D. Rohan Jeyarajah

Hepatopancreaticobiliary (HPB) surgery: what is the right fellowship for the right training?

BACKGROUND Reduced resident work hours over the last several years have led to inadequate exposure to hepatopancreaticobiliary (HPB) and complex upper gastrointestinal (UGI) surgical procedures. Therefore, residents are seeking additional training in this field. The purpose of this study is to determine the role of a new fellowship model in the training of general surgery residents in complex HPB/UGI diseases. METHODS We propose a surgical training model in benign as well as malignant diseases of the UGI tract. The proposed model would focus on an integrated approach that involves allied specialties such as gastroenterology (GI) and radiology. RESULTS The fellowship was set as 1-year duration with 1-month rotations on interventional GI and transplantation. The fellow spent the remaining 10 months on a UGI laparoscopic and open surgery service caring for complex benign and malignant disease of the esophagus, stomach, bile duct, pancreas, and liver. Didactic conferences were focused specifically at an organ-based approach to diseases of these organs. During a 12-month fellowship, exposure to complex diseases of the UGI tract was accomplished without negatively impacting the general surgery residency program. CONCLUSION This new mode of advanced training provides a bridge between surgical oncology and transplantation, and it is an excellent model for postgraduate surgical training in UGI diseases.

Estimating the need for hepato-pancreatico-biliary surgeons in the USA

BACKGROUND Hepato-pancreatico-biliary (HPB) fellowship training has risen in popularity in recent years and hence large numbers of graduating fellows enter the workforce each year. Studies have proposed that the increase in HPB-trained surgeons will outgrow demand in the USA. This study shows that the need for HPB-trained surgeons refers not to the meeting of demand in terms of case volume, but to improving patient access to care. METHODS The National Inpatient Sample (NIS) database for the years 2005-2011 was queried for CPT codes relating to pancreatic, liver and biliary surgical cases. These numbered 6627 in 2005 and increased to 8515 in 2011. Cases were then mapped to corresponding states. The number of procedures in an individual state was divided by the total number of procedures to give a ratio for each state. A similar ratio was calculated for the population of each state to the national population. These ratios were combined to give a ratio by state of observed to expected HPB surgical cases. RESULTS Of the 46 states that participate in the NIS, only 18 achieved ratios of observed to expected cases of >1. In the remaining 28 states, the number of procedures was lower than that expected according to each states population. CONCLUSIONS The majority of the USA is underserved in terms of HPB surgery. Given the growing number of HPB-trained physicians entering the job market, this sector should focus on bringing understanding and management of complex disease to areas of the country that are currently in need.

Training in Hepatopancreatobiliary Surgery: Assessment of the Hepatopancreatobiliary Surgery Workforce in North America.

Objective: Evaluate the current status of Hepatopancreatobiliary (HPB) Surgery workforce in North America. Background: HPB fellowships have proliferated, with HPB surgeons entering the field through 3 pathways: transplant surgery, surgical oncology, or HPB surgery training. Impact of this growth is unknown. Methods: An anonymous survey was distributed to 654 is used as HPB surgeons from October 2012 to January 2013. Questions evaluated satisfaction with job availability after training and description of current practice. Nationwide Inpatient Sample (NIS) data from 2003 to 2010 was queried to describe the growth of HPB cases in the United States; these data were compared to prior HPB workforce projections performed using 2003 NIS data. Results: A total of 416 HPB surgeons responded (66%). HPB surgeons are concentrated in a small number of states/provinces with a lack of HPB surgeon workforce in central United States. HPB graduates from 2008 to 2012 report increased difficulty in identifying an HPB-focused practice versus prior to 2008. Mature HPB surgery practices report a composition of 25% to 50% non-HPB operative cases. Fifty-one percent of respondents reported an opinion that current HPB Surgeon production was excessive; however, 2010 NIS data demonstrate that major HPB surgery cases have grown significantly more than was previously projected using 2003 NIS data. Conclusions and Relevance: A cohesive strategy for responsibly responding to the HPB surgical workforce requirements of North America is needed. Elevation of training standards, standardization of requirements for certification, and careful modeling that accounts for regionalization of care should be pursued to prevent overtraining and decentralization of HPB surgical care in the future.

Qualities and characteristics of successfully matched North American HPB surgery fellowship candidates

BACKGROUND Hepato-pancreato-biliary (HPB) fellowships in North America are difficult to secure with an acceptance rate of 1 in 3 applicants. Desirable characteristics in an HPB surgery applicant have not been previously reported. This study examines the perceptions of trainees and HPB program directors with regards to positive attributes in applicants for HPB fellowships. METHODS Parallel surveys were distributed by email with a web-link to current and recent HPB fellows in North America (from the past 5 years) with questions addressing the following domains: surgical training, research experience, and mentorship. A similar survey was distributed to HPB fellowship program directors in North America requesting their opinion as to the importance of these characteristics in potential applicants. RESULTS 32 of 60 of surveyed fellows and 21 of 38 of surveyed program directors responded between November 2014-February 2015. Fellows overall came from fairly diverse backgrounds (13/32 were overseas medical graduates) about one third of respondents having had some prior research experience. Program directors gave priority to the applicants interview, curriculum vitae, and their recommendation letters (in order of importance). Both the surveyed fellows and program directors felt that the characteristics most important in a successful HPB fellowship candidate include interpersonal skills, perceived operative skills, and perceived fund of knowledge. CONCLUSION Results of this survey provide useful and practical information for trainees considering applying to an HPB fellowship program.

Surgical management of gastric varices and morbid obesity: a novel approach

BACKGROUND Morbid obesity is a growing pandemic. The greater prevalence of chronic conditions such as diabetes, hypertension, and heart and liver disease has made management of obesity challenging. Many surgical techniques are in practice, each with some elements of restrictive or malabsorptive components. Nonalcoholic steatohepatitis can lead to portal hypertension, which can further manifest as upper gastrointestinal bleeding. METHODS We performed sleeve gastrectomy at a nonuniversity tertiary care center, as a novel approach for the management of isolated gastric varices, in a morbidly obese cirrhotic patient. RESULTS The operating time was 142 minutes. The estimated blood loss was 150 mL. The patient did not receive intraoperative or postoperative transfusions. The length of stay was prolonged to 10 days because of an ischemic cardiac event that was managed by coronary angioplasty on postoperative day 7. The patient did not develop any other complications. During the next couple of months, the patient lost significant weight and had no complaints. CONCLUSION Sleeve gastrectomy with devascularization is a durable approach that will address the problems of both portal hypertension and morbid obesity, with the desired effect of weight reduction and treatment of gastric varices using a single surgical approach.

Extended Drainage of the Pancreatic Duct After Pancreaticoduodenectomy

HYPOTHESIS Because of better survival following pancreaticoduodenectomy (PD), patients may develop complications due to PD and not due to malignancy per se. Exocrine insufficiency may be related to pancreatic duct obstruction or strictures attributable to duct-to-mucosa anastomosis, as in pancreaticojejunostomy. We propose a technique of managing a post-PD duct obstruction. DESIGN Retrospective review from September 2005 to August 2008. SETTING Methodist Dallas Medical Center, Dallas, Texas, a referral, high-volume, nonuniversity tertiary care center. PATIENTS All patients who underwent surgery for anastomotic pancreaticojejunal stricture. MAIN OUTCOME MEASURES Perioperative outcomes. RESULTS All the patients were women and aged 62, 78, and 45 years. Comorbidities were documented in 2 patients. Two patients presented with severe acute abdominal pain and hyperamylasemia while 1 was asymptomatic. Two patients underwent magnetic resonance cholangiopancreatography with secretin stimulation. Endoscopic retrograde cholangiopancreatography was attempted in 1 patient. Operating time was 99 minutes, 158 minutes, and 154 minutes. Estimated blood loss was 250 mL, 400 mL, and 500 mL. A single-layer, side-to-side pancreaticogastrostomy was performed as the drainage procedure in all patients. There was no mortality associated with any of the patients within 30 days. Morbidity was seen only in 1 patient. None of the patients needed a reoperation. The mean length of hospital stay was 9 days. All patients were asymptomatic for pain. CONCLUSION We propose a durable technique for treating pancreatic ductal strictures post-PD that appears to result in superior postoperative outcome.

Training and practice of the next generation HPB surgeon: analysis of the 2014 AHPBA residents' and fellows' symposium survey.

BACKGROUND Hepato-pancreato-biliary (HPB) surgery is a complex subspecialty drawing from varied training pools, and the need for competency is rapidly growing. However, no board certification process or standardized training metrics in HPB surgery exist in the Americas. This study aims to assess the attitudes of current trainees and HPB surgeons regarding the state of training, surgical practice and the HPB surgical job market in the Americas. STUDY DESIGN A 20-question survey was distributed to members of Americas Hepato-Pancreato-Biliary Association (AHPBA) with a valid e-mail address who attended the 2014 AHPBA. Descriptive statistics were generated for both the aggregate survey responses and by training category. RESULTS There were 176 responses with evenly distributed training tracks; surgical oncology (44, 28%), transplant (39, 24.8%) and HPB (38, 24.2%). The remaining tracks were HPB/Complex gastrointestinal (GI) and HPB/minimally invasive surgery (MIS) (29, 16% and 7, 4%). 51.2% of respondents thought a dedicated HPB surgery fellowship would be the best way to train HPB surgeons, and 68.1% felt the optimal training period would be a 2-year clinical fellowship with research opportunities. This corresponded to the 67.5% of the practicing HPB surgeons who said they would prefer to attend an HPB fellowship for 2 years as well. Overall, most respondents indicated their ideal job description was clinical practice with the ability to engage in clinical and/or outcomes research (52.3%). CONCLUSIONS This survey has demonstrated that HPB surgery has many training routes and practice patterns in the Americas. It highlights the need for specialized HPB surgical training and career education. This survey shows that there are many ways to train in HPB. A 2-year HPB fellowship was felt to be the best way to train to prepare for a clinically active HPB practice with clinical and outcomes research focus.

White Paper: SSAT Commitment to Workforce Diversity and Healthcare Disparities.

The Society for Surgery of the Alimentary Track (SSAT) is committed to diversity and inclusiveness of its membership, promotion of research related to healthcare disparities, cultural competency of practicing gastrointestinal surgeons, and cultivation of leaders with unique perspectives. The SSAT convened a task force to assess the current state of diversity and inclusion and recommend sustainable initiatives to promote these goals. Working through the current committee structure of the Society, and by establishing a permanent Diversity and Inclusion liaison committee, the SSAT will maintain its commitment and strive towards diversity of thought and inclusiveness on every level to improve the well-being and betterment of its membership and the patients they serve.

Nodal sampling in pancreaticoduodenectomy: does it change our management?

BACKGROUND Lymph node involvement in periampullary malignancy is the single most important factor in predicting survival in pancreaticoduodenectomy (PD). The role of nodal sampling in PD has not been well evaluated. This study evaluates the utility of nodal sampling of nodal stations 8 and 12, which are easily dissected early in PD, in overall final nodal status. PATIENTS AND METHODS Fifty patients underwent PD at a single institution by a one surgeon over a 15 month period. Nodal stations 8 and 12 were sent separately for pathologic evaluation. Twenty-eight patients had a final diagnosis of periampullary malignancy. Demographic and pathologic data were collected retrospectively from patient charts. Positive and negative predictive values of nodes 8 and 12 were evaluated. RESULTS Eighteen of 28 patients with a diagnosis of periampullary malignancy had pathologically negative nodes 8 and 12, and a final nodal status (all peripancreatic lymph nodes) negative for nodal involvement. Nine of 28 patients had a negative nodal sampling result, but a positive final nodal status for metastatic tumor. The remaining four patients had both positive nodal sampling and final nodal status for metastatic tumor. The negative predictive value of negative nodes 8 and 12 was 0.625. CONCLUSION The negative predictive of a negative node 8 and 12 of 0.625 suggests that the decision to proceed with or abort PD should not be based on intraoperative evaluation of these nodes. Performance of PD should be undertaken if technically feasible, and not based on intraoperative nodal assessment.