Results
The 14 transplant surgeons reported to be performing transplant surgery in authoritative positions for 3–15 years. All interview partners with the exception of one reported to be routinely involved in donor surgery of the pancreas as well, being a member of a regional recovery team. According to the interview partners, transplant surgeons have the sole responsibility of the accept/refuse decision for offered pancreases in 11 transplant centers, whereas a joint decision between transplant surgeons and nephrologists is the usual procedure in three transplant centers.
As illustrated schematically in Figure 1, we identified seven main factors influencing the decision-making process (the numbers in brackets refer to Figure 1 and to the subheadings of the following text): The decision to accept or refuse an offered donor pancreas is mainly based on medical criteria. The key factors of medical criteria are the donor's medical history (1), and, significantly more important, the donor organ macroscopy (2). The decision-making process is also influenced by confidence in the recovery team's expertise (3). Non-medical aspects play a role in certain circumstances, mainly in terms of staff shortage (4) or prior decisions of other centers (5). The decision is also influenced by the comparatively benign prognosis of patients waiting for a pancreas transplant (6). Finally, the decision-making process can also be guided by strategic considerations, e.g. regarding competition with other centers, or risk management (7).
Figure 1.
Categories of criteria that play a role when deciding to accept/reject a pancreas.
1. Donor medical history
All interview partners mentioned at least 3–6 donor characteristics that are considered decisive for evaluating a pancreas offer. Some of these characteristics were named by almost every interview partner: age, length of ICU stay, cause of death, lab results, and co-morbidities. Other characteristics, such as BMI, history of alcohol abuse, or administration of blood transfusions were named less frequently. When asked about resuscitation of the donor, the majority of interview partners denied this criterion to be of importance. While there was a broad consensus on the donor characteristics that are relevant to evaluate a pancreas offer, the cut-offs used for some of these characteristics varied substantially between interview partners.
Donor age. Donor age plays a prominent role for the evaluation of the pancreas. The upper age limit which was considered acceptable ranged from 40 to 55 years of age. The majority of interviewed surgeons pointed out that the donor age needed to be judged in relation to other donor characteristics: the more risk factors were present, the less tolerable is an age above 45 or 50 years.
With a 50-year-old, you need to check what other factors there might be…How is his/her glucose level? Does co-morbidity play a role? Does the offered organ appear to be from a biologically younger donor? (IP11).
Two surgeons, however, reported to have fix cut-offs for donor age.
We have relatively strict guidelines… It starts already with age. As a rule, we do not accept organs that are more than 40 years old. (IP 06)
Length of ICU stay. Most interview partners explained that they appraised the length of ICU stay in relation to other donor characteristics; however, there was a wide range of rough cut-offs mentioned (from 5 days to 2–3 weeks up to 20–30 days).
[The length of ICU stay] should not exceed a week. If it's two and half to three weeks, I would be skeptical about the organ. (IP 10)
[I don't draw] a line there. There are patients who have stayed in the ICU for three or four weeks. With this deadline of one week and then rolling their eyes, saying: 'Oh, 10 days already!' For us, this is nonsense; it's no reason to turn down an organ. (IP 05)
Lab results. The majority of interviewed surgeons reported to routinely check the laboratory values of the donor, but none named concrete limits. The donor's lab results are only one of many aspects that influence the accept/refuse decision. Some surgeons stated that lab results play a minor role compared to the organ macroscopy.
Interdependence of donor characteristics. Most surgeons explained that as a rule, none of the mentioned donor criteria alone justified an organ refusal; different factors need to be weighed against each other. Organs may be declined for a number of relative risk factors. It became clear, throughout the interviews, that different factors were not assessed in relation to each other in a systematic process, but very individually and intuitively for every donor.
The decision is cumulative: old age, pancreatitis, poor circulation, and then - on top of that - maybe overweight. Then you add it all up. But refusing it [the organ] just because of a single criterion, we wouldn't do that. (IP 05)
The refusal reasons that are given to the ET, these are just an accumulation of bad gut feelings. (IP08)
P-PASS: The P-PASS, a score system combining several risk factors of the donor, does not serve as a decision aid; four out of 14 interview partners mentioned that they use it, but explained that its significance was either limited or decreasing in importance.
Matching between donor and potential recipient. The majority of interview partners stated that it is not crucial that the donated organ matches well with the potential recipient, e.g. in terms of size – other than e.g. in liver transplantation.
Evidence base. Although not explicitly asked in the interview, the surgeons expressed that their criteria and cut-offs are based on various grounds, as presented in Table 2 .
2. Organ macroscopy
The surgeons stated unanimously that the macroscopy of the pancreas is the key parameter for judging its quality. Many surgeons described it as superior to information about the donor's general medical condition for the assessment of the pancreas quality.
If the CRP is a little high, it doesn't mean that you can't transplant [the pancreas]. It's the same with lipase: as long as it isn't above 1000 [U/l], it doesn't bother me. If it [the pancreas] is macroscopically fine and recovered well, you would certainly transplant it. (IP 09)
For me, the surgical parameters are more important, but the nephrologists primarily look at age, lab results, sodium, amylase, … creatinine, glucose (…). I rather look at the parenchyma (…), vascularization [and the] cold ischemic time. (IP 07)
3. Confidence in recovery team
Pancreas macroscopy as viewed by recovery team. Normally, the transplant surgeons who need to decide to accept an organ have to rely on the donor surgeon's judgment of the organ macroscopy, often communicated via phone. If the recovery team describes the pancreas quality as poor, transplant surgeons react differently, according to the interviews, as shown in Table 3 . Trust plays an important role in this context.
The policy of eagerly accepting offered pancreases with the aim to inspect the organs personally ( Table 2 , 2nd category) is explicitly criticized by one interviewee. This approach might decrease the organ's probability to be transplanted elsewhere in case of refusal, due to overlong cold ischemic time.
There are certainly centers that accept such an organ just so that they can have it and, more or less, take it off the market for any other center. And then in the end, [they] decide not to transplant it. And eventually, with this approach, you won't be able to transplant it at all. You experience that every day basically. This is definitely the wrong trend and you have to work against it. And if you …start that too,…in order not to fall behind, then this spiral will keep on going. It's the same as in the 1980s with the arms race between the USA und Soviet Union …". (IP02)
Technical quality of pancreas recovery. Almost all interviewed consultants agreed that the success of the transplantation is dependent upon a skilled organ recovery. In principal, this factor cannot influence the accept/refuse decision prior to actually receiving the accepted organ in the transplant center; however, there were hints that a lack of confidence in the donor surgeon's competence might influence the decision to accept an organ.
For me, it's essential to have a good donor and an excellent recovery. That's why I'm convinced […] that you can say that your reason for refusal was that the recovery surgeon had no clue. And I'm one of the few people who gives this as the reason. (IP04)
4. Capacity of transplant center
The vast majority of the interviewed transplant surgeons was convinced that transplant centers in Germany occasionally turn down pancreas offers due to staff shortage. However, nine out of 14 clearly ruled out that option for their own respective hospitals, declaring that refusals on the grounds of staff shortage were 'nonsense' or 'a non-issue'. According to the interview partners, the main reason for capacity problems is a limited number of experienced transplant surgeons in a hospital, coinciding with sickness, holidays or scientific conferences. Three interviewed surgeons admitted that they had already refused organs for capacity reasons.
I'm with a center now where this [capacity] problem is not really the issue. Because we've spread ourselves out pretty well…So there's always someone there who is available and who is able to transplant a pancreas. I could certainly imagine though, that it's different in smaller centers, because I already know how difficult it is for us to organize ourselves this way. (IP 11)
I have already refused organs because it simply wasn't possible, logistically. On Easter Sunday, an organ offer arrives, and the surgeon on call is sick. Then I have to refuse the organ for organizational reasons. (IP 07) We inform all potential recipients on the waiting list about the possibility of a capacity shortage – for whatever reasons: ICU bed, surgeon, other things… I have already cancelled organs due to capacity problems. We communicate this to our patients in a transparent way. (IP 08)
Whereas two interview partners emphasized that it was the obligation of a transplant center to have the necessary resources for transplantation available at any time and under any circumstances, others (6/14) described capacity problems as unavoidable or even legitimate.
If you provide a transplant program in your hospital, you have to make sure that the organs that come in can be transplanted. […] You also have the responsibility for the patient, who has been on the waiting list for years. And then say, 'Oh, there were three others in parallel and there was only one surgeon who had to take care of all of them" – the patient on the waiting list will not understand that.' (IP05)
[A transplant surgeon] is allowed to get sick, to go on holiday…, meaning that he can't [operate]. And I can very well imagine that someone says, due to logistical reasons [they can't do it]. And this shouldn't be seen as a reason to stigmatize these people. (IP04)
It transpired in the interviews that transplant surgeons might be led into using medical reasons as a pretext when an organ needs to be refused for organizational reasons.
5. Previous turn-downs by other centers
If the pancreas had previously been offered to other transplant centers by Eurotransplant and had been refused, it was of little to no relevance for most interview partners.
We always look at the organ individually. You can't imagine what we have experienced – pancreases are refused for the most diverse reasons. We always want to see for ourselves what's there. (IP 12)
In four out of 14 interviewed surgeons, however, there was a tendency to consider or to at least be influenced by the decisions of other transplant centers.
I ask what was the reason [for turning down the organ]. This is for me, above all, a time-saving factor. When I get a phone call at 3 a.m., and they tell me there had already been 3 centers. And these 3 centers are certainly not that stupid, they must have had some reason. (IP 08)
As a rule, a good organ is accepted by the first center. If it isn't accepted, this is already sort of suspicious. (IP 07)
6. Patient's prognosis
The interviewed surgeons pointed out that a pancreas transplant differs from a liver, heart or lung transplant in that the indication is, as a rule, not vital. Therefore, the organ needs to be selected more carefully, because the willingness to compromise is smaller than in cases of life-threatening conditions. This may lead to a cautious acceptance policy.
If I am in doubt, I'd rather refuse. Simply because the recipients are so selected. You can hardly expect them to put up with the possibility that it doesn't work well afterwards […] If you don't transplant the recipient, the chance that he or she dies is small. If you give him or her a bad organ, the chance that he or she dies is actually given. You simply have to consider that. (IP 08).
The waiting time …for pancreas-kidney-transplants in Germany is… not so extreme that you need to rush someone into transplant surgery…I cannot endanger a human being in order to perform a transplant when I know that an organ from a good pool will arrive within the next 18 months anyway. (IP 13)
This flexibility in accepting or turning down an offered pancreas is accentuated by the lack of clear standards and cut-offs; therefore almost any pancreas can be refused.
And most of the donors do have some flaw…. And then this one flaw can be made into a big deal, and that's why we only utilize only [so few] of the offered organs. And then there is the question: how many flaws do you want to accept? If you don't want to run any risks, then you don't accept any flaw. (IP 03)
7 Strategic aspects
Some further factors which relate to expectations of the hospital administration or aspects of competition (with other transplant centers) might also influence the decision making process, although this was only hinted at in few interviews.
Here, we need to justify ourselves very well, in the clinic and to our boss, and need to have good reasons if we turn down such an offer. (IP 05)
In addition, younger surgeons who are inexperienced or surgeons from a center with a higher rate of complications might decline an organ offer in order not to risk a surgical failure, as two interviewees surmised.
A lot of this is about experience. A center that, for example, has had many complications will certainly be more restrictive. And when there's a tiny little thing [about the pancreas], they say, for safety reasons, that they refuse it. A center with more experience and fewer complications will surely loosen its criteria…Experience plays a major role there. (IP 09)
BMC Surg. 2013;13(47) © 2013
BioMed Central, Ltd.
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