Transplant Surgery

Course Director                     Tim Schmitt, M.D.

Attendings                              Tim Pruett, M.D.

                                                Ken Brayman, M.D.

                                                Rob Sawyer, M.D.

                                               

Goals

The educational goals of the transplant rotation are to provide the student with an understanding of the common problems of patients with end stage organ disease pre and post transplantation and basic clinical decision-making skills in this patient population applicable to their future practice.

Curriculum and Learning Objectives

These are summarized in Tables 1- 6

Orientation

Students will be presented with a handbook at the beginning of the academic year outlining the learning objectives for the transplant surgery rotation. While on this rotation students will present each patient examined to the faculty on a daily basis. Complications will be presented by residents at the weekly mortality and morbidity conference. Attendance is mandatory for medical students.

Assessment

Much medical student education and assessment occurs during patient care activities. Assessment in this setting has the advantage of a high degree of realism and an ability to assess complex tasks and decision-making.

Student competence will be assessed as follows:

Faculty and residents will assess each student daily using questions, assignments, and feedback on real life clinical problems. By providing feedback and encouraging students to reflect on their own clinical behavior, students will become better judges of their own strengths and weaknesses.

Medical students will be determined to have achieved the intended learning outcomes of instruction if based on the direct observation of and interaction with experienced physicians, and nursing staff on rounds, in the operating room, in clinic and during case conferences this student:

  • Consistently recognizes common clinical problems in the pre-transplant patient with end stage disease and constructs appropriate diagnostic and treatment algorithms for each condition.
  • Consistently appropriately evaluates the suitability for transplantation of a patient referred to the transplant center with end stage liver and / or kidney disease in accordance with accepted listing criteria.
  • Consistently develops appropriate management plans for patients with end-stage liver and or kidney disease who develop common general surgical problems.
  • Is able to identify post transplant problems that require immediate referral to a transplant center.
  • Communicates effectively to patients and their families the risks of undergoing liver / kidney transplantation, dialysis access and living organ donation.
  • Is able to discuss the process of organ allocation and prioritization.
  • Critically evaluates his / her practice on a daily basis.

 

Responsibilities

Students should participate in all inpatient and outpatient clinical activities and educational activities but are particularly responsible for:

 

  • 1. Following the day-to-day care of all in house patients, including the evaluation of all potential organ recipients. Patients should be presented to the attending on rounds.
  • 2. The organization of flow - sheets, co-ordination of daily lab values and immunosuppression orders under the direction of the Surgery Attending on Service.
  • 3. Performing H & P as requested in clinic
  • 4. Assist with donor organ recovery.
  • 5. Assist with all transplant operations.  You should be completely prepared for every OR case prior to scrubbing in.  This means that you have reviewed the patient's history and know the results of all laboratory, radiology, and pathology studies.  In addition you will be expected to read about the patient's disease process, the treatment options, and the details of the proposed surgery, including relevant anatomy and the surgical techniques involved.
Table 1. ESLD

Upon completion of the transplant surgery rotation all students will be able to:

LEARNING OBJECTIVES

Assessment

 

KNOWLEDGE

Satisfactory

Not assessed

Needs improvement

Recognize the following common clinical problems and construct appropriate diagnostic and management algorithms for each condition: 

  • Ascites
  • Variceal bleeding
  • Hepato- renal syndrome
  • Encephalopathy
  • Substance abuse

 

 

Assess the suitability for transplantation of a patient referred with ESLD with reference to:

  • MELD scoring system (Model for End stage Liver Disease)
  • UNOS listing criteria (United Network for Organ Sharing)
  • Absolute and relative contraindications

 

 

Outline a management plan with particular reference to the increased risk of surgery for patients with ESLD who develop the following common general surgical problems:

  • Umbilical hernia
  • Inguinal hernia
  • Gallstones

 

 

SKILLS

 

 

 

Perform a paracentesis

 

 

 

Obtain informed consent

 

 

 

ATTITUDE

 

 

 

Demonstrate professional attitudes and values towards, colleagues, and patients.

 

 

 

Approach patients in non-judgmental and patient-centered manner with empathy and professionalism.

 

 

 

Model professionalism, respect, and enthusiasm for learning during clinical encounters.

 

 

 

Reveal self-awareness through reflection of successful and unsuccessful patient encounters.

 

 

 

Table 2. Liver Transplantation

Upon completion of the transplant surgery rotation all medical students will be able to:

LEARNING OBJECTIVES                                                                                                                                 Assessment

KNOWLEDGE

Satisfactory

Not assessed

Needs improvement

Develop a differential diagnosis and a management plan appropriate to their level of training for the following clinical scenarios in the early post liver transplant patient:

  • Bleeding / coagulopathy
  • Decreased urinary output
  • Abnormal liver function tests
  • Volume overload / ascites
  • Fever

 

 

 

Recognize and outline a management plan for each of the following categories of post transplant complications:

  • Graft dysfunction / non-function
  • Infection: bacterial, viral and fungal
  • Rejection: acute / chronic
  • Technical: Bleeding, biliary, arterial, wound related

 

 

 

Recognize and outline a management plan for each of the following medical complications:

  • Diabetes
  • Renal Failure
  • Drug toxicity
  • Neurological problems
  • Altered mental status

 

 

 

Recognize the most common post transplant problems that require immediate referral to a transplant center:

  • Fever
  • Vomiting / diarrhea
  • Dehydration

 

 

 

SKILLS

 

 

 

Obtain informed consent from a patient undergoing liver transplantation

 

 

 

Evaluate the post transplant patient for post operative complications

 

 

 

 

Table 3. ESRD

Upon completion of the transplant surgery rotation all medical students will be able to:

LEARNING OBJECTIVES                                                                                             Assessment

KNOWLEDGE

Satisfactory

Not assessed

Needs improvement

Describe the different forms of dialysis access and their indications, advantages and disadvantages. 

 

 

 

Explain the difference between dialysis and hemofiltration, and the basic mechanisms of peritoneal and hemo dialysis.

 

 

 

Describe the role of vascular ultrasound in the evaluation of a patient for vascular access.

 

 

 

Describe the diagnosis, evaluation, and treatment of the common complications of angioaccess.

 

 

 

Develop an algorithm for selecting an appropriate form of angioaccess

 

 

 

SKILLS LEARNING OBJECTIVES

 

 

 

Conduct an initial evaluation for hemodialysis access.

 

 

 

Educate a patient on the different forms of renal replacement therapy, including the pros and cons of each.

 

 

 

Table 4 Renal Transplantation

Upon completion of the transplant surgery rotation all medical students will be able to:

LEARNING OBJECTIVES                                                                                                               ASSESSMENT

KNOWLEDGE

Satisfactory

Not assessed

Needs improvement

Describe and discuss the indications and contraindications for kidney transplantation

 

 

 

Describe and discuss the diagnosis and management of the following common categories of complications

  • Technical
  • Medical
  • Infective
  • Immunological
  • Drug related

 

 

 

SKILLS

 

 

 

Obtain informed consent for kidney transplantation

 

 

 

Table 5 Pancreas Transplantation

Upon completion of the transplant surgery rotation all medical students will be able to:

LEARNING OBJECTIVES

Assessment

KNOWLEDGE

Satisfactory

Not assessed

Needs improvement

Describe and discuss the indications and contraindications of pancreas transplantation

 

 

 

Describe and discuss the diagnosis and management of the following common categories of complications:

  • Technical
  • Medical
  • Infective
  • Immunological
  • Drug related

 

 

 

SKILLS LEARNING OBJECTIVES

 

 

 

Obtain informed consent for pancreas transplantation

 

 

 

 

Table 6 Organ Donation

 

Upon completion of the transplant surgery rotation all medical students will be able to:

LEARNING OBJECTIVES

Assessment

KNOWLEDGE

Satisfactory

Not assessed

Needs improvement

Describe the criteria for brain death

 

 

 

Define donation after deceased cardiac death

 

 

 

Assess suitability, indications and contraindications for patients undergoing living donor nephrectomy or hepatectomy

 

 

 

Develop a differential diagnosis and management plans appropriate to their level of training for the following clinical scenarios in the post operative liver donor:

  • Pain management
  • Fever
  • Decreased oxygen saturation
  • Elevated liver function tests

 

 

 

Identify the indications and contraindications for deceased organ donation

 

 

 

Distinguish the following categories of deceased donors

  • Directed donation
  • Marginal donors
  • High risk donors
  • Deceased cardiac death (DCD)

 

 

 

Describe with relation to organ allocation

  • Role of UNOS
  • Role of LifeNet
  • Virginia Consent laws

 

 

 

Discuss the following ethical dilemmas / issues

  • Informed consent
  • Autonomy
  • Solicitation
  • Coercion