Abdominal Organ Transplantation Anesthesia

Clinical Curriculum

The Abdominal Organ Transplant Anesthesia (AOTA) fellowship focuses on liver transplantation and major abdominal surgical oncology anesthesia. The Toronto General Hospital is the largest transplant centre in Canada and is among the largest centres in North America. Currently, the hospital performs 180–220 kidney transplants, 180–220 liver transplants, and 25–35 pancreas transplants. Included in these numbers is the Living Donor program for both kidney and liver transplants, which accounts for an average of 50–60 transplants of each organ every year.

As a fellow, you will be actively involved in the management of these patients during the whole perioperative period, from preoperative assessment to optimization of anesthetic and postoperative care. This also includes participating in the transplant listing meetings, in which each patient and their respective challenges are discussed with a multidisciplinary team to guarantee optimal communication between the teams, continuity of care, and the best possible outcomes.

Listing meetings are presently done over Teams video conferencing, and fellows will be invited to these meetings upon request. Liver Listing at 9:00 a.m. and Kidney/Pancreas Listing at 1:00 p.m. on Fridays.

The majority of the liver transplants you will do are cadaveric; we accept NDD (DBD) and DCD donors. We have one of the widest acceptance criteria in North America, including taking donors who are actively hepatitis C positive. Combined with normothermic machine perfusion technology, this means we are able to accept grafts from all over North America that would otherwise be wasted. You will become extremely familiar with the perioperative implications of these leading-edge technologies, as well as making your own contributions through ROTEM blood product management and occasionally TEE.

The living donor program for both liver and kidney recipients is expanding rapidly. Fellows will be involved in both living donor and recipient case management. These cases are only possible because healthy individuals have volunteered to undergo dangerous surgery for the benefit of someone else and therefore command a premium of care and attention from us.

As mentioned above, the AOTA program also carries a significant load of oncologic procedures, such as complex pancreatomies and liver and bowel resections. Many of our patients are referred because they have been told they are inoperable by their local cancer centres. Our surgeons undertake major composite resections with vascular reconstructions that would be considered impossible elsewhere. We are also seeing a significant expansion in the types of procedures that can be done in a minimally invasive manner, such as laparoscopic liver resections, bowel resections, and robotic pancreatic surgery. While the postoperative outcomes are excellent, the intraoperative challenges for us can be considerable.

For the most up-to-date information on the program at TGH, please visit the AOTA website.

Call duties

Calls for liver transplantation are done from home for 24 hours in a one-in-three to four rotation. As we are a high-volume centre, there will be a liver transplant more often than not during your call, so call-backs to the OR are frequent. Your pager typically goes off at 0400 for a start time of 0600 (patient on the table).

Potential applicants from countries with limits on working hours should note that no such legislation exists in Canada. It would be impossible to gain the level of experience for which we are known if there were. However, we aim to make sure no one works >24 hours unless they have had sufficient rest and wish to finish their overnight cases.

Education Curriculum

There is formal teaching almost every day, in addition to clinical supervision by expert staff.

• Monday: Professor’s rounds (monthly): academic anesthesia experts from the university lecture specifically for our fellows
• Tuesday: Fellow’s rounds by staff on their particular academic expertise, spread evenly between different subspecialty interests
• Wednesday: didactic echocardiography and case presentation rounds
• Thursday: TEE reporting to NBE echo exam standards
• Friday: Grand rounds (entire department)

We also run a monthly AOTA journal club in which fellows present a topic for discussion among themselves and the staff who have a special interest in HPB. This is a good opportunity to discuss the latest evidence in liver transplantation anesthesia informally and potentially come up with academic projects.

As one of our clinical fellows, you will officially be a student at the University of Toronto and have access to their significant educational resources, including libraries, seminars, open lectures, and heavily discounted books, equipment, citations, and systematic review software (we use Endnote and Covidence).

Research

Participation in research and education is expected. Research is integrated into the fellowship, with academic time provided to those involved in projects, with a goal of one non-clinical day per week up to a maximum of 40 days over a 12-month fellowship period. The amount of academic time given throughout the year will be titrated according to productivity, just as it is for our staff. Our database of liver transplant recipients and donors has been running for 20 years and is available for retrospective research. The increasing bureaucratic complexity of medical research makes designing, getting approval, funding, and completing a research project unrealistic within a single fellowship year.

However, many of our fellows have started projects while here and completed them after having left, and we are happy to facilitate this. Alternatively, you may work on a specific part of an ongoing research effort (study design, grant proposal, REB, data analysis, write-up), hand it over to the next fellow, and still receive credit.

Review publications are quite achievable within the year, provided you start early and manage your time effectively. We have a departmental librarian to construct professional search strategies for systematic reviews, and other narrative reviews, book chapters, editorials, etc. come up frequently.

Participation and presentation at academic conferences are encouraged. Travel grants are available for research presentations at eligible North American meetings.

Application Requirements and Process

The fellowship is aimed at anesthesiologists in their early professional careers. Interested applicants need to have successfully completed all the required anesthesia examinations in their country, be registered with the official regulatory authorities, and have at least five years of anesthesia training and experience at an academic centre. (One of the five years may include a rotational year, also known as an internship, houseman year, or medical officer year.)

Experience as a staff anesthesiologist based in the operating room in an academic setting for 1-2 years is strongly advised. Your clinical anesthesia practice should be current, and exposure during the preceding three years of a fellowship should have a strong operating room component.

You will need to have significant experience managing life-threatening situations such as massive transfusions, cardiac failure, critical vasoplegia, hemodynamically unstable arrhythmias, and profound fluid shifts before you start this fellowship. This is not the opportunity to acquire this experience; you will need to be comfortable and able to manage independently in such situations when you arrive. We are here to teach you the technically demanding subspecialty of transplant anesthesia, preferably so that you go on to do a transplant in your consultant life, not give you an opportunity to gain “big case experience.”

It is very hard to come to a new country with a completely different medical system and culture, possibly in a second language, and jump straight into doing some of the most complex anesthesia there is. We often offer people a 6- to 12-month placement in our Advanced Clinical Practice (ACP) fellowship, which offers excellent experience in non-transplant cases in its own right, as a way into our program with a “softer landing." It’s an opportunity to get used to our department and Canadian practice without the intensity of the AOTA fellowship and for us to get to know you with a view to offering you an AOTA fellowship if all goes well.

A current and valid ACLS certification is a requirement.

Applicants need to apply by using the online platform.

Shortlisted candidates will be contacted 12–18 months before the tentative start date for reference letters and to further the application. Please do not send any reference letters until requested to do so.

Successful candidates will be notified about 9–15 months ahead of a potential start date. An interview may be required.

Begin Your Application

• The January 2025 application process has closed.
• If you are interested in applying for July 2025, please complete this online application form.
• If you are interested in applying for January 2026, please complete this online application form.

Direct inquiries to

Dr. Adam Snyman
Coordinator, Fellowship Program
Toronto General Hospital
200 Elizabeth Street, EN3-438
Toronto, ON, Canada M5G 2C4
adam.snyman@uhn.ca