Overview of Clinical Services
The Transplant Surgical Fellow is responsible for leading each clinical team under the direct guidance of the transplant surgeon and a transplant nephrologist or hepatologist, each of whom typically spends one week on the service at a time. In turn, the transplant fellow supervises the house staff, provides daily teaching, and coordinates patient care with nursing staff and consultant services.
Operative Exposure
The UCSF transplant fellow will have the opportunity to master back table preparation of the kidney and the pancreas, ex vivo vascular and ureteral reconstruction as necessary, kidney and pancreas transplantation, laparoscopic donor nephrectomy, and transplant nephrectomy. The estimated volume for each fellow is:
- Kidney transplant = 100+
- Pancreas transplant = 5-6
- Laparoscopic donor nephrectomy = 40+
In addition, the fellow is expected to participate in all operative cases related to complications of kidney and pancreas transplantation including exploration for bleeding or possible vascular thrombosis, repair of ureteral leak, ureteral revision secondary to obstruction, lymphocoele drainage (both laparoscopic and open), and enteric conversion of bladder-drained pancreas allografts. The fellow will have some exposure to dialysis access procedures and to occasional general surgery procedures performed on transplant recipients.
The fellow's operative experience on the Liver Transplant Service is extensive. The fellow will be fully exposed to deceased and living donor transplantation for both adult and pediatric patients. This includes participating in living donor left lateral segmentectomy and right hepatic lobectomy. The estimated volume for each fellow is:
- Adult liver transplantation = 100+
- Pediatric liver transplantation = 5-6
- Living donor liver transplantation (adult and pediatrics) = 8-12
- Living donor hepatectomy (left lateral segmentectomy and right lobectomy) = 8-12
The fellow is expected to participate in all operative cases related to complications of liver transplantation including exploration for bleeding, repair of bile leak, and biliary revision for obstruction. The Liver Transplant Service also offers exposure to hepatic resections and occasional surgical shunt procedures (typically distal splenorenal or Rex shunts). Finally, during the past several years, there has been an increasing volume of operative radiofrequency ablation for hepatocellular carcinoma as either a bridging strategy to transplantation or as definitive therapy.
Kidney and Pancreas Transplant Services
In addition to the transplant surgery fellow, the transplant surgery attending, and the transplant nephrology attending, the Kidney/Pancreas Transplant Service is staffed by one or two surgical interns, one third-year surgical resident, a nephrology fellow and often, a transplant nephrology fellow, a post-transplant nurse coordinator, a transplant pharmacist, and often medical and/or pharmacy students. The service census averages 15 patients with 1 to 2 patients in the Intensive Care Unit. During daily inpatient rounds, all patients are examined; results of laboratory, radiological, and histological tests are reviewed; and a plan for patient care is determined.
Kidney/Pancreas Transplant Services All patients scheduled to undergo kidney donation or kidney and/or pancreas transplantation are admitted to the service in the peri-transplant period.
The transplant fellow is responsible for evaluating each patient's suitability to undergo transplantation on admission. Moreover, all kidney and kidney pancreas transplant recipients who require hospitalization for any medical or surgical problem(s) are admitted to the service.
The fellow is expected to gain expertise in the comprehensive medical management of the post-transplant patient including the prescription of appropriate immunosuppression and diagnosis of rejection. In light of the high volume of our program, the fellow will be generously exposed to medical and surgical complications of kidney and pancreas transplantation.
It is the full expectation of our program that the fellow will master the necessary diagnostic and therapeutic strategies to handle such contingencies. The fellow is also expected to attend the weekly multidisciplinary Kidney and Pancreas Selection Conference where pre- transplant patients are presented and concerns regarding their candidacy discussed.
Liver Transplant Services
In addition to the transplant surgery fellow, the transplant surgery attending, and the transplant hepatology attending, the Liver Transplant Service consists of two surgical interns, two medical interns, a third-year surgical resident, two senior gastroenterology fellows, an inpatient nurse coordinator, and a transplant pharmacist along with medical and/or pharmacy students. The transplant surgery fellow and attending surgeon has primary responsibility for the care of post-transplant patients while the gastroenterology fellows and the hepatologist have primary responsibility for the care of pre-transplant liver patients and perform all inpatient liver allograft biopsies. Similar to the Kidney/Pancreas Service, patients are examined; results of laboratory, radiological, and histological tests are reviewed; and a plan for patient care is determined. Typically, the service census averages 18 to 20 patients with 4 to 6 in the Intensive Care Unit.
For those who come in for transplant from home, the transplant fellow is expected to review all pre-admission workups to determine whether the evaluation is satisfactory and complete. The transplant fellow is expected to attend the weekly multidisciplinary Liver Transplant Selection Committee Meeting where all pre-transplant candidates are presented and concerns regarding candidacy are discussed. As for the peri- and post-transplant population, the goal of delivering comprehensive medical, surgical, and immunosuppressive care is quite similar to the Kidney/Pancreas Service.
We believe that the UCSF Liver Transplant Service rotation provides unique and invaluable training. The full integration of hepatology and transplant surgery and of the pre-transplant and the post-transplant care exposes the fellow to the full spectrum of medical and surgical management. The fellow will gain intimate familiarity with the physiology of acute and chronic liver disease, the tempo of decompensation, the potential for recovery, and the appropriate application and timing of liver transplantation.
Multi-Organ Procurements
As soon as the fellow matriculates, his/her training in deceased donor multi-organ procurement of livers, kidneys, and pancreata begins. While the majority of procurements involve brain-dead donors in our donor service area, there has been an increase in donation after cardiac death in recent years. Typically, the incoming fellow spends approximately three months performing procurements under the direct supervision of the senior fellows until they are certified to lead the procurement team themselves.
It is expected that the fellow will gain ample exposure to unusual anatomic situations including pediatric and infant donors, donors who have had cardiac surgery, donors with aortic/iliac aneurysms, and donors with aberrant vascular anatomy (accessory or replaced left and right hepatic arteries, retroaortic renal veins, renal arteries arising from iliac arteries, etc.). During the entire fellowship, the transplant fellow performs an average of 125 deceased donor multi-organ procurements over the two-year training cycle.