Hepatobiliary and Liver Transplantation Anesthesiology Fellowship

The Hepatobiliary and Liver Transplantation Anesthesiology Fellowship at VGH is a 12-month program designed to prepare the individual for an academic career that focuses on the perioperative care of high acuity hepatobiliary (HPB) and transplant patients. Important secondary goals include training in basic perioperative transesophageal echocardiography (TEE) leading to basic PTE certification, and research in the domains of HPB and transplant anesthesia.

Expectations of the Fellow

  • To become an expert in:
    • perioperative care of complex HPB and liver transplant patients.
    • complex coagulation and transfusion management as guided by ROTEM and conventional coagulation parameters.
    • The complex interplay of multi-disciplinary services involved in operation of a large-volume transplant program.
    • Basic transesophageal echocardiography as a hemodynamic monitoring tool.
    • technical skills including the placement of thoracic epidurals and insertion of invasive lines
  • To teach residents, medical students and other staff
  • To work towards completion of all components for the Basic Perioperative TEE certification
  • To complete a scientific or quality improvement project relevant to the practice of HPB or liver transplant anesthesiology.
  • To present the project findings at the annual departmental research day and at a national or international scientific meeting.
  • To present academic topics at the HPB division rounds and at VGH Anesthesia Grand Rounds.

Clinical Experience

Procedural Training

  • VGH is the provincial referral centre for complex HPB patients and the only liver transplant centre. The annual volume of relevant surgical cases include: 100 liver transplants, 160+ liver resections, 140+ pancreatic resections, and 40+ biliary tract surgeries.
  • The liver transplant program at VGH serves a full spectrum of transplant candidates with the only exception of pediatric patients. Program specific features include:
    • All transplants are performed with organs donated by deceased donors
    • A living donor program is being developed currently
    • Both classic and Piggyback caval reconstruction approaches are used.
    • Venovenous bypass is almost never required, but the capacity exists for its use.
    • Combined liver-kidney transplants are offered.
    • Pancreatic and combined pancreatic-kidney transplants are offered
    • Over 80% of transplants are completed in daytime hours, to provide best possible care to complex transplant recipients.

Echocardiography training

  • This will include 4 weeks of dedicated TEE training under the guidance of the cardiac anesthesiologists at VGH. This will occur both in the cardiac ORs as well as during complex non-cardiac cases including liver transplants. The fellow will have the opportunity to participate in additional 4 weeks of training during their elective block if desired. Additional learning will occur throughout the year with regular use of TEE in liver transplants. Our expectation is that the fellow would meet the necessary requirements to pass the Basic US National Board of Echocardiography Perioperative Transesophageal Examination (Basic PTE) and complete their number of studies for their certification.

Hepatobiliary and Liver Transplant Surgery

  • The fellow will gain significant experience in the following procedures and monitoring modalities:
    • Thoracic epidural analgesia
    • Invasive lines and monitors
    • TEE
    • ROTEM
    • FloTrac (non-invasive cardiac output monitor)
    • Cell salvage
    • Intraoperative CRRT
  • The fellow will participate actively in pre-transplant assessment of candidate patients and in discussions at the multi-disciplinary transplant activation rounds (ie. selection committee meetings).
  • The fellowship curriculum consists of the following 12 month-long blocks:
    • Orientation (1 block)
    • HPB / liver transplant anesthesiology (8 blocks)
    • TEE (1 block)
    • Hepatology (1 block)
    • Elective (1 block) (eg. TEE, TTE, perioperative anesthesia, vascular anesthesia, major abdominal anesthesia, airway, etc).
  • Dedicated didactic or interactive HPB learning opportunities will occur once per month, facilitated by members of the HPB group.
  • Other learning opportunities can be guided by the fellow’s interests through regularly organized meetings at VGH and UBC. These may include attendance to grand rounds, echo rounds, liver rounds, HPB divisional rounds, journal club, and others.
  • The fellow will have teaching opportunities both in and outside of the OR, where residents, medical students, anesthesia assistant trainees, and other learners may be present. Both clinical and academic teaching opportunities are available

Weekly Schedule

  • 3 days in HPB OR or other fellowship blocks
  • 1 day in general clinical anesthesia in independent practice
  • 1 academic day per week
  • This general weekly schedule will remain in place throughout the year, even when the fellow is on non-HPB anesthesia rotations.
  • There are opportunities for the fellow to be involved in after-hours transplants throughout the year
  • The fellow will meet with fellowship directors regularly to review their progress
  • A written summative evaluation is provided to the fellow and reviewed with the program directors at the end of the fellowship year.