A transplant surgeon specializes in removing damaged or dysfunctional organs and replacing them with a more functional organ received from a living or deceased donor. An organ transplant can not only save a patient’s life, but it can provide an improved quality of life and extend the life of the patient as well. More than 2500 solid organ transplant operations are performed each year in the United Kingdom, and with advances in immunosuppression and anesthetic and surgical techniques, more than 85% of renal, liver, and heart transplants are functioning one year after surgery (Pettigrew, 2004).
Organs that can currently be transplanted successfully include the heart, pancreas, liver, lungs and kidneys, among others. Other non-organ transplants performed by a transplant surgeon may involve eye tissue, skin, bones, tendons, ligaments, bowels, veins and heart valves. A single organ or multiple organs can be transplanted at a time, although performing multiple transplants is an extremely complex process.
Transplant surgery may be required for a variety of reasons. If an organ is failing, a transplant is required for the patient to sustain life. A tumor or infection can destroy or weaken organs and bones, which leads to the need for a transplant. Bones and limbs can sometimes be replaced as opposed to amputation. Severe burn victims receive skin transplants to replace the skin lost. Some transplant surgeons may specialize in infant organ transplants as well.
Most transplant surgeons specialize in transplanting a specific organ, although many have experiences in more than one area before they select their specialty. This type of medical surgeon works as part of a transplant team to provide the best possible transplant care to their patient. Transplant surgeons not only work as part of a transplant team, they also perform evaluations of living donors, remove and preserve organs and provide post-operative care to transplant patients.
The Organ Transplant Team
A transplant surgery team consists of multiple health care professionals with varying levels of expertise, education and training. The transplant surgeon is responsible for removing the organ from the donor (in most cases, if the donor is living) and for management and oversight of all aspects of the patient’s care. For example, they will monitor all lab results and ensure the incision is healing properly without infection. Immunosuppressive medication management is performed by the transplant surgeon throughout the pre- and post-operative care.
A transplant physician is responsible for monitoring non-surgical aspects of patient care. They work closely with the transplant surgeon to monitor the organ function and adjust medications as needed, and with the nurses and other staff who help care for and monitor the patient.
The transplant coordinator is a registered nurse (RN) who schedules evaluation tests, such as evaluating potential donors. They may also provide recommendations for the patient to improve the probability of a successful transplant, including changes in diet and lifestyle. A dietician is also a RN who will create a plan for the patient before and after the surgery.
Social workers and financial planners are also part of a transplant team. They work with the patient and the family to ease the stress of the effects a transplant surgery can have not only financially, but emotionally as well. The financial planner will work with insurance companies and help the patient with other financial resources available to cover the costs of transplant surgery.
Heart and Lung Transplants
A cardiothoracic surgeon typically performs heart and lung transplants. Heart transplants may be performed due to severe heart failure as the result of cardiomyopathy, coronary artery disease or congenital heart disease. A lung transplant may be the result of chronic obstructive airway disease, cystic fibrosis and idiopathic pulmonary fibrosis.
Kidney and Liver Transplants
A general transplant surgeon may perform transplants of the liver or kidney, or they may specialize in one or the other. Kidney or renal transplants are required for patients with renal failure or end stage renal disease. Most of these patients required dialysis prior to receiving a transplant. Donor kidneys are transplanted on to the iliac vessels with an anastomosis between the transplant ureter and recipient bladder (Pettigrew, 2004). Most kidney transplant surgeons have education and training in general transplant or urological surgery.
Liver transplants are required due to failure of the liver caused by various forms of cirrhosis, including biliary, alcoholic, or viral hepatitis. Because of the liver’s large size, it is a very difficult organ to transplant, and there are significant risks of hemorrhage.
The History of Transplant Surgery
Kidney Transplants
Kidneys were the first organ to be successfully transplanted. Since Jaboulay and Carrel developed the techniques required to perform vascular anastomoses at the turn of the last century, there has been a desire to treat organ failure by transplantation (Watson and Dark, 2012). The first kidney transplants were attempted using a goat and a pig kidney, and both of them failed. The technique of joining the renal and brachial vessels was used, which was the basis for future transplant attempts.
The first use of a human kidney in a transplant occurred in Kiev in 1936, although the six attempts all failed, mostly due to lack of preservation of the healthy kidneys. The major limitation of transplant experimental surgery was the limited number of donor kidneys and proper preservation of the deceased donor’s organs. Kidneys left in deceased donor’s body lost blood supply, thus losing their ability to properly function.
In the 1950s, live kidney donors began to be used, which eliminated the lack of blood supply and lack of preservation. Although this improved the success of kidney transplant surgery, it was only a short-term solution, because of the vessel connections. That solution came from France in 1951 and involved placing the kidney extra peritoneally in an iliac fossa, where the external iliac vessels are easy to access, and the bladder is close by for anastomosis to the donor ureter; this is the technique still used today (Watson and Dark, 2004).
Liver Transplants
Liver transplants were difficult because the patient had significant deteriorating health and the transplant itself is more challenging than a kidney transplant because of the large size of the liver. The first attempted liver transplants in the United States occurred in Denver and were performed by a Dr. Starzl, but they were unsuccessful attempts.
Dr. Starzl performed extensive research on animals prior to performing a human organ transplant. Working with the animals, he discovered that the liver needed to cool before the transplant and to maintain a venous return to the heart. Although these were significant discoveries, it would be 20 more years before the first successful liver transplant.
Heart Transplants
Dr. Norman Shumway of California is considered the pioneer in cardiac transplantation because of his extensive animal research in which he identified cooling the heart and leaving part of the atria in situ. Dr. Christiaan Barnard of South Africa, who had previously visited Dr. Shumway’s office, was the first to perform a successful human heart transplant in 1967. Although more than 100 heart transplants were done around the world in the next year, only a few of them were successful. The introduction of endomyocardial biopsy, classification of the histological rejection, and the introduction of ciclosporin led to an increase in successful heart transplants.
Lung Transplants
The first lung transplant was performed by Dr. James Hardy in 1963 in Jackson, Mississippi. Prior to his first human lung transplant, Dr. Hardy performed nearly 400 transplants on dogs. Although most of the dog transplants were not successful, Dr. Hardy proceeded to experiment with human organs, although his first human patient was serving a life sentence in prison. The initial transplant was a success; however, the prisoner developed progressive kidney failure and died 18 days later.
In 1981, Dr. Norman Shumway performed three heart-lung transplant surgeries, and two of them were successful, with one patient dying four days after the transplant surgery. The success was due to refining surgical techniques and the use of cyclosporine. The first successful lung transplant was in 1983 by the Toronto Lung Transplant Group.
Immunosuppression
In the 1950s, success in bone marrow transplantation between siblings had been achieved using total body irradiation and for a while, this was pursued in kidney transplantation but with little success (Watson and Dark, 2004). The real breakthrough came with the introduction of chemical immunosuppression that could suppress the immune system sufficient to permit engraftment of the transplant, while at the same time being suitably specific such that other protective immune responses remained intact (Watson and Dark, 2004).
The most significant advance in immunosuppression was the discovery of ciclosporin in the 1970s. Ciclosporin was developed as an anti-fungal drug, but scientific research and clinical trials quickly identified its potent immunosuppressive effects. The use of this drug in transplant surgeries led to a dramatic increase in the success rates of liver, pancreas, heart and lung transplants (Watson and Dark, 2004).
Modern Transplant Surgery
In 1987, approximately 45 transplants were performed, and by 1990, over 400 were performed worldwide (Hatchem, 2008). By the mid-1990s, nearly 1400 transplant surgeries were being performed on a yearly basis. The number has gradually increased to approximately 2200 per year.
Skin, hair, and organ transplants are performed around the world on a daily basis. While transplant surgery still has its complications, the success rate today is higher than it has ever been. Advances in surgical techniques, donor and recipient selection and medical therapies have all contributed to the increase and success in the number of organ transplants. Although transplant surgery has progressed significantly, there are still complications associated with organ transplantation.
The greatest challenge of modern-day transplant surgery is the risk of rejection, which can be chronic and lead to death. The other great challenge presented to professionals in this field is the lack of available organs for patients who need transplants. Thousands of people are in need of healthy organs to replace their failing ones, but there is a severe shortage of viable organs and organ donors.
Organ Donation
There are three types of organ donation: Living, Deceased, and Vascularized Composite Allografts (VCA). According to Donate Life, more than 117,000 people including children are in need of an organ transplant that will save their life. Nearly 82% of these people need a kidney transplant and 13% are in need of a liver. In 2015, nearly 6,000 living donors participated in organ donation to help save a life.
Living Donation
Living donors can not only donate blood, they may also donate bone marrow and kidney without harming their own health, although there are some risks involved. A living donor would register as a donor with a transplant center, or participate in a testing event, where people are asked to be tested to see if they qualify for organ donation. Twenty-five percent of living organ donors are not related to the recipient.
In a direct donation, the donor may choose the person who will receive the transplant, particularly in the case of a friend or family member in need. A non-direct donation is done by a medically matched donor and recipient; sometimes they may meet, and other times the donor may choose to remain anonymous.
Deceased Donation
Deceased organ donation is the process of giving an organ or a part of an organ, at the time of the donor’s death, for the purpose of transplantation to another person (Donate, 2017). This can allow you to pass on life to a person who is in need and could live a longer and fuller life with a new organ. Only certain deceased donors can sustain the blood and oxygen flow needed until the time of recovery. Typically, these patients have suffered a fatal brain injury.
All efforts are made to save the patient’s life. If tests determine the absence of brain activity, the patient may be considered if they have indicated the desire to be an organ donor.
Vascularized Composit Allografts (VCAs)
Vascularized Composite Allografts (VCAs) involve the transplantation of multiple structures that may include skin, bone, muscles, blood vessels, nerves and connective tissue (Donate, 2017). Most VCAs are for hand face transplants. VCAs return vital function and identify to people who have suffered a devastating illness or injury (Donate, 2017). This type of donation must be specifically identified on a donor registration form – it is not considered a standard organ donation. The family of a deceased donor may choose to authorize this type of donation as well.
How to Become a Transplant Surgeon
A transplant surgeon performs long and intensive surgery that can last for several hours. This type of surgeon must have excellent stamina and endurance, in addition to good communication and analytical problem-solving skills. Transplant surgeons must have expertise in not only medicine, but also infectious disease, immunology and pharmacology. Rarely do transplant surgeons work regular shifts; they work 12 to 16 or more hours a day, including weekends. They will also be on-call at certain times.
Surgeons in this medical field find this profession to be challenging and demanding, but also satisfying. Transplant surgeons have a long relationship with most of their patients, and they are able to save or significantly improve their patient’s life. They perform critical care and utilize new medical technology and advances. Most surgeons work in hospitals, and there is little opportunity for private practice. This career can be extremely stressful not only physically but emotionally as well.
Educational Requirements
Extensive education and training is required to become a transplant surgeon. An undergraduate degree, medical school, residency and a fellowship are all required to become licensed in this medical field. An aspiring transplant surgeon will need to be dedicated to achieving their goal, because the path to becoming a licensed surgeon is long and demanding. Throughout the education and training programs, students will focus on their specialized organ of choice.
Undergraduate degree
Although there is no specific major required, most future transplant surgeons major in a science, such as biology, chemistry or physics, while some may choose a social science such as sociology or psychology. It is important to maintain a high grade point average to increase the chances of being accepted into medical school. Near the third year of an undergraduate program, the student will take the Medical College Admissions Test (MCAT). The MCAT must be passed in order to be accepted into an accredited medical school.
Medical School
Medical school admission is extremely competitive. Students need a high MCAT score, high grades, and should also demonstrate their unique skills and abilities. Volunteering at a hospital or medical center and participating in multiple extra-curricular activities is recommended to improve a medical school application and gain experience in the medical field.
During medical school, students will spend the first two years in the classroom, taking courses in biochemistry, anatomy, physiology, medical law and many others. Some laboratory training is done so students can practice basic medical procedures. Medical school students spend the remaining two years working under the supervision of a licensed physician or surgeon in a hospital or other medical center. They receive hands-on training and education working with patients.
General Surgery Residency
Many Transplant Surgeons first develop an interest in transplantation while training in General Surgery; therefore, the choice of a Residency for General Surgery may already have been made with other considerations or priorities in mind (AWS, 2004). Some students may have already decided to pursue transplantation surgery, so they choose a General Surgery program that offers training in areas relevant to transplant surgery, such as Immunology, Infectious Disease, Clinical Transplantation or Critical Care.
The residency program may last anywhere between five and eight years, depending on the program and the area of expertise chosen by the resident. A residency program should be accredited by the American Board of Surgery or the American Board of Urology.
Fellowship Program
A fellowship allows a transplant surgeon to develop proficiency in the surgical and medical management of patients with end-stage organ diseases (AWS, 2017). There are approximately 50 accredited programs for Solid Organ Transplantation, and only 20 of these programs include all abdominal organs (liver, kidney, pancreas). The others are specific to the organ, including programs for cardiothoracic transplant surgeons (heart and lung). It is extremely beneficial to complete a program the encompasses more than one organ to understand other transplant surgeries as well.
Fellowship programs provide instruction in histocompatibility/immunology, infectious disease, and pre- and postoperative management of patients who require transplantation, as well as in performance and interpretation of special diagnostic techniques necessary for management of rejection and other problems in transplant recipients (AWS, 2017). During a fellowship, each student will act as the principal surgeon for at least 75 patients.
As the principal surgeon, the fellow will perform kidney, liver and pancreas transplants (or heart and lung transplants). Where applicable, multi-organ transplants will be performed. Programs specialized on one specific organ will also provide clinical and laboratory experiences to the fellow. A fellowship may last anywhere between 2 and 4 years so the fellow can experience the long-term patient relationship and post-operative care. In addition to performing organ transplants, a fellow will also evaluate living donors and preserve donated organs.
Licensing and Certification
A transplant surgeon must obtain a license in the state they wish to work in. Certification is offered for General Surgeons by the American Board of Medical Specialists, while the American Society of Transplant Surgeons (ASTS) offers accreditation to transplant surgeons after they have practiced for a minimum of one year.
Job Prospects
The U.S. Bureau of Labor Statistics (BLS) projects a 20% rate of job growth for surgeons by the year 2024. Most of the job growth for surgeons is in rural and low-income areas, where there is a lack of medical professionals of all specialties. General surgeons and transplant surgeons, have a mean annual salary of $247,520, according to the BLS.
J. E. Watson and J. H. Dark. Organ transplantation: historical perspective and current practice. British Journal of Anaesthesia; 108 (1); January 1, 2012.
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