Novel Method of Evaluating Liver Transplant Surgery Fellows Using Objective Measures of Operative Efficiency and Surgical Outcomes

Background: 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. Study Design: 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. Results: 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. Conclusions: 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.