Background
Hepatic artery infusion pump (HAIP) therapy has become increasingly commonplace in the treatment of intrahepatic tumors. When combined with standard chemotherapy, HAIP therapy demonstrates ...a higher response rate than chemotherapy alone. Biliary sclerosis is observed in up to 22 % of patients, for whom no treatment has been standardized. This report describes orthotopic liver transplantation (OLT) both as a treatment for HAIP-induced cholangiopathy and as a possible definitive oncologic treatment after HAIP-bridging therapy.
Methods
A retrospective study reviewed patients who had undergone HAIP placement followed by OLT at the authors’ institution. Patient demographics, neoadjuvant treatment, and postoperative outcomes were reviewed.
Results
Seven OLTs were performed for patients with prior HAIP placement. The majority were women (
n
= 6), and the median age was 61 years (range, 44.5–65.5 years). Transplantation was performed for five patients due to biliary complications secondary to HAIP and two patients because of residual tumor after HAIP therapy. All the OLTs had difficult dissections due to adhesions. Because of HAIP-induced damage, atypical arterial anastomoses were required in six patients (2 patients used a recipient common hepatic artery below the gastroduodenal artery takeoff; 2 patients used recipient splenic arterial inflow; 1 patient used the junction of the celiac and splenic arteries; and 1 patient used the celiac cuff). The one patient with standard arterial reconstruction experienced an arterial thrombosis. The graft was salvaged with thrombolysis. Biliary reconstruction was duct-to-duct in five cases and Roux-en-Y in two cases.
Conclusions
The OLT procedure is a feasible treatment option for end-stage liver disease after HAIP therapy. Technical considerations include a more challenging dissection and an atypical arterial anastomosis.
An increasing number of transplant centers have adopted robot-assisted living donor nephrectomy. Thus, a transplant fellow assessment tool is needed for promoting operative independence in an ...objective and safe manner.
In this pilot study, data was prospectively collected on both fellow performance with focus on technique, efficiency, and communication (“overall RO-SCORE”), and operative steps (“operative steps RO-SCORE”). Robotic user performance metrics were analyzed from the da Vinci Xi system, including fellow percent active control time (ACT) and handoff counts.
From July 2020 to February 2021, twenty-one robot-assisted donor nephrectomies were performed. In regression analysis, fellow performance (based on both RO-SCOREs and robot % ACT) was significantly associated with both time and case number, with time-to-independence modelled at 8.4–14.2 months, and case number-to-independence estimated at 15–22 cases. Robot user metrics provided valid objective measures alongside RO-SCOREs.
This pilot study provides an effective assessment tool for promoting operative competency in robot-assisted donor nephrectomy among transplant fellows.
•Transplant centers are rapidly adopting robot-assisted living donor nephrectomy.•Objective assessment is critical for fellows to gain independence in this procedure.•Performance was measured with RO-SCORE and da Vinci Xi robot user-specific metrics.•Estimated time to independence was 8.4 to 14.2 months; estimated case number to independence was 15 to 22.•This novel tool provides a comprehensive assessment of transplant fellow competency.
Abstract
Introduction
Despite considerable interest in robotic surgery, successful incorporation of robotics into transplant programs has been challenging. Lack of a dedicated OR team with expertise ...in both robotics and transplant is felt to be a major barrier. This paper assesses the impact of a dedicated robotic transplant team (DART) on program growth and fellowship training at one of the largest robotic transplant programs in North America.
Methods
This is a single center, retrospective review of all robotic operations performed on the transplant surgery service from October 2017 to October 2022. DART was incorporated in February 2020 and included transplant first assists (RFAs), scrub technologists and circulating nurses who received robotic training. Robotic experience before and after DART was compared to assess its impact on program growth and training.
Results
Four hundred and two robotic cases were performed by five transplant surgeons: 63 pre‐DART and 339 post‐DART. 40% of cases were transplant‐related and 59.5%, HPB. There was a significant increase in case volume (2.5–10.6 cases/month,
p
< .0001) and complexity (36.5% vs. 70.3% high complexity cases,
p
< .0001) post‐DART. RFA case coverage increased from 17% to 95%, and participation of transplant fellows as primary surgeons increased from 17% to 95% post‐DART period (both
p
< .05). Conversion rates (9.5% vs. 4.1%) and room turn‐around‐times (TAT) (58.4 vs. 40.3 min) were lower post‐DART (
p
< .05). There were no emergent conversions, conversions in transplant patients, or robot‐related complications in either group.
Conclusion
OR teams with expertise in robotics and transplant surgery can accelerate growth of robotic transplant programs while maintaining patient safety.
The majority of liver transplantations (LTs) in North America are performed by transplant surgery fellows with attending surgeon supervision. Although a strict case volume requirement is mandatory ...for graduating fellows, no guidelines exist on providing constructive feedback to trainees during fellowship.
A retrospective review of all adult LTs performed by abdominal transplant surgery fellows at a single American Society of Transplant Surgeons-accredited academic institution from 2005 to 2019 was conducted. Data from the most recent 5 fellows were averaged to generate reference learning curves for 8 variables representing operative efficiency (ie total operative time, warm ischemia time, and cold ischemia time) and surgical outcomes (ie intraoperative blood loss, unplanned return to the operating room, biliary complication, vascular complication, and patient/graft loss). Data for newer fellows were plotted against the reference curves at 3-month intervals to provide an objective assessment measure.
Three hundred and fifty-two adult LTs were performed by 5 fellows during the study period. Mean patient age was 56 years; 67% were male; and mean Model for End-Stage Liver Disease score at transplantation was 22. For the 8 primary variables, mean values included the following: total operative time 330 minutes, warm ischemia time 28 minutes, cold ischemia time 288 minutes, intraoperative blood loss 1.59 L, biliary complication 19.6%, unplanned return to operating room 19.3%, and vascular complication 2.3%. A structure for feedback to fellows was developed using a printed report card and through in-person meetings with faculty at 3-month intervals.
Comparative feedback using institution-specific reference curves can provide valuable objective data on progression of individual fellows. It can aid in the timely identification of areas in need of improvement, which enhances the quality of training and has the potential to improve patient care and transplantation outcomes.
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We investigated the use of robotic objective performance metrics (OPM) to predict number of cases to proficiency and independence among abdominal transplant fellows performing robot-assisted donor ...nephrectomy (RDN). 101 RDNs were performed by 5 transplant fellows from September 2020 to October 2023. OPM included fellow percent active control time (%ACT) and handoff counts (HC). Proficiency was defined as ACT ≥ 80% and HC ≤ 2, and independence as ACT ≥ 99% and HC ≤ 1. Case number was significantly associated with increasing fellow %ACT, with proficiency estimated at 14 cases and independence at 32 cases (R
2
= 0.56,
p
< 0.001). Similarly, case number was significantly associated with decreasing HC, with proficiency at 18 cases and independence at 33 cases (R
2
= 0.29,
p
< 0.001). Case number was not associated with total active console time (
p
= 0.91). Patient demographics, operative characteristics, and outcomes were not associated with OPM, except for donor estimated blood loss (EBL), which positively correlated with HC. Abdominal transplant fellows demonstrated proficiency at 14–18 cases and independence at 32–33 cases. Total active console time remained unchanged, suggesting that increasing fellow autonomy does not impede operative efficiency. These findings may serve as a benchmark for training abdominal transplant surgery fellows independently and safely in RDN.
Abdominal organ transplantation faces several challenges: burnout, limited pipeline of future surgeons, changes in liver allocation potentially impacting organ procurement travel, and travel safety. ...The organ procurement center (OPC) model may be one way to mitigate these issues. Liver transplants from 2009 to 2016 were reviewed. There were 755 liver transplants performed with 525 OPC and 230 in‐hospital procurements. The majority of transplants (87.4%) were started during daytime hours (5 am‐7 pm). Transplants with any portion occurring after‐hours were more likely to have procurements in‐hospital (P < .001). Daytime cases (n = 400) had more OPC procured livers and hepatitis C recipients and were less likely to have a donation after circulatory death donor (all P < .05). In adjusted analyses, daytime cases were independently associated with extubation in the operating room and less postoperative transfusion. There were no significant differences in short‐ or long‐term postoperative outcomes. For exported livers, 54.3% were procured by a local team, saving 137 flights (151 559 miles). The OPC resulted in optimally timed liver transplants and decreased resource utilization with no negative impact on patient outcomes. It allows for ease in exporting organs procured by local surgeons, and potentially addresses provider burnout, the transplant surgery pipeline, and surgeon travel.
The use of an organ procurement center results in more daytime liver transplant operations, less resource utilization with no difference in posttransplant complications or long‐term recipient and graft survival, a decrease in the number of flights for surgeons, and shorter travel distances.
The 2022 incoming fellows’ expectations for their robotics training, as well as their perceptions of the utility of the surgical robot, are not well defined.
Cross-sectional survey of 24 AHPBA ...fellows in 2022, analyzed with descriptive statistics and Spearman's rho.
Of 33 current AHPBA fellows, 22 completed the survey (66.7%). Study participants had limited-to-moderate experience with robotics prior to fellowship (mean 2.5 ± SD 1.1; range 1–4). Most participants agreed that robotics influenced their fellowship choice (mean 4.14 ± SD 0.87; range 1–5), would make then more marketable (mean 4.77 ± SD 0.52; range 1–5) and improve job prospects (mean 4.68 ± SD 0.87; range 1–5). Of the study participants, 55% responded that robotics training is “essential” in fellowship, while 64% responded that it is “essential” for their careers. Fellows were only slightly satisfied with overall robotics training within their respective programs (mean 3.44 ± SD 1.17; range 1–5) The majority (73.7%) expect that robotics will comprise <25% of their training. Notably, the majority (75%) have no formal robotics training curriculum.
This survey identifies potential gaps where robotics training could be improved for future incoming AHPBA fellows.
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