioning one year after surgery. Although surgeons from different specialties are concerned with transplantation, transplant surgeons share common characteristics and training requirements.
Some colleagues perceive transplant surgeons to be workaholics who barely see the light of day. Although transplant surgeons do require stamina and the ability to work hard, you don't need to be Superman or Superwoman. You need to be attracted to “big” surgery—long operations on sick patients requiring intensive support services. You must be committed, analytical, and have excellent communication skills. An interest in immunology is an advantage.
Transplant surgery is one of the most “medical” of surgical specialties—you need a good working knowledge of medicine, infectious diseases, and pharmacology. The shortage of donor organs means that you have to come to terms with making potential life or death decisions regarding who is put on the transplant operation waiting list. Most importantly, it is essential that you are comfortable working in a multidisciplinary environment where decisions are made collectively.
A career in transplant surgery won't give you uninterrupted sleep and lots of private work, but it will provide you with a unique combination of intellectual and surgical demands (see box).
Heart and lung transplant operations are performed by cardiothoracic surgeons, while abdominal organs are implanted by surgeons with diverse training backgrounds. Some units are staffed by consultants who practise both liver and renal transplantation. These multiorgan abdominal transplant surgeons are the closest thing to a general transplant surgeon, as no surgeons perform both thoracic and abdominal organ transplantations.
Heart transplantations are performed for severe, refractory heart failure due to cardiomyopathy, coronary artery disease, or congenital heart disease. Indications for lung transplantation include chronic obstructive airways disease, cystic fibrosis, and idiopathic pulmonary fibrosis.
The working pattern of a cardiothoracic transplant surgeon is determined by the time limits imposed by organ preservation techniques. With maximum cold ischaemic times for both organs of six hours, recipient surgery usually begins in the early hours of the morning. Cardiothoracic transplantation is evolving into a subspecialty which also includes the implantation and monitoring of ventricular assist devices for the treatment of end stage heart failure. The United Kingdom has seven cardiopulmonary transplant centres: Papworth, Newcastle, Birmingham, Harefield, Glasgow, Great Ormond Street, and Manchester. In addition to their transplantation commitments, cardiothoracic transplant surgeons have a full general cardiothoracic workload.
Pros and cons
Technically challenging surgery
High public profile
Relatively low volume of patients but long duration of contact
Exposure to critical care and high technology medicine
Often life saving surgery
Multiple subspecialty interests bring variety
Long, demanding surgery, often done at night
Little or no private work
Strain of operating on live donors who gain no physical benefit from surgery
Emotionally stressful owing to frequent contact with death, either of cadaveric donors or recipients
Risk of transmissible diseases in liver transplant surgery
Renal transplantation is the most cost effective treatment for end stage renal disease and provides a better quality of life than dialysis. Donor kidneys are transplanted on to the iliac vessels with an anastomosis between the transplant ureter and recipient bladder. Given the anatomy of this operation it is not surprising that renal transplantations are undertaken by surgeons initially trained in general or urological surgery.1 Renal transplant surgery also includes vascular access surgery for renal replacement therapy (for example, arteriovenous fistula formation) and insertion of peritoneal dialysis catheters. The United Kingdom has more than 25 renal transplant centres.
The most common causes of liver failure that require transplantation are cirrhosis due to primary biliary cirrhosis, alcoholic cirrhosis, or viral hepatitis B or C. The liver is the most difficult intra-abdominal organ to transplant because of its size, the risk of torrential bleeding from portal hypertension, and the precision required for fine arterial and biliary anastomoses. Liver transplant surgeons are trained in general surgery and commonly have a practice in hepatobiliary surgery. The United Kingdom has seven liver transplant units: King's College Hospital, Birmingham, Leeds, Cambridge, Edinburgh, Royal Free Hospital, and Newcastle.
A week in the life of a transplant surgeon
A typical working week for a transplant surgeon who specialises in multiorgan abdominal transplantation might include the following.⇓
Renal recipient assessment clinic
This entails assessing patients referred for consideration of acceptance on to the waiting list and six-monthly reviews of those already on the list. For new patients, the surgeon needs to determine if the patient is fit enough to withstand transplant surgery and whether the potential benefits of transplantation outweigh the risks. Evaluation of vascular and urinary anatomy and function is vital. Those waiting long periods for a transplant operation require psychological support and encouragement from all members of the transplant team.
Transplant recipient follow up clinic
In the early stages after the operation, transplant recipients are followed up weekly. Blood is taken for liver and renal function tests and immunosuppressant levels. Screening for immunosuppressant side effects (for example, hyperlipidaemia, diabetes, hypertension, skin cancer) is important, as is patient education (for example, cessation of smoking, avoidance of exposure to the sun, and compliance with drug treatment).
Transplant surgery on-call duties
Once brain death has been confirmed and consent has been given for organ donation, the donor transplantation coordinator contacts the on-call transplant surgeon. After reviewing the waiting list and discussing possible recipients with the on-call physician (nephrologist or hepatologist), the transplant surgeon decides whether the organ on offer is suitable for use. Important donor variables include age, medical and social history, weight, blood group, tissue type (for kidneys), organ function, and the circumstances surrounding death. The consultant will often be called during the night to discuss the retrieval. Once the organ has been retrieved the consultant will supervise back table preparation in the early morning. Finally, the consultant will perform or supervise the implant procedure. As retrievals often result in more than one usable organ (for example, liver and kidneys), surgery on multiple recipients can stretch on through the day and into the next night.
Transplant multidisciplinary team meetings
Meetings are held in order to review the progress of ward patients and discuss patients referred for waiting list consideration. The decision to take a patient off the waiting list because of chronically deteriorating health is particularly difficult as it may represent the patient's last hope for recovery from organ failure. Decisions regarding transplant waiting lists raise many ethical issues (see below).
Transplant recipients are seen daily by a transplant consultant, either a physician, a surgeon, or commonly both. Postoperative patients require intensive management to detect and treat vascular, biliary, or urological complications. Graft rejection occurs in 20-30% of recipients and requires treatment with steroids.
General surgical commitments
These include general surgery on calls, clinics, ward rounds, and multidisciplinary team meetings.
Organ donors may be living or cadaveric; cadaveric donors may be heartbeating (that is, death is declared by fulfilment of brain death criteria) or non-heartbeating. Consent for organ retrieval is taken from the families of cadaveric donors by the consultant looking after the donor (that is, the intensive care consultant or neurosurgeon). In the United Kingdom, half of the families approached decline consent for cadaveric donation.
Common to all transplant specialties is the pressing need to reduce the growing disparity between the demand and supply of organs. Almost 400 people die on the transplant waiting list each year. This has stimulated a search for alternative sources of donated organs. Older donors or donors with organ function outside normally accepted criteria (marginal donors) are increasingly being used. In 2003, 6% of kidneys and 2% of transplanted livers came from non-heartbeating donors. Despite initial concerns about organ quality this source of organs is gaining acceptability.
One quarter of all transplanted kidneys come from living donors. The introduction of laparoscopic live donor nephrectomy may make living kidney donation more acceptable to potential donors. Living donation of a liver segment or lung lobe is also possible, but carries a considerable mortality risk. More efficient use of organs is also possible. Liver transplant surgeons are able to split livers along anatomical planes, enabling both a child and an adult recipient to benefit from one cadaveric organ. Research into human embryonic stem cells may result in a source of transplantable tissues in the future.
Transplant surgeons regularly face ethical dilemmas. Most dilemmas centre on the distribution of a scarce resource among a population for whom transplantation offers the best chance of survival. Here are two fictional but typical cases.
You are a liver transplant surgeon on call. You have been offered a liver from a 70 year old donor with moderate fatty changes and mildly abnormal liver function tests. Your waiting list has six patients who are size and blood group matched for this liver, three of whom have been waiting for a year. The individual who receives this marginal liver faces a higher risk of postoperative complications, but its use will benefit others on the waiting list by increasing their chances of getting a subsequent organ. Is this utilitarian viewpoint ethical?
A 40 year-old mother of three with primary biliary cirrhosis is presented at your transplant multidisciplinary team meeting. She has had two previous liver transplants, and her current transplanted liver is failing due to recurrent disease. She is cachectic, and septic from multiple hepatic abscesses resistant to therapy. Without another transplant she will probably die within weeks. A third transplant has a 50% peri-operative mortality risk and could be used in those awaiting their first liver transplant. What would you do?⇓
Senior house officer level
At senior house officer (SHO) level, a six month attachment to a transplant unit is advisable but not essential. Working in a transplant unit may mean that you are given less responsibility than you've had in previous jobs, but this is balanced by the opportunity to perform procedures such as central line insertion and to improve your skills in managing patients with end stage organ failure. In renal units, you can acquire basic surgical skills by performing arteriovenous fistula surgery and inserting peritoneal dialysis catheters. Assisting in donor organ retrieval surgery will help you to understand the issues surrounding donor organ selection and offers you exposure to operative anatomy that you will rarely see in other operations.
You will need to pass your exams for membership of the Royal College of Surgeons (MRCS) by the end of your surgical SHO rotation. You'll need at least six months' experience as an SHO in cardiothoracic surgery, general surgery, or urology before applying for a national training number in those programmes. Getting on remains highly competitive and you will need to have good clinical experience and publications to be successful. A period of formal research (MS, MD, PhD) is no longer a prerequisite, but remains advantageous, for those seeking to enter the specialist registrar (SpR) grade.
Specialist registrar level
Cardiothoracic surgery,2 general surgery, and urology have six year training programmes made up of five years of clinical training and one flexible year, which may be spent in research, advanced subspecialist training, or overseas. The clinical years consist of three years' generalist training and two of subspecialist training. During the first three years it is essential to acquire a breadth of operative experience.
Organ retrievals are the key “bread and butter” procedures to be mastered by SpRs before proceeding to organ insertion. Retrievals are long operations that take place in the early hours of the morning when emergency theatre time becomes available. Mistakes result in damaged or unusable organs. Close cooperation between the retrieving surgeon and the team receiving the organ is essential. Any unexpected findings such as abnormal vascular anatomy must be clearly communicated to the receiving surgeon.
Training in transplant surgery characteristically entails close consultant supervision. It is rare for even a senior SpR to perform a liver, heart, or lung transplant operation without a consultant scrubbed. These operations will be performed unsupervised for the first time as a junior consultant. In contrast, renal transplantation provides a good training opportunity for more junior SpRs. SpRs on renal units are also expected to master peritoneal dialysis catheter insertion, fistula formation, and ureteric stent removal via flexible cystoscopy.
Training and the European Working Time Directive
Introduction of the European Working Time Directive (EWTD) means that by August 2004 no junior doctor in the United Kingdom should work more than an average of 58 hours a week, with further reductions to 48 hours by August 2009. This decline in training opportunities is bound to have an appreciable impact on the ability of SpRs to learn essential techniques. With increasingly inexperienced specialist registrars, some centres are using consultants to retrieve organs. This overloads already busy consultants. One possible solution is to create a supraregional retrieval service to which SpRs would be attached for up to a year. With fewer hours, working in a supportive unit with sufficient patient volume and where training is a priority is therefore essential. Training transplant SpRs under EWTD restrictions will be a considerable challenge.
Modernising medical careers
Major changes to the UK medical career structure will shortly be introduced. After graduating from medical school, junior doctors will enter two year foundation programmes before progressing to basic specialist training programmes. Shorter, more generalist, higher specialist surgical training will lead to a certificate of completion of specialist training in three or four years. Presumably those trainees interested in transplantation will apply for subspecialist training posts of two or three years' duration at this point. Many details remain to be worked out.
The Royal College of Surgeons of England has estimated that an additional 21 renal, 15 liver, and seven cardiothoracic transplant consultants are needed in the United Kingdom,3 and the government plans to address this shortfall. This expansion should shift the perception among surgical trainees that transplant surgery is an overworked specialty and thus improve recruitment. However, owing to the relatively small pool of consultant positions, committing yourself to training in transplant surgery will not guarantee a career.
UK Transplant (www.uktransplant.org.uk): provides details on UK transplant statistics, patient information, and legislation surrounding transplantation
British Transplantation Society (www.bts.org.uk): contains transplantation guidelines, position statements on ethical issues, links to transplant related sites, and information on the society's activities
www.ustransplant.org: website for the US transplant recipient registry with a transplantation glossary and US transplant statistics and links
Modernising Medical Careers (www.mmc.nhs.uk): information on upcoming changes to the SHO grade and proposals for altering specialist training and the non-consultant career grade
You must plan your training carefully to ensure that you can market yourself in a related specialty if you are unsuccessful in finding a post as a consultant transplant surgeon. This back-up plan might be vascular surgery, general urology, hepatobiliary surgery, or general cardiothoracics, depending on your SpR programme. In order to increase your chances of becoming a consultant transplant surgeon, a higher research degree in a transplant related subject is highly recommended and should be undertaken at some point during SHO or SpR training. Even with the above problems, trainees in transplantation face good employment prospects.