Intestinal & Multivisceral Transplantation

Specific Program Description:

I. Clinical Activities:

The intestinal and multivisceral transplant fellowship requires completion of general surgery residency program. The program is a full one-year of clinical and research fellowship designed for trainees who are seeking training in intestinal and multivisceral transplantation including a different combination of en bloc visceral organs such as stomach, duodenum, small bowel, pancreas and liver. During the fellowship period, trainees will participate in the management of both the adult and pediatric intestinal and multivisceral recipients.

The intestinal and multivisceral transplant fellowship has been designed to provide comprehensive training in patient care, surgical techniques, and clinical research. The medical management before transplantation focuses on the nutritional support of the short bowel syndrome patients, gut rehabilitation, pathology of the complex gastrointestinal disorders and candidate selection. Teaching the cutting edge surgical techniques of donor and recipient operations including allograft implantation aims to polish the surgical skills of the transplant fellow, increase the creativity and broaden the surgical ability to safely handle complex abdominal diseases. The transplant fellow will master the post-operative care of the most complex and highly immunogenic allograft recipients including monitoring of immunosuppression and critical care management with prompt response to the post-operative medical and surgical complications. With more than 200 patients being evaluated annually for gut rehabilitation including surgical reconstruction and transplantation, the intestinal and multivisceral transplant fellow is intended to develop a cumulative experience in the medical and surgical treatment of patients with intestinal failure. The case volume is an equal mix of both adult and pediatric transplants. In addition, the fellows will participate in a large number of ancillary procedures such as portal hypertensive surgery and intestinal reconstructive procedures.

The focus during the first 3 months of the fellowship year is on the state-of-art management of short bowel syndrome and postoperative care of both adult and pediatric intestinal and multivisceral recipients. Meanwhile, they participate in the donor operation learning the surgical techniques of retrieving the different types of intestinal allografts including intestine, en bloc liver/intestine, and multivisceral. They will also learn the bench technique of preparing the visceral allograft particularly the required complex vascular reconstruction. At the end of the first half of the year, fellows are able to take the lead in the donor operation and actively participate in the recipient procedure particularly removal of the native organs. During the second half of the fellowship period, the trainees are usually able to perform part of the lengthy and very challenging transplant operation including vascular reconstruction and restoration of continuity of the gastrointestinal tract. At the end of the fellowship, the fellow is usually capable of performing straight forward cases of isolated intestinal and combined liver/intestinal transplantation. Fellows with gifted hands and fine surgical techniques are usually able to take full responsibility in transplanting complex patients with multivisceral transplantation.

II. Clinical Research:

Intestinal and multivisceral transplantation is an evolving field with great opportunities for clinical research and establishment of a unique academic career for a young transplant surgeon. One of the academic goals of this highly specialized program is to assist the transplant fellow in conducting valuable clinical research activities that will help him to better understand the different aspects of the procedure. For further advancement of the field of intestinal and multivisceral transplantation, the program is currently focusing on the following areas of relevant clinical research:

• Organ preservation and monitoring of ischemia reperfusion injury
• Allograft Immunogenicity and induction of tolerance
• Innate immunity and intestinal transplantation
• Outcome analysis and causes of late graft loss
• Long-term graft survival and risk factors
• Chronic rejection particularly of the intestinal component of the visceral allograft
• The immunoprotective effect of the concomitantly transplanted liver
• Opportunistic infections and risk of post-transplant lymphoma
• Monitoring of intestinal allograft functions and achievement of nutritional autonomy
• Intestinal allograft recipients and micronutrients deficiencies

Didactic Components:

Outpatient clinics are held four times a week. All of the staff mentioned below participates in the relevant clinic with full-time clinical and teaching activities. Two clinics are designed for the adult pre-transplant evaluation and gut rehabilitation. One clinic is devoted for post-operative care and are staffed mainly by the transplant physicians and coordinators. The last clinic specifically for pediatric services. The Transplant Fellows participate in the decision making process of monitoring immunosuppression and prompt diagnosis of underlying pathology of patient symptoms. In addition, the fellows take part in the endoscopic examination of the intestine for monitoring allograft rejection. On a weekly basis, a morbidity and mortality conference, patient selection conference, and intestine pathology conference, for both the pediatric and adult services, are held for patient care and continued medical education. Furthermore, the research activities of the program are discussed on a regular basis for educational and publication purposes.

Teaching Staff:

The staff of the Center for Gut and Rehabilitation & Transplantation (CGRT) is a multidisciplinary team that includes surgeons, gastroenterologists, psychiatrist, nurse practitioner, nutritionist, pharmacist, social worker, case manager and transplant coordinators. The teaching physicians that carry full responsibility and supervise the fellows are:

Physicians:

A. Surgeons

• Kareem Abu-Elmagd, MD
• Cristiano Quintini, MD
• Bijan Eghtesad, MD
• Koji Hashimoto, MD
• Masato Fujiki, MD
• Anil Vaidya, MD

B. Gastroenterologists

• Donald Kirby, MD
• Abdullah Shatnawei, MD

C. Psychiatrist

• Kathy Coffman, MD

Program Director:

Kareem M. Abu-Elmagd, MD, PhD, FACS 
Director, Center for Gut Rehabilitation & Transplantation (CGRT)
9500 Euclid Avenue
Desk A100
Cleveland, OH 44195
Phone: 216.445.8876
Fax: 216.636.7060
E-mail: abuelmk@ccf.org