Training, practice, and referral patterns in hepatobiliary and pancreatic surgery: survey of general surgeons.
ABSTRACT Subspecialization has changed the way that general surgery is practiced. Hepatobiliary and pancreatic surgery (HPB) is maturing as a subspecialty. The objective of this study was to identify the current levels of practice, self-assessments of adequacy of training, referral patterns, and perceptions regarding regionalization of HPB care to high-volume centers. A total of 240 nonstratified general surgeons from across Canada were randomly selected to receive a survey developed by an expert work group. A reference group of 10 HPB specialists were also polled for a total of 250 respondents. The overall response rate was 73% (182 responders). Subspecialty training had been completed by 65% of respondents. This included surgical oncology (15%), HPB (15%), HPB and transplant (8%), laparoscopy (7%), liver transplantation (5%), and other (50%). This training was obtained in Canada (51%), the United States (35%), Europe (11%), and Australia (3%). Ninety-five percent of responders believed that some HPB services should be regionalized. Similarly, most responders thought that they were not adequately trained to perform these procedures. The following were especially considered subspecialty procedures: major hepatectomy (93%), pancreaticoduodenectomy (90%), and biliary reconstruction (79%). The majority of non-HPB surgeons do not consider themselves adequately trained to perform complex HPB procedures. Furthermore, most surgeons think that major hepatectomy, pancreaticoduodenectomy, and biliary reconstruction should be referred to HPB specialists at high-volume centers.
Article: Training minimal invasive approaches in hepatopancreatobilliary fellowship: the current status.[show abstract] [hide abstract]
ABSTRACT: There has been an increasing role of advanced minimally invasive procedures in hepatopancreatobilliary (HPB) surgery. However, there are no set minimum laparoscopic case requirements. A 14-question electronic survey was sent to 82 worldwide HPB fellowship programme directors. Forty-nine per cent (n=40) of the programme directors responded. The programmes were predominantly university based (83%). Programmes had either one (55%) or two fellows (40%) each year. Programmes (35-48%) had average annual volumes of 51-100 hepatic, 51-100 pancreatic and 25-50 biliary cases. For many programmes, <10% of hepatic (48%), pancreatic (40%) and biliary (70%) cases were done laparoscopically. The average annual fellow case volumes for hepatic, pancreatic and biliary surgeries were 25-50 (62%), 25-50 (47%) and <25 (50%), respectively. The average annual number of hepatic, pancreatic and biliary cases done laparoscopically by a fellow was 9, 9 and 4, which constitutes 36%, 36% and 16%, respectively, of the International Hepato-Pancreato-Billiary Association (IHPBA) requirement. We surmise that the low average number of surgeries performed by minimally-invasive techniques by HPB fellows is not sufficient in today's practice. Should there be an increase in the minimal number of hepatic, pancreatic and complex biliary cases to 50, 50, and 25, with at least 50% of these performed laparoscopically?HPB 03/2011; 13(3):149-52. · 1.60 Impact Factor
Article: Evaluation of Hepato-Pancreato-Biliary (HPB) fellowships: an international survey of programme directors.[show abstract] [hide abstract]
ABSTRACT: This report describes a survey undertaken with the aim of assessing the current status of available fellowships in hepatopancreatobiliary (HPB) surgery in order to identify steps to be taken to ensure the provision of successful training in this specialty. An online survey was conducted among members of the International Hepato-Pancreato-Biliary Association (IHPBA) targeting registered and non-registered HPB surgery fellowships. A total of 71 programmes are registered on the IHPBA website and 40 fellowship directors completed the survey. Only 18 completed surveys referred to programmes previously listed on the website. Responses showed great diversity among centres regarding their requirements for application, the duration of training and exposure to HPB cases during the fellowship. Factors associated with higher levels of training included the country of fellowship, a third year of training and the presence of a well-structured HPB curriculum. Over 90% of responders seek official accreditation from their regional association (i.e. the European, American and Asian-Pacific HPB Associations). Most programmes would welcome official IHPBA or regional association monitoring of their fellowship. This survey discloses important information which will allow the IHPBA Education and Training Committee to move forward. The next steps should include close monitoring of the performance of fellows by creating a fellows' registry, as well as a blog or forum which can be used to further enhance communication among fellows. The availability of registration to both programme directors and fellows may eventually lead to an official fellowship accreditation process.HPB 04/2011; 13(4):279-85. · 1.60 Impact Factor
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ABSTRACT: In several clinical situations, including resection of malignant or benign biliary lesions, reconstruction of the biliary system using the Roux-en-Y jejunum limb has been adopted as the standard procedure. The basic technique and the procedural knowledge essential for most gastroenterological surgeons are described in this article, along with a video supplement. Low complication rates involving anastomotic insufficiency or stricture can be achieved by using proper surgical techniques, even following small bile duct reconstruction. Using the ropeway method to stabilize the bile duct and jejunal limb allows precise mucosa-to-mucosa anastomosis with interrupted sutures of the posterior row of the anastomosis. Placement of a transanastomotic stent tube is the second step. The final step involves suturing the anterior row of the anastomosis. In contrast to the lower extrahepatic bile duct, the wall of the hilar or intrahepatic bile duct can be recognized within the fibrous connective tissue in the Glissonean pedicle. The portal side of the duct should be selected for the posterior wall during anastomosis owing to its thickness. Meticulous inspection to avoid overlooking small bile ducts could decrease the chance of postoperative intractable bile leakage. In reconstruction of small or fragile branches, a transanastomotic stent tube could work as an anchor for the anastomosis.Journal of hepato-biliary-pancreatic sciences. 11/2011; 19(3):203-9.