Transplant surgeon

A transplant surgeon is a surgeon who performs organ transplants. Among the many organs that can be transplanted are: kidneys. livers, hearts, lungs, the pancreas, the intestine (especially the small intestine), and recently, faces, tracheal (windpipe) tissue, and penises. At the present time, some organs, notably the brain and its constituent lobes and subdivisions, cannot be transplanted, and even if possible (recently, research has been done into the subject), would be very controversial for many. However, more extensive research into the transplantation of individual neurons and supportive brain tissue, or groups thereof (including glia, astrocytes, other neural connective tissue, and the surrounding meninges) has been done, and may be more practical and somewhat less controversial. Substitution of whole genes or chromosomes, or large portions thereof, for the purpose of genetic therapy or engineering (which is not actually transplantation, since these are not whole organs, or even tissues) is generally not yet feasible. While the use of tissue grafts- which is much more common- is not transplantation, since an entire organ is not transferred, these two are closely related (skin, hair, and subdermal tissue, connective tissue, musculoskeletal tissue, and corneas are commonly grafted).

Sometimes, the separation of conjoined individuals requires transplantation of an organ or organs, especially if complications develop. End-stage renal disease (stages 5 and 6; either acute and non-reversible, or chronic), severe congestive or other heart failure or certain congenital cardiac structural defects (where the blood cannot be oxygenated or backflows, or where the ejection fraction or distribution of blood is insufficient); and advanced chronic obstructive pulmonary disease, cystic fibrosis (when the lungs are no longer able to function), or emphysema, are possible indicators for, respectively, renal (kidney), cardiac (heart), or pulmonary (lung) transplantation.

There are distinct parameters for who is eligible for transplantation of the different organs. Broadly speaking (this is not meant to be exhaustive), these include: age, how long they have been on the waiting list, how urgently they need the organ (which is often related to how long they've been on the list, and whether they are actually in end-stage disease, which has its own laboratory and functional criteria per organ); their prognosis (how stable they are now- whether they can survive major invasive surgery and the anesthesia and post-op period, and how they have been, and how they likely will fare with and/or without the organ, versus with other therapies that are not transplantation- such as continued dialysis or getting an artificial heart or left ventricular assist device). Care must be taken when finding organs for the very young (this requires special training, or at least knowledge of, pediatric and newborn transplantation procedures), or certain very elderly patients (there may or may not be mandatory or preferred cut-off ages for receiving an organ or tissue, depending on the location, the institutions involved, the surgical team, whether the patient has any relevant co-morbidities and whether they are capable of caring for their new situation, how long and how well they might live, and the patient's and family's wishes). Transplantation rejection concerns, and the need to find willing donors or to have others give consent (for the deceased, in a cadaveric procedure), and the need to match them and to screen the needed blood products and other materials and maintain sterility and asepsis, are all very relevant issues, as is how to proceed if rejection becomes an issue (treatment, and if need be, removal), and how to deal with immune suppression post-transplant (this has become somewhat easier in recent years). Those with diabetes (particularly if it is advanced, and especially if it is not well-controlled), those who are culpably non-compliant with their medication and treatment plans, those who abuse substances (any drugs, alcohol, or tobacco), those who are uncooperative, those whose diseases or prognoses are not amenable to transplantation (or who may go on to need another of the same organ soon), those who have advanced and uncontrolled active liver or kidney disease, some prisoners, and those with advanced symptomatic AIDS or metastatic cancer with little chance of remediation are generally not candidates for transplantation (or would be low on the priority list independently of any other factors), though in certain cases exceptions can, especially recently, with better technology and better knowledge and protocols, be made, per the discretion of the organ network, the institutions, and the patient's doctor and surgical team.

Admission to the specialty, like many other surgical specialties, is very competitive. There is a shortage of organs and tissues available, and more donors and more surgeons and more locations capable of these procedures are needed, in both developed and developing countries. Because these patients are often somewhat unstable, on some form of life support and/or life-sustaining technologies (cardiopulmonary bypass, respirator/ventilator or breathing tube, implantable cardioverter/defibrillator, some form of dialysis or other renal replacement therapy, artificial liver, parenteral nutrition, etc.), these procedures- especially if they involve the vital organs (heart, lung, liver, pancreas; kidney transplantation could be included here but is more common)- usually only take place in Level I trauma centers that usually are academic medical centers (teaching hospitals), or at least at a relatively large, well-staffed hospital with a 24-hour operating and emergency room service, 24-hour intensive and critical care available, a good hospital pharmacy, 24-hour advanced skilled nursing care available, access to the person's GP and specialist, and 24-hour easy access to anesthesia practitioners, surgeons and physicians, and nurses with expertise in the transplanted organ and in emergency, operative, and intensive care. At smaller (Level II or III) institutions in smaller cities, it is still often possible to perform renal and corneal transplantation (especially on adults), and do skin grafts; the extent of their services varies with the personnel and the organ at stake (hearts, livers, and lungs have extensive arterial, venous, and capillary vasculature, extensive connections to muscle, fascia, and connective tissue, connections to ligaments, tendons, and other body parts, and numerous small parts and nerves and nerve junctions, require a number of anastomoses, or joining of tissues, and are near other important structures). Training in the U.S. usually involves the four years of the undergraduate pre-medical track, four years of medical school, a rotating first year of residency (the former internship year), and then four more residency years (for a total of 5) in general surgery. At some point during those four years, a transplant surgeon would likely train to some extent in emergency surgical procedures, vascular surgical procedures, surgical procedures involving pediatric and/or geriatric cases, and a variety of surgical cases, featuring different conditions, degrees of urgency, and age groups, that require critical and/or intensive care. During their first residency rotational year, they are likely to focus on the surgical field, the emergency room, and critical/intensive care and post-operative/recovery care, as well as some time with immunology, anesthesia, pediatrics, and rehabilitation, and to spend some time with a paramedic or flight crew. During their residency, they will likely be exposed to a progressively increasing number of transplant cases, with more and more degrees of difficulty, and with less oversight over time. They can also complete another residency afterward in the specialty of the organ systems they most prefer to transplant (cardiovascular, pulmonology, gastrointestinal/hepatic, nephrology/urology, etc.). Fellowships can be done in general transplant medicine or in certain areas of transplant medicine and surgery. Among the possible specialties are: transplantation rejection medicine/immunology, pediatric and/or neonatal transplantation of certain organs, sense organ transplantation (primarily, corneas and research into future advances), transplantation research (i.e., into neural or brain region transplantation), obstetric transplantation (of pregnant women), geriatric transplantation, trauma/burn transplantation surgery, emergency or critical care transplant surgery (for unstable cases: emergency, septic, or acute degeneration cases needing transplants), post-transplantation rehabilitation, and oncologic or diabetic transplantation cases. It is a very stressful position demanding high accuracy in a very unforgiving surgical environment, requiring a very steady physical and motor presence and a calm, professional, and composed personality with a reasonably good bedside manner and the capacity for teamwork involving various personalities and multiple guidelines from multiple institutions, with not-uncommon failure and complication rates and with frequent transfers of patient care between facilities.^{[1][2][3][4][5][6][7][8][9][10][11]}

See also

• Transplant surgery

References