Six National University Consortium in Liver Transplant ProfessionalsTraining (SNUC-LT) Program in Japan

K. Takagia, K. Miurab, S. Nakanumac, S. Sakamotod, H. Yamamotoe, T. Yagia, S. Eguchif, T. Ohtac,T. Wakaib, M. Ohtsukag, S. Uemotoh, M. Kasaharad, and Y. Inomatae,*aDepartment of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry, and PharmaceuticalSciences, Okayama, Japan; bDivision of Digestive and General Surgery, Niigata University Graduate School of Medical and DentalSciences, Niigata, Japan; cDepartment of Gastroenterologic Surgery, Kanazawa University Graduate School of Medical Science,Ishikawa, Japan; dOrgan Transplantation Center, National Center for Child Health and Development, Tokyo, Japan; eDepartment ofTransplantation and Pediatric Surgery, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan; fDepartment ofSurgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan; gDepartment of General Surgery, ChibaUniversity Graduate School of Medicine, Chiba, Japan; and hDepartment of Hepatobiliary Pancreatic Surgery and Transplantation,Kyoto University Hospital, Kyoto, Japan

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ABSTRACT

Background. There has been no public structured training program for transplant sur-geons in Japan. However, such a program is crucial for optimizing liver transplant surgeryand training young professionals in liver transplant surgery. A comprehensive trainingprogram was recently developed and the underlying concepts, structure and curriculum,and results of this program are described here.Methods. We developed a 3-year training program in 2014 called the Six NationalUniversity Consortium in Liver Transplant Professionals Training (SNUC-LT) programsupported by the Ministry of Education, Culture, Sports, Science, and Technology. Thisprogram is based on strong cooperation among 6 national universities (Kumamoto,Okayama, Nagasaki, Kanazawa, Niigata, and Chiba Universities). The program includesvarious courses to help trainees learn transplant theory and practice as well as to teachsurgical skills required to safely perform transplant surgery.Results. Three trainees completed the specially designed 3-year curriculum. Theyattended lectures on transplant theory for an average of 59 hours and participated in anaverage of 44 liver transplant surgeries and 51 liver resections for transplant practice.Trainees from low-volume centers had sufficient opportunities to attend operations inhigh-volume centers because of the cooperative agreement among the universities. Afterfinishing the program, the trainees were certified as talent-proven liver transplant surgeons.Conclusions. The SNUC-LT program is the first national program in Japan to havestrong professional support. Our multicenter program enables young surgeons to havemore abundant knowledge, more extensive experience, better surgical skills, andsmoother communication skills in the field of liver transplantation.

*Address correspondence to Yukihiro Inomata, Department ofTransplantation and Pediatric Surgery, Kumamoto UniversityGraduate School of Medical Sciences, Kumamoto, Japan.E-mail: yino@kuh.kumamoto-u.ac.jp

THE TOTAL annual volume of liver transplantationsperformed in Japan has decreased after a peak of 570

cases in 2005 [1]. The most frequent indications for trans-plantation are cholestatic disease, neoplastic disease, andhepatocellular diseases [1]. Regarding hepatocellular dis-eases, the incidence of viral hepatic cirrhosis has recentlydecreased owing to improvements in therapies for viral

7rg/10.1016/j.transproceed.2017.11.026

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Transplantation Proceedings, 50, 168e174 (2018)

Fig 1. Overview of the Six National University Consortium in Liver Transplant Professionals Training program. This program was basedon strong cooperation among Kumamoto, Okayama, Nagasaki, Kanazawa, Niigata, and Chiba Universities. Kyoto University and theNational Center for Child Health and Development (NCCHD) also provided input. Trainees had the flexibility of attending liver transplan-tations at any institution.

SNUC-LT PROGRAM IN JAPAN 169

hepatitis [2]; however, the incidence of both alcoholic livercirrhosis and nonalcoholic steatohepatitis has increased [1].The reduction in the number of liver transplantations per-formed in Japan might be due not only to improvements intherapeutic outcomes in viral liver diseases but also to pooraccess to liver transplant surgeons and a decreased ability offacilities to accept patients. Despite the decreasing numberof liver transplantations performed in Japan, liver trans-plantation remains the best treatment option for patientswith end-stage liver diseases.Transplant surgeons are required to be highly skilled,

with great expertise and vast experience. However, the

Table 1. The Curriculum of the Six National University Consortium inSurgeo

Item

Candidates Surgeons who have finished general trPeriod 3 yearsRequirement Liver transplant theory for �40 hours aLiver transplant theory (Essential) Principles of transplantation

pathologic diagnosis) and surgical te(Optional) Basic Course in liver transpla

Liver transplant practice (Essential) Performing each procedurerecipient surgery)

(Optional) Simulation course†

Teaching system Supported by consultant surgeons in tKanazawa, Niigata, and Chiba Univefor Child Health and Development)

*This course is organized by the European Society for Organ Transplantation.†This course was performed with the use of pigs as models for deceased-donor l

numbers of available liver transplant surgeons and opera-tions performed in each institution in Japan are limited.Therefore, it is crucial for each facility to optimize trans-plant surgery and the training of young surgeons for themto develop surgical technique and expertise and gainexperience. In North America, the American Society ofTransplant Surgeons has organized transplant fellowshipprograms, and they approve each fellow who completes thetraining pathway as a board-certified transplant surgeon[3,4]. In Europe, the European Society for Organ Trans-plantation (ESOT) organizes an annual Master Class onRetrieval Surgery for young transplant surgeons [5]. In the

Liver Transplant Professionals Training (SNUC-LT) Program forns

Content

aining in gastroenterologic surgery

nd liver transplant practice for �100 hours (10 cases) in >3 facilities(ethics, indications of diseases, perioperative management, andchniquesntation*for living- and deceased-donor liver transplantation (donor surgery,

he 6 collaborating universities (Kumamoto, Okayama, Nagasaki,rsities) and instructor facilities (Kyoto University and National Center

iver transplantation.

170 TAKAGI, MIURA, NAKANUMA ET AL

Netherlands, a complete trajectory of training and certifi-cation was developed in 2010 to train transplant surgeonsin abdominal organ retrieval techniques [5]. In Germany,the importance of a training program in the field oftransplantation has also been reported [6]. However, therehas been no national training program for transplant sur-geons in Japan.Therefore, a comprehensive training program was

recently developed and implemented in Japan to optimizethe training of young liver transplant surgeons. Here, wedescribe the underlying concepts, structure and curriculum,and results for this program.

Table 2. Results of Each Trainee’s Experience in LiverTransplant Theory and Practice

Category Trainee A Trainee B Trainee C

Liver transplant theoryAcademic lecture 5 (14 h) 6 (17 h) 4 (12 h)Cosponsored seminar 6 (14 h) 4 (9 h) 8 (18 h)Lectures on pathology 7 (14 h) 9 (18 h) 6 (12 h)Basic Course* 3 (30 h) 1 (10 h) 1 (10 h)

Liver transplant practiceLiver transplantations†

Kumamoto University 3 (1) 44 (1) 2 (0)Okayama University 56 (8) 1 (0) 2 (0)Nagasaki University 1 (0) 0 (0) 1 (0)Kanazawa University 0 (0) 0 (0) 7 (1)Niigata University 0 (0) 0 (0) 0 (0)Chiba University 0 (0) 0 (0) 0 (0)Kyoto University 1 (0) 1 (0) 2 (1)NCCHD 3 (0) 5 (1) 4 (0)

Liver resection‡

Lobectomy or more 28 (7) 8 (2) 12 (11)Sectionectomy 25 (12) 1 (1) 11 (11)Segmentectomy 10 (3) 1 (1) 10 (10)Partial resection 17 (6) 3 (3) 27 (26)

Simulation course§ 4 3 5

Abbreviation: NCCHD, National Center for Child Health and Development.*This course was organized by the European Society for Organ

Transplantation.†Data are presented as n (deceased-donor liver transplantations).‡Data are presented as n (number as primary surgeon).§This course was performed with the use of pigs as models for deceased-

donor liver transplantation.

METHODS

We developed the first public training program in Japan to train livertransplant surgeons in 2014. This program is called the Six NationalUniversity Consortium in Liver Transplant Professionals Training(SNUC-LT) program (https://snuclthp.kuh.kumamoto-u.ac.jp). Theinitiative was adopted by Kumamoto University and became anationwide program. The SNUC-LT program is based on strongcooperation among 6 national universities (Kumamoto University,Okayama University, Nagasaki University, Kanazawa University,Niigata University, and ChibaUniversity) that are regional transplantcenters in Japan. This program also receives assistance from high-volume centers, such as Kyoto University and the National Centerfor ChildHealth andDevelopment. The aimof this program is to trainyoung professionals in liver transplantation through interinstitutionaltraining standards. An overview of the SNUC-LT program is shown inFig 1. The program offers various courses for trainees to learn trans-plant theory and practice as well as to train them in surgical skills toenable them to perform transplantation safely. Furthermore, the ex-periences of each trainee are evaluated annually.

This training program has been funded by the Ministry of Cul-ture, Sports, Science, and Technology from the fiscal years2014e2018 Budget of Japan, under “Programs for Training HighlySpecialized Medical Professionals in Cooperation with UniversityHospitals.” The total budget was $484,413 in 2014, $441,754 in2015, and $440,623 in 2016 with an exchange rate of US$1¼ U103.4[7]. The funds were distributed to each facility and used to coverpersonal expenses, travel expenses, material fees, and other relatedcosts.

The curriculum of this program is summarized in Table 1.Candidates are surgeons who have finished general training ingastroenterologic surgery. The length of the program for eachsurgeon is 3 years. Trainees are required to learn liver transplanttheory for �40 hours and to participate in liver transplant practicefor �100 hours (10 cases). This program offers various courses fortrainees to learn liver transplant theory and engage in practice,which are strongly supported by the 6 universities and 2 instructorfacilities.

Regarding liver transplant theory, trainees are required to learnthe principles of transplantation (ethics, indications of diseases,perioperative management, and pathologic diagnosis) and surgicaltechniques. Academic lectures are held twice per year. Cosponsoredseminars are also available that accompany annual conferencesrelated to surgical and transplantation societies. Lectures on pa-thology are supervised by Kyoto University. Trainees can attend theBasic Courses in Liver Transplantation organized by ESOT tosupplement the scarce opportunities for deceased-donor organprocurement available in Japan.

Regarding liver transplant practice, trainees are required tolearn each procedure for living- and deceased-donor liver trans-plantation (both donor and recipient surgery). They can receivetraining not only at their institutions, but also at the othercollaborating institutions where they can perform liver trans-plantation. Furthermore, practical simulation courses for organprocurement and transplant operations with the use of large ani-mals (as substitutes for deceased-donor liver transplantation) areheld twice per year.

RESULTS

In 2014, 3 surgeons were selected from among the 6 na-tional universities. They completed a 3-year structuredtraining program based on a curriculum for transplant the-ory and practice. The results of each trainee’s experiences inthis program are presented in Table 2.Regarding transplant theory, trainees learned the princi-

ples of transplantation, surgical techniques, and pathologicdiagnosis by attending an average of 59 hours of variouslectures and seminars. They also attended Basic Coursesorganized by ESOT: trainee A: 11th European DonorSurgery Master Class and 9th Basic Course on the SplitLiver; trainee B: 12th European Donor Surgery MasterClass and 10th Basic Course on the Split Liver; and traineeC: the 2nd Basic Course in Liver Transplantation.Regarding transplant practice, the following list shows the

number of liver transplantations performed in each

Fig 2. The results of each trainee’s experiences with liver transplant procedures by year. (A) Living-donor liver transplantation/donorsurgery. (B) Living-donor liver transplantation/recipient surgery. (C) Deceased-donor liver transplantation/donor surgery. (D) Deceased-donor liver transplantation/recipient surgery. Abbreviations: BD, bile duct; HV, hepatic vein; HA, hepatic artery; IVC, inferior vena cava;PV, portal vein.

SNUC-LT PROGRAM IN JAPAN 171

Fig 2. (continued).

172 TAKAGI, MIURA, NAKANUMA ET AL

institution from November 2014 to March 2017 with thenumber of deceased-donor transplants shown in parenthe-ses: Kumamoto University, 85 (3); Okayama University, 56(8); Nagasaki University, 47 (7); Kanazawa University, 7 (1);Niigata University, 0; Chiba University 4 (0); Kyoto Uni-versity 111 (19); and National Center for Child Health andDevelopment, 154 (13). Each facility provided, in part or inentirety, on-site training for the procedure of transplantoperations not only for trainees belonging to the institutionbut also for trainees from other universities. Consequently,trainees learned the procedures for living- and deceased-donor liver transplantation, with an average of 44 cases ofliver transplant surgery. Trainee A was trained primarily atthe host institution and attended 8 operations at 4 otherinstitutions. Trainee B, who belonged to a low-volumecenter, received training at Kumamoto University for 1year and experienced >40 cases of liver transplantation.Trainee C, who also belonged to a low-volume center,experienced many more liver transplant surgeries at 5 otherinstitutions than at his home institution. Figure 2 shows theresults of each trainee’s experiences with liver transplantprocedures by year. In the 1st year, no trainee performedprocedures as a primary surgeon. However, in the 3rd year,all trainees performed some procedures as the primarysurgeons in living-donor liver transplantation. Deceased-donor liver transplantations are limited in Japan; there-fore, all trainees performed these operations as assistants.In contrast, trainees participated in an average of 51 liverresections and performed an average of 31 procedures asprimary surgeons. During simulation courses, each trainee

learned the procedures of organ procurement and thenperformed organ procurement as primary surgeons.Furthermore, they also performed conventional orthotopicliver transplantation (Fig 3).After finishing the 3-year training program, they were

certified as talent-proven liver transplant surgeons accord-ing to evaluation by the faculty committee. Now, 13 sur-geons from 6 national universities have completed thistraining program as the 2nd, 3rd, and 4th groups of trainees.

DISCUSSION

The SNUC-LT program is the 1st unique national programin Japan to train talent-proven surgeons in liver trans-plantation. Training programs for liver transplant surgeonshad not previously been conducted in Japan; therefore,training was conducted at each facility as a part of thegeneral education for a surgeon. However, it might bedifficult for surgeons in low-volume centers to obtain suffi-cient experience and learn surgical skills outside of theirinstitutions. Furthermore, even in high-volume centers,learning surgical techniques and gaining expertise at otherinstitutions might be difficult. These varied backgroundscould result in differences in clinical outcomes among fa-cilities. Accordingly, a comprehensive training program foryoung transplant surgeons was necessary to further improveclinical outcomes and training for transplant surgeons.To forge a strong collaboration in this program, 6 hos-

pitals with the same training systems were selected. Eachuniversity hospital already had some experience with liver

Fig 3. Practical simulation courses for organ procurement andtransplant operation using large animals. (A) After performing or-gan procurement, the back-table maneuver technique was used.(B) Conventional orthotopic liver transplantation performed bytrainees. The photograph shows reconstruction of the IVC inthe upper part of the liver. (C) Reconstruction of the IVC in thelower part of the liver. Abbreviations as in Fig 2.

SNUC-LT PROGRAM IN JAPAN 173

transplantation, mainly living-donor liver transplantation.However, all hospitals were in rural cities, not in urban citiessuch as Tokyo or Kyoto. Therefore, those university hospi-tals were not able to put much effort into training onlytransplant surgeons and did not have sufficient resources totrain experienced liver transplant surgeons in a relativelyshort period. The mutual cooperation of these 6 hospitals isexpected to increase the number of transplant surgeons,develop their knowledge and techniques, standardize theirmedical competence, and establish a reciprocal relationshipin the field of liver transplantation.Regarding the curriculum for surgeons, transplant surgeons

require not only surgical skills but also expertise and experi-ence in transplantation. Therefore, the curriculum was set fortrainees to learn liver transplant theory for >40 hours and toparticipate in liver transplant practice for >100 hours.Through several lectures and seminars, the principles oftransplantation and surgical techniques were taught.Furthermore, the Basic Courses organized by ESOT wereconsidered to be helpful for learning deceased-donor organprocurement. Regarding transplant practice, the greatestadvantage of this program is that trainees had the flexibility toattend real transplant surgeries at other facilities after con-firming the surgery schedule on the program website.Learning the characteristics and differences of each facilitywas expected. Furthermore, experiences with organ procure-ment were supplemented with practical simulation courses.Concerning the results of each trainee’s experiences, all

trainees finished the curriculum, consisting of liver trans-plant theory and practice, and were then certified as talent-proven liver transplant surgeons. Indeed, each traineegained sufficient knowledge related to transplantation,including ethics, indications of diseases, perioperativemanagement, pathologic diagnosis, and surgical techniques.The Basic Courses organized by ESOT provided traineesthe opportunity to not only learn transplant theory, but alsoexpand their global perspective. Regarding transplantpractice, trainees learned differences in surgical proceduresand perioperative management between facilities and thenprovided feedback on these to their home facilities. Eventrainees from low-volume centers had sufficient opportu-nities to attend operations in higher-volume centers. Inaddition, the practical simulation courses were helpful fordeceased-donor liver transplant training. This programincreased the personal experience for each trainee. Thisaccumulation of experiences is likely to enhance andmaintain the trainees’ motivation to become transplantsurgeons. In addition, the program might also be helpful tomaintain or increase such motivation among already-trainedliver transplant surgeons, possibly decreasing the drop-outrate to other surgical fields in the near future in Japan [8].The addition of better trained transplant surgeons willdecrease the burden on existing transplant surgeons. Thisadvantage has already been shown in deceased-donor organharvesting. For example, when an organ from a donorhospital was allocated to a program university that was farfrom the donor hospital, a trainee nearer the donor hospital

174 TAKAGI, MIURA, NAKANUMA ET AL

could attend the deceased-donor procurement surgery aspart of their onsite training in donor surgery. This cooper-ation could decrease the number of member surgeons dis-patched from the transplant institution while presenting theassisting trainee with the important opportunity to partici-pate in organ harvesting.Despite our important findings, this program has a few

limitations. First, it might be difficult to evaluate the surgicalskill and development of the surgeon objectively. Eachtrainee performed portions of procedures as primary sur-geons step by step; however, no trainees performed all livertransplant procedures over the 3 years owing to the diffi-culties and complexities associated with transplantation.Although each trainee had sufficient experience withtransplant theory and practice, further developments arerequired for them to become highly skilled surgeons. Sec-ond, trainees’ experiences with deceased-donor liver trans-plantation were limited because of the small numbers ofdeceased donors in Japan. The donor action programshould be widely publicized to increase the number ofdeceased donors in the future. Studying abroad in Westerncountries would be another solution for trainees to learndeceased-donor surgery after finishing the present program.Third, it was often difficult for trainees to attend operationsat other facilities because they had their own tasks tocomplete at their home institutions. However, in beingtasked to travel and participate in complex surgeries atpartner institutions, the trainees learned about characteris-tics of other facilities through those experiences. Finally, ournext challenge is to expand and develop this program in thefuture. Although this program has just begun, we hope thatit will lead to the standardization of training programs fortransplant surgeons in Japan.

CONCLUSION

Our multicenter program enables young surgeons to obtaingreater knowledge, more extensive experiences, better sur-gical skills, and smoother communication skills in the fieldof liver transplantation. Our program is the 1st sucheducational program in Japan with strong professionalsupport. Based on our experience so far, we think that theprogram is effective and reasonable for training generationsof surgeons in this field.

COLLABORATORS

The following are members of the SNUC-LT program:Yasuhiko Sugawara (Kumamoto University GraduateSchool of Medical Sciences, Kumamoto, Japan); YuzoUmeda (Okayama University Graduate School of Medicine,

Dentistry, and Pharmaceutical Sciences, Okayama, Japan);Mitsuhisa Takatsuki and Masaaki Hidaka (Nagasaki Uni-versity Graduate School of Biomedical Sciences, Nagasaki,Japan); Takashi Kobayashi (Niigata University GraduateSchool of Medical and Dental Sciences, Niigata, Japan);Hiroyuki Takamura (Kanazawa University Graduate Schoolof Medical Science, Ishikawa, Japan); Satoshi Kuboki(Chiba University Graduate School of Medicine, Chiba,Japan); Toshimi Kaido, Shintaro Yagi, and Hironori Haga(Kyoto University Hospital, Kyoto, Japan); and AkinariFukuda (National Center for Child Health and Develop-ment, Tokyo, Japan).

ACKNOWLEDGMENTS

The authors are grateful to the staff of the participating trans-plantation institutions listed above for their support in this program.They also thank Yasuhiro Fujimoto (Shizuoka City Shizuoka Hos-pital, Shizuoka, Japan) and Taku Iida (Kyoto Prefectural Universityof Medicine, Kyoto, Japan) for their support in practical simulationcourses.

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