The Japanese Association of Medical Sciences established a Uterus Transplantation (UTx) Ethics Review Committee to examine, from the standpoint of medical, ethical, legal, and social perspectives, whether UTx can be performed in Japan. The Committee concluded that carefully designed clinical research studies with a small number of live-donor UTx cases may be conducted. At the same time, comprehensive measures regarding diagnosis, treatment, and care of patients with congenital deficiency in the uterus should be established, and it should be requested to include the uterus in the list of legally transplantable organs from deceased donors. Furthermore, an inspection committee jointly formed by the Japanese Society of Transplantation and the Japanese Society of Obstetrics and Gynecology should be implemented to oversee individual UTx cases.

A new medical technique called uterus transplantation has been considered as an option for raising children of women with uterine factor infertility. Clinical studies have already begun overseas, and 87 uterus transplantations have been performed so far, and 49 babies have been born. Uterus transplantation, like other assisted reproductive technology, involves many medical, ethical, and social challenges that must be carefully considered for clinical application. However, uterus transplantation is highly expected to bring the gospel to women with uterine factor infertility who were previously unable to raise children.

Since 2014, more countries have been doing uterine transplants after the world’s first report of a uterine transplant delivery by Professor Brännström’s team in Sweden. Even in Japan, although it has not been applied to humans, transplantation technology has reached a certain level and has reached the stage of preparing for clinical application.

The target of uterine transplantation is a patient with a uterine defect disease who desires fertility treatment, and congenital uterine defect (Mayer-Rokitansky-Küster-Hauser syndrome) can be considered as a consensus. In actual practice, it is important to consider the following points.

1. There are still unresolved issues to be considered and a clinical trial study should be conducted.

2. The choice of donor should be careful. This is because it is necessary to perform highly invasive surgery on a healthy donor in order to perform this technique. Brain death transplantation is also possible, but the hurdles are high in Japan. Therefore, living body transplantation is the main focus.

3. As for the conditions of the recipient, it is necessary to consider that the patient can obtain a pregnant egg, that she is of an age that allows pregnancy and delivery, and that she and her partner desire fertility treatment.

4. In addition, it is necessary to consider the level of medical facilities and what to do about the necessary expenses.

While solving these problems, it is necessary to carry out cross- medical society efforts and proceed with preparations.

As a transplantation surgeon, I celebrate and admire the success of uterus transplantation and birth after uterus transplantation. It was brought about by the scientific achievement in organ transplantation. But, as the history of uterus transplantation is short, many key issues on it remain unresolved. Living donor or cadaveric donor, age of donor, operation for hysterectomy in living or cadaveric donor, preservation time of uterus, histocompatibility, immunosuppressive drugs, diagnosis and treatment of rejection, problems in the newborn baby, medical cost and comparison with surrogate conception are discussed.

Uterus transplantation (UTx) has become a new potential option for women with absolute uterine factor infertility (UFI), who desire to give birth to their own children. In UTx, organ transplantation from living or deceased donors is used under the goal of assisted reproductive technology. In July of 2021, the commission for ethical issues on UTx under the Japanese Association of Medical Sciences published the report, and allowed the conducting of clinical research on UTx with a limited number of patients. This article discusses bioethical considerations of UTx. Transplantation from a living donor is an exceptional procedure which does not fulfill ethical principles of non-maleficence nor justice. Autonomy is also affected because the national guideline requires that a donor should primarily be a family member of the recipient and it raises a concern whether both a donor and a recipient feel pressure. Transplantation from a living donor is accepted because beneficence (saving a patient’s life) surpasses the other principles. This formula cannot be applied to UTx from living donors because the uterus is not a vital organ, and it is difficult to ethically justify such a transplantation. The interest of children is another important ethical issue. From a research ethics perspective, UTx is an unproven intervention to achieve the clinical goal for UFI women. Implementing UTx not as treatment but as clinical research first is supported by the standard of research ethics today. However, allowing clinical research embraces the practice of UTx itself, while unresolved ethical considerations are left behind. Continuous discussion open to public, review of institutional systems including legislation reform, and wholistic care and support for UFI women are needed.

On July 14, 2021, a committee created by the Japanese Association of Medical Sciences for studying ethical issues of uterus transplantation released a report allowing the transplant to be performed as clinical research. The author, who was a member of the committee, explains the legal background to and implications of the report.

【Objective】 As the number of organ transplants is increasing in Japan, overwork of transplant doctors will become a matter of concern. The aim of this study is to clarify the working status of transplant doctors who are involved in organ procurement surgery from deceased donors, according to the result of a survey conducted by the Japanese Society for Transplantation.

【Methods】 A request to answer a questionnaire was sent to all members of the Society by e-mail so that transplant doctors could answer on the web from December 1, 2020 to February 1, 2021. Another questionnaire request was sent to the hospital directors of 132 transplant facilities so that the person in charge who was involved in employment management could answer on the web from December 1, 2020 to February 28, 2021.

【Results】 In the questionnaire to transplant doctors, 340 doctors answered. On the other hand, 41 out of 132 transplant facilities (31%) responded. As for the question “Are there any points on which you would like improvement regarding work related to organ procurement surgery?” (free description), 151 out of 340 respondents answered and the answers were classified into several categories. The most common category was allowance, followed by the matter regarding transportation of equipment for organ procurement, and the answers regarding these two problems accounted for a half of the total. The other requests included improving organ procurement schedules, securing rest time, enhancing mutual aid systems for organ procurement, clarifying compensation for doctors, and specialization of donor and recipient surgeries.

【Conclusion】 According to the requests raised by transplant doctors, it was revealed that they are desperately working for organ procurement surgery and their working environment is not ideal. In order to maintain high standards of clinical transplantation in Japan, it is necessary to make an effort toward improving the organ donation / transplantation medical system at various levels.

【Objective】 To purpose of this nationwide survey was to validate workplace characteristics among 340 transplant surgeons undertaking deceased donor organ transplantation in Japan.

【Methods】 A nationwide survey was conducted among transplant surgeons who are involved deceased donor organ transplantation in Japan. An online questionnaire was sent to transplantation physicians who belong to the Japan Society for Transplantation, and the answers regarding the information about the workplace environment were collected.

【Results】 The survey revealed that transplant physicians are likely to be overworked with less financial compensation in the deceased donor organ transplantation procurement. Preparations for deceased donor procurement occupied an average of 21 hours and necessitate 5 transplant physicians to carry out the procedure. Many transplant physicians are not allowed to accept paid leave in lieu of additional wages for overtime work (or graveyard shift for procurement operation) agreed upon in the relevant hospitals.

【Conclusion】 Although career satisfaction might be high in transplant physicians, a significantly unhealthy and uncompensated work environment had been reported with high turnover and burnout rates. Initiative should be taken to facilitate collaborative efforts between surgeons and transplant centers in order to increase the local procurement of organs, the regional allocation system, the courier system for necessary equipment for procurement, and most importantly adequate compensation for this honorable profession.

【Objective】 In Japan, the working conditions of transplant surgeons involved in organ procurement have not been surveyed so far. This survey by the Workstyle Reform Committee of the Japanese Society for Transplantation was conducted between December 2020 and February 2021 to analyze the working conditions of surgeons involved in organ procurement from brain-dead donors and donors after cardiac arrest (hereinafter, cardiac-arrest donors).

【Methods】 Although organ transplantation after cardiac arrest is limited to kidney transplantation in Japan, a questionnaire similar to that used in the survey of the working conditions of surgeons involved in organ procurement from brain-dead donors was distributed to examine the differences in the working conditions, etc., between surgeons involved in organ procurement from brain-dead donors and cardiac-arrest donors. The target population for this survey conducted by the Workstyle Reform Committee of the Japanese Society for Transplantation between December 1, 2020 and February 28, 2021, were 340 members of the Japanese Society for Transplantation (surgeons).

【Results】 The time spent in management for organ procurement was as expected: in organ procurement from brain-dead donors, processes were often performed according to the predetermined schedule and the management was completed within a relatively short period of time (within 3 hours). On the other hand, in the case of organ procurement from cardiac-arrest donors, in which organ procurement was initiated after declaration of the end of life, various situations were encountered, and the management period prior to organ procurement sometimes was as long as 2 full days to 3 days or more. The large majority of all respondents performed organ procurement surgery following the sequence of management prior to organ procurement. This was common to both organ procurement from brain-dead donors and organ procurement from cardiac-arrest donors. The survey participants were asked about the interval between completion of organ procurement and the start of transplantation surgery or other tasks, and the responses revealed that approximately 80% of the surgeons continued to work, performing the transplant surgery or other tasks, following organ procurement, without taking any rest. The time spent in organ procurement was 12 to 24 hours, including travel time, in both organ procurement from brain-dead donors and organ procurement from cardiac-arrest donors, except that in some cases of organ procurement from cardiac-arrest donors, 2 to 3 days were required for the organ procurement, because the time to cardiac arrest was unexpectedly long.

【Conclusion】 The results of this questionnaire survey reveal that transplant surgeons, who are few in number at present, are forced to start working very early after obtaining information on organ donation and continue to work for extended periods of time without rest.

The medical consultant (MC) system is a Japan-specific brain-dead donor evaluation and management system, which was started in 2002 with an expectation of increasing transplantable organ numbers. The average number of transplanted organs per donor was over 5.0 thanks to the MC system. An MC is dispatched to a donation hospital to evaluate and improve donor conditions, resulting in long actual working hours (often during or over midnight). We conducted a survey to disclose working conditions and relevant compensation among transplant physicians. The theme of this report is focused on those of MCs. What is found by analyzing responses is that hard working conditions for and inadequate compensation to MCs. The MC system has been functioning effectively to expand transplantable organs per donor in Japan. If a number of brain-dead donors will continuously increase, the MC system will not be maintained. It is imperative to maintain this system by reforming the duties of MCs but leveraging the expertise of MCs as transplant physicians.

【Objective】 Since 1968, given the distrust of the public after the first heart transplant performed by Dr. Wada, transplant teams in Japan have been working tirelessly without complaint. Additionally, such teams are inherently exposed to occupational risks because of the urgency of travel associated with organ procurement. Under these circumstances, overstraining them will lead to problems. In this study, based on the result of a survey conducted by the Japanese Society for Transplantation, the current situation of employment management in the transplant facilities is examined, with special attention to accident compensation related to organ procurement as a means to ensure the safety and health of the transplant team.

【Methods】 From December 1, 2020 to February 28, 2021, directors of 132 transplant facilities were contacted via post with a survey containing 39 questions for the person in charge involved in employment management to complete. From December 1, 2020 to February 1, 2021, another survey containing 37 questions was emailed to all the members of the Society for the transplant doctors to complete.

【Results】 Of the 132 transplant facilities, only 41 (31%) responded to the survey. In total, 340 transplant surgeons participated in the survey. A total of 34 out of 40 facilities (85%) have a notification system for organ procurement travel. Out of 280, only 218 doctors (78%) requested permission to travel for organ procurement. Out of 39 hospitals, 36 (92%) permit their transplant teams to apply for industrial accident insurance. Moreover, only 3 of the 37 facilities (8%) contract a special insurance to cover accidental damage; however, this compensation is insufficient for recouping lost profits.

【Conclusion】 The current employment management of transplant facilities in Japan has some issues with accident compensation related to organ procurement. For Japan to maintain high standards of clinical transplant, it is necessary to establish a new accident compensation system related to organ procurement.

【Objective】 This study focuses on the working conditions of transplant doctors in Japan. The objective of this part is to clarify reward, overtime pay, and incentives to the transplant doctors.

【Methods】 This survey was conducted in the form of an anonymous questionnaire to members of the Japan Society for Transplantation (JST) and transplant facilities in Japan. The questionnaire for the JST members was conducted via a web format. Requests for the questionnaire to the JST members were sent using e-mail addresses registered at JST. With regard to the transplant facilities, a letter of request was mailed to the director of each facility so that the administrators involved in employment at each facility could respond. The questionnaires were answered from December 1, 2020 to February 28, 2021.

【Results】 We received responses from 340 JST members and 41 transplant centers nationwide. From the responses of JST members, 65% (198/305) of doctors received overtime pay. On the other hand, transplant centers responded that 86% (31/36) of them provided overtime pay for the organ procurement surgery and 84% (26/31) of them provided overtime pay for transplant surgery. Only 6 transplant centers replied that they provide incentives for organ procurement and transplant surgery.

【Conclusion】 This questionnaire revealed that not all the doctors received overtime pay and only a few centers provided incentives for organ procurement and transplant surgery. In order to develop organ transplantation in Japan, it is imperative to improve the remuneration for doctors performing transplants.

【Objective】 The current study aimed to clarify the influence of recipient age on PT outcomes and to identify the prognostic factors for older recipients.

【Methods】 We retrospectively analyzed the outcomes of PT in recipients aged ≥50 years (older group; n=94) in comparison with those aged <50 years (younger group; n=285) using the Japanese database. Prognostic factors in the older group were analyzed by a logistic regression model. The influence of recipient age on survival outcomes was analyzed using propensity score matching.

【Results】 The patient survival rate was significantly poorer in the older group (P<0.001). The surgical complications were comparable between the groups. Patient death due to infection or/and multiple organ failure or cardiac/cerebrovascular events was more frequently seen in the older group than in the younger group (P=0.012 and P=0.045, respectively). Multivariate analysis revealed that a longer duration of diabetes was an independent risk factor of 1-year mortality in the older group. In a propensity score-matched comparison, the patient survival rate of older recipients (n=77) was significantly poorer than that of younger recipients (n=77) (P=0.026).

【Conclusion】 PT should be considered with appropriate caution, especially for older recipients with a long duration of diabetes.

Since central pontine myelinolysis (CPM) is a demyelinating disease of the pons that is commonly associated with neurological disorders, if it occurs post-transplant in organ recipients, a comprehensive support system including rehabilitation and holistic care should be established. Here, we report our experiences of recipient transplant coordinators (RTC) in promoting cooperation among transplant providers for smooth implementation of the support system.

【Case presentation】 A 60-year-old female patient with acute liver failure with hepatic coma received liver transplantation from a deceased donor. Ten days after transplantation, she developed a neurological disorder, including impaired consciousness and respiratory muscle paralysis. She was diagnosed with CPM, which was possibly associated with immune-suppressive drugs. As a result, the calcineurin inhibitor was switched to everolimus. To restore neurological function, multidisciplinary approaches were implemented, with RTCs promoting cooperation among transplant providers. The RTCs also motivated the recipient to continue her physical rehabilitation. Their positive attitude allowed the patient, as well as the family, to feel relieved from mental distress during the post-transplant period. Although the recipient’s neurological function improved, she required assistance in her activities of daily living. Therefore, the RTCs coordinated the discharge of the recipient to a rehabilitation facility capable of caring for her. The recipient was discharged 140 days after transplantation.

【Conclusion】 It is important to provide holistic supportive care for recipients with neurological disorders due to CPM. RTCs can play a pivotal role in promoting cooperation among transplant providers.

Intestinal failure is a complicated medical condition resulting in the loss of absorptive area or in severe gastrointestinal bacterial overgrowth. Prolonged use of parenteral nutrition (PN) puts patients at risk of multiple complications, including catheter-related bloodstream infection (CRBSI), intestinal failure-associated liver disease (IFALD), and renal impairment. Intestinal rehabilitation programs (IRPs) have recently been recognized as playing a significant role in outcome improvement, care coordination, and complication prevention. We herein report an adult case of chronic idiopathic intestinal pseudo-obstruction (CIIP) that underwent isolated intestinal transplantation (ITx) from a deceased donor. Because the loss of central vascular access was his indication for ITx, a catheter for perioperative management was inserted in the azygous vein via intercostal veins punctured under ultrasound guidance. A total of 255 cm of small intestine with a 10-cm ascending colon graft was transplanted, and the proximal side was anastomosed to the native duodenum. Because the native gastro-duodenum dysmotility remained even after isolated ITx for CIIP, decompression of the native gastroduodenum with a gastro-jejunum tube via gastrostomy and feeding via tube enterostomy at the graft intestine were needed during the first four to five months after ITx. However, such management was effective in achieving full enteral feeding at an early stage with stable immunosuppressive therapy. Intervention with an IRP for management before ITx helped prevent CRBSIs and facilitated his continuing parenteral nutrition until ITx. Multidisciplinary collaboration on an IRP team is mandatory for the perioperative management of ITx patients.

A 6-year-old girl with megacystis-microcolon-intestinal hypoperistalsis syndrome was referred to our hospital for intestinal rehabilitation. However, oral enteral nutrition did not improve the delayed gastric emptying and intestinal stasis. Furthermore, because intestinal failure-associated liver disease (IFALD) disturbed the increase of parenteral nutrition, growth retardation was further aggravated and renal dysfunction with the primary disease was prolonged. Therefore, cadaveric intestinal transplantation (ITx) was indicated for IFALD and growth retardation at the age of 10 years. The transplanted graft was an isolated intestinal graft with the colon. Systemic drainage was adopted for venous reconstruction. Regarding intestinal reconstruction, native gastric-transplanted intestinal anastomosis was performed. Rabbit antithymocyte globulin was used as the medication for induction treatment. Thereafter, re-colostomy and anastomotic plasty of the native gastric-transplanted intestinal anastomosis were performed at 2.5 months post-transplantation due to stomal prolapse and obstruction of the native gastric-transplanted intestinal anastomosis. Tacrolimus and a steroid were administered as a maintenance immunosuppression therapy post transplantation, and everolimus was added due to the detection of human leukocyte antigen antibodies at 5 months post transplantation. Oral administration for secondary diabetes was started at 6 months post transplantation. At 13 months post transplantation, delayed gastric emptying improved, nourishment management mainly consisted of oral enteral nourishment, and dependence on parenteral nutrition decreased. The growth retardation and vigor improved. No episode of acute rejection occurred after ITx.