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Galvin D, O'Reilly B, Greene R, O'Donoghue K, O'Sullivan O. A national survey of surgical training in gynaecology: 2014-2021. Eur J Obstet Gynecol Reprod Biol 2023; 288:135-141. [PMID: 37517105 DOI: 10.1016/j.ejogrb.2023.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 07/21/2023] [Accepted: 07/24/2023] [Indexed: 08/01/2023]
Abstract
OBJECTIVES Over the last decade barriers to surgical training have been identified, including reducing access to theatre lists, reducing numbers of major surgical procedures being performed, increasing numbers of trainees and reduction in working hours since the introduction of the European Work Time Directive (EWTD). We aimed to assess the impact of these challenges on training in gynaecology over time. STUDY DESIGN We designed a study which aimed to assess both trainers and trainees perception of gynaecological surgical training in Ireland. The purpose of this was to identify confidence levels and challenges and to highlight potential areas for future improvement of surgical training in gynaecology. A a cross-sectional survey was distributed to all trainees and trainers registered with the Royal College of Physicians of Ireland Obstetrics and Gynaecology higher specialist training programme in 2014, 2017 and again in 2021. RESULTS During the study period trainees' confidence that the training programme prepared them to perform gynaecological surgery fell significantly. This fall in confidence was most evident for trainees' ability to perform abdominal hysterectomy (40.9% vs 15.2%, χ2 = 4.61, p =.03) and vaginal hysterectomy (31.8% vs 12.1%, χ2 = 4.58, p =.03) when comparing 2014 with 2021. All trainees reporteded that gynaecology was not given adequate time in the training programme to prepare them to practice independently as consultants. Themes identified by participants to improve training included dedicated access to theatre time with a named trainer, increased simulation training and subspecialisation at later stages of training. CONCLUSION Our findings show an overall decrease in trainees' and trainers' confidence in the surgical training available in gynaecology over an eight-year period.. This is particularly true for major gynaecology procedures. Efforts must be made to ensure trainees have improved access to surgical training in gynaecology. Potential solutions include improving access to simulation and incorporation of subspecialist training into later stages of training.
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Affiliation(s)
- Daniel Galvin
- Department of Obstetrics and Gynaecology, College of Medicine and Health, University College Cork, Ireland.
| | - Barry O'Reilly
- Department of Obstetrics and Gynaecology, College of Medicine and Health, University College Cork, Ireland
| | - Richard Greene
- Department of Obstetrics and Gynaecology, College of Medicine and Health, University College Cork, Ireland
| | - Keelin O'Donoghue
- Department of Obstetrics and Gynaecology, College of Medicine and Health, University College Cork, Ireland; INFANT Research Centre, University College Cork, Cork, Ireland
| | - Orfhlaith O'Sullivan
- Department of Obstetrics and Gynaecology, College of Medicine and Health, University College Cork, Ireland
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Docimo S, Sucandy I, Luhrs A, Snow T, Pechman D. TAVAC: choledochoscopy disposable scopes, and the single-stage vs. two-stage approach to choledocholithiasis. Surg Endosc 2023; 37:6611-6618. [PMID: 37464066 DOI: 10.1007/s00464-023-10267-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 06/28/2023] [Indexed: 07/20/2023]
Abstract
BACKGROUND Previous studies have been published evaluating the benefits and drawbacks of clearing the common bile duct of stones using a single-stage approach (LCBDE + LC) versus a two-stage approach (ERCP followed by LC). These studies have demonstrated that a single-stage approach offers similar outcomes and morbidities as a two-stage approach, with the added benefit of a lower cost and shorter length of stays. However, it is significant we understand why LCBDE is not commonly performed currently and also the lapse in surgical trainee exposure and competence in LCBDE. This paper aims to address the lapse in surgical trainee exposure to LCBDE, evaluate the scopes currently available to perform LCBDE, and review current data evaluating the risks and benefits of single-stage versus two-stage approaches to. METHODS We utilized PubMed to analyze all publications related to the various disposable scopes utilized to perform choledochoscopy. We also discuss the need for disposable scopes and how this new market niche is transforming the choledochoscopy space. RESULTS We analyzed the data related to single-stage and two-stage approach to choledocholithiasis. We noted an overall shorter length of stay and also decreased costs in favor of a single-stage approach. CONCLUSION A single-stage LCBDE is the most cost-effective treatment option for choledocholithiasis in patients with choledocholithiasis undergoing a cholecystectomy. In addition, single-stage approach is associated with shorter length of stay. Knowledge of the available choledochoscopes and tools available to surgeons to perform choledochoscopy is significant. The evidence does support the use of disposable choledochoscope from a cost and cross-contamination perspective. Additionally, efforts should be made to incorporate LCBDE into the teaching paradigm of surgical training programs.
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Affiliation(s)
| | - Iswanto Sucandy
- Digestive Health Institute at AdventHealth Tampa, Tampa, USA
| | - Andrew Luhrs
- Department of Surgery, Warren Alpert Medical School of Brown University, Providence, USA
| | - Tim Snow
- Sentara Martha Jefferson Hospital, Charlottesville, USA
| | - David Pechman
- Zucker School of Medicine at Hofstra, Northwell Health, Hempstead, USA
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3
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Champavier PG, Beyer-Berjot L, Arnoux PJ, Py M, Casanova R, Berdah S, Birnbaum DJ, Guilbaud T. An Ex Situ Cadaver Liver Training Model Continuously Pressurized to Simulate Specific Skills Involved in Laparoscopic Liver Resection: the Lap-Liver Trainer. J Gastrointest Surg 2023; 27:521-533. [PMID: 36624325 DOI: 10.1007/s11605-022-05566-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 12/17/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Laparoscopic liver resection (LLR) requires delicate skills. The aim of the study was to develop a training model mimicking as much as possible intraoperative bleeding and bile leakage during LLR. We also assessed the educational value of the training model. METHODS The Lap-liver trainer (LLT) combined a continuously pressurized ex situ cadaver liver and a customized mannequin. The customized mannequin was designed by computer-aided design and manufactured by 3D printing. The left lateral sectionectomy (LLS) was chosen to assess the feasibility of a LLR with the LLT. Eighteen volunteers were recruited to perform LLS and to assess the educational value of the LLT using a Likert scale. RESULTS The customized mannequin consisted of a close laparoscopic training device based on a simplified reconstruction of the abdominal cavity in laparoscopic conditions. Ex situ cadaver livers were pressurized to simulate blood and bile supplies. Each expert surgeon (n = 3) performed two LLS. They were highly satisfied of simulation conditions (4.80 ± 0.45) and strongly recommended that the LLT should be incorporated into a teaching program (5.00 ± 0.0). Eight novice and 4 intermediate surgeons completed a teaching program and performed a LLS. Overall, the level of satisfaction was high (4.92 ± 0.29), and performing such a procedure under simulation conditions benefited their learning and clinical practice (4.92 ± 0.29). CONCLUSIONS The LLT could provide better opportunities for trainees to acquire and practice LLR skills in a more realistic environment and to improve their ability to deal with specific events related to LLR.
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Affiliation(s)
| | - Laura Beyer-Berjot
- Aix-Marseille Univ, Univ Gustave Eiffel, LBA, Marseille, France.,Aix-Marseille Univ, Center for Surgical Teaching and Research (CERC), Marseille, France.,Aix-Marseille Univ, APHM, Hôpital Nord, Department of Digestive Surgery, Marseille, France
| | | | - Max Py
- Aix-Marseille Univ, Univ Gustave Eiffel, LBA, Marseille, France
| | | | - Stéphane Berdah
- Aix-Marseille Univ, Univ Gustave Eiffel, LBA, Marseille, France.,Aix-Marseille Univ, Center for Surgical Teaching and Research (CERC), Marseille, France.,Aix-Marseille Univ, APHM, Hôpital Nord, Department of Digestive Surgery, Marseille, France
| | - David Jérémie Birnbaum
- Aix-Marseille Univ, Center for Surgical Teaching and Research (CERC), Marseille, France.,Aix-Marseille Univ, APHM, Hôpital Nord, Department of Digestive Surgery, Marseille, France
| | - Théophile Guilbaud
- Aix-Marseille Univ, Univ Gustave Eiffel, LBA, Marseille, France.,Aix-Marseille Univ, Center for Surgical Teaching and Research (CERC), Marseille, France.,Aix-Marseille Univ, APHM, Hôpital Nord, Department of Digestive Surgery, Marseille, France
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Cano ME, Uad P, Ardiles V, Sanchez Claria R, Mazza O, Palavecino M, de Santibañes E, Pekolj J, de Santibañes M. Impact of resident involvement on patient outcomes in laparoscopic cholecystectomy of different degrees of complexity: analysis of 2331 cases. Surg Endosc 2022; 36:8975-8980. [PMID: 35687252 DOI: 10.1007/s00464-022-09349-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 05/20/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Resident involvement in the operating room is a vital component of their medical education. Laparoscopic cholecystectomy (LC) represents the paradigmatic minimally invasive training procedure, both due to its prevalence and its different forms of complexity. We aim to evaluate whether the supervised participation of residents as operative surgeons in LC of different degrees of complexity affects postoperative outcomes in a university hospital. METHODS This is a retrospective, single-center study that included all consecutive adult (> 18 years old) patients operated for a LC between January 1, 2012 and December 31, 2017. Each surgical procedure was recorded according to the level of complexity that we established in three types of categorization (level 1: elective surgery; level 2: cholecystitis; level 3: biliary instrumentation). Patients were clinically monitored at an outpatient clinic 7 and 30-day postoperative. Postoperative outcomes of patients operated by supervised residents (SR) and trained surgeons (TS) were compared. Postoperative complications were graded according to the Clavien-Dindo classification of surgical complications. RESULTS A total of 2331 patients underwent LC during the study period, of whom 1573 patients (67.5%) were operated by SR and 758 patients (32.5%) by TS. There were no significant differences among age, sex, and BMI between patients operated in both groups, with the exception of ASA (P = 0.0001). Intraoperative cholangiography was performed in 100% of the patients, without bile duct injuries. There were no deaths in the 30 postoperative days. The overall complication rate was 5.70% (133 patients), with no significant differences when comparing LC performed by SR and TS (5.09 vs. 6.99%; P = 0.063). The severity rates of complications were similar in both groups (P = 0.379). Patient readmission showed a statistical difference comparing SR vs TS (0.76% vs. 2.2%; P = 0.010). The postoperative complications rate according to the complexity level of LC was not significant in level 1 and 2 for both groups. However in complexity level 3 the TS group experienced a greater rate of complications compared to the SR group (18.12% vs. 9.38%; P = 0.058). In the multivariate analysis, the participation of the residents as operating surgeons was not independently associated with an increased risk of complications (OR 1.22, 95% CI 0.84-1.77; P = 0.275), neither other risk factors like age ≥ 65 years, BMI, complexity level 2-3, or ASA ≥ 3-4. The association of another surgical procedure with the LC was an independent factor of morbidity (OR 3.85, 95% CI 2.54-5.85; P = 0.000). CONCLUSION Resident involvement in LC with different degrees of complexity did not affect postoperative outcomes. The participation of a resident as operating surgeon is not an independent risk factor and may be considered ethical, safe, and reliable whenever implemented in the background of a residency-training program with continuous supervision and national accreditation. The sum of other procedures not related to a LC should be taken as a risk factor of morbidity.
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Affiliation(s)
- Maria Emilia Cano
- Department of General Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Pedro Uad
- Department of General Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Victoria Ardiles
- Division of HPB Surgery and Liver Transplant Unit, Department of General Surgery, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1181ACH, Buenos Aires, Argentina
| | - Rodrigo Sanchez Claria
- Division of HPB Surgery, Department of General Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Oscar Mazza
- Division of HPB Surgery, Department of General Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Martin Palavecino
- Division of HPB Surgery, Department of General Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Eduardo de Santibañes
- Division of HPB Surgery and Liver Transplant Unit, Department of General Surgery, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1181ACH, Buenos Aires, Argentina
| | - Juan Pekolj
- Division of HPB Surgery and Liver Transplant Unit, Department of General Surgery, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1181ACH, Buenos Aires, Argentina
| | - Martín de Santibañes
- Division of HPB Surgery and Liver Transplant Unit, Department of General Surgery, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1181ACH, Buenos Aires, Argentina.
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Novel advances in surgery for Gallstone Disease. Curr Gastroenterol Rep 2022; 24:89-98. [PMID: 35829827 DOI: 10.1007/s11894-022-00844-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 12/19/2021] [Accepted: 06/08/2022] [Indexed: 10/17/2022]
Abstract
PURPOSE OF REVIEW Examine recent advances in the treatment of patients with complex gallstone disease. RECENT FINDINGS Laparoscopic common bile duct exploration (LCBDE) has been shown to be an effective and safe treatment for choledocholithiasis, resulting in decreased hospital length of stay and costs when compared with ERCP plus laparoscopic cholecystectomy (LC). Novel simulator-based curricula have recently been developed to address the educational gap that has resulted in an underutilization of LCBDE. Patients with cholecystitis who are too ill to safely undergo LC have traditionally been treated with percutaneous cholecystostomy (PC). Endoscopic ultrasound (EUS) guided gallbladder drainage is a novel definitive treatment for such patients and has been shown to result in decreased complications and hospital readmissions compared to PC. The management of symptomatic gallstone disease during pregnancy has evolved over the last several decades. While it is now well established that laparoscopic procedures under general anesthesia are safe throughout a pregnancy, recent studies have suggested that laparoscopic cholecystectomy during the third trimester specifically may result in higher rates of preterm labor when compared with non-operative management. Finally, indocyanine green (ICG) fluorescence cholangiography is a novel imaging modality that has been used during laparoscopic cholecystectomy and may offer better visualization of biliary anatomy during dissection when compared with traditional intraoperative cholangiography. A number of recent technological, procedural, educational, and research innovations have enhanced and expanded treatment options for patients with complex gallstone disease.
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Azoulay D, Eshkenazy R, Pery R, Cordoba M, Haviv Y, Inbar Y, Zisman E, Lahat E, Salloum C, Lim C. The Impact of Establishing a Dedicated Liver Surgery Program at a University-affiliated Hospital on Workforce, Workload, Surgical Outcomes, and Trainee Surgical Autonomy and Academic Output. ANNALS OF SURGERY OPEN 2021; 2:e066. [PMID: 37636559 PMCID: PMC10455269 DOI: 10.1097/as9.0000000000000066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 03/31/2021] [Indexed: 02/07/2023] Open
Abstract
Objective To detail the implementation of a dedicated liver surgery program at a university-affiliated hospital and to analyze its impact on the community, workforce, workload, complexity of cases, the short-term outcomes, and residents and young faculties progression toward technical autonomy and academic production. Background Due to the increased burden of liver tumors worldwide, there is an increased need for liver centers to better serve the community and facilitate the education of trainees in this field. Methods The implementation of the program is described. The 3 domains of workload, research, and teaching were compared between 2-year periods before and after the implementation of the new program. The severity of disease, complexity of procedures, and subsequent morbidity and mortality were compared. Results Compared with the 2-year period before the implementation of the new program, the number of liver resections increased by 36% within 2 years. The number of highly complex resections, the number of liver resections performed by residents and young faculties, and the number of publications increased 5.5-, 40-, and 6-fold, respectively. This was achieved by operating on more severe patients and performing more complex procedures, at the cost of a significant increase in morbidity but not mortality. Nevertheless, operations during the second period did not emerge as an independent predictor of severe morbidity. Conclusions A new liver surgery program can fill the gap between the demand for and supply of liver surgeries, benefiting the community and the development of the next generation of liver surgeons.
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Affiliation(s)
- Daniel Azoulay
- From the Centre Hépato-Biliaire, Hôpital Universitaire Paul Brousse, AP-HP, Université Paris-Saclay, Villejuif, France
- Department of General Surgery B, Chaim Sheba Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Rony Eshkenazy
- Department of General Surgery B, Chaim Sheba Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Israel
- Intensive Care Unit, Sheba Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Ron Pery
- Department of General Surgery B, Chaim Sheba Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Israel
- Department of Surgery, Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN
| | - Mordechai Cordoba
- Department of General Surgery B, Chaim Sheba Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Yael Haviv
- Intensive Care Unit, Sheba Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Yael Inbar
- Department of Radiology, Sheba Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Eliyahu Zisman
- Department of Anesthesiology, Sheba Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Eylon Lahat
- Department of General Surgery B, Chaim Sheba Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Chady Salloum
- From the Centre Hépato-Biliaire, Hôpital Universitaire Paul Brousse, AP-HP, Université Paris-Saclay, Villejuif, France
| | - Chetana Lim
- Department of HPB and Liver Transplantation, Pitié-Salpêtrière Hospital, AP-HP, Paris, France
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Implementation of an educational program for pancreaticoduodenectomy in a university hospital: a retrospective observational study. JOURNAL OF PANCREATOLOGY 2021. [DOI: 10.1097/jp9.0000000000000070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
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Guilbaud T, Fuks D, Berdah S, Birnbaum DJ, Beyer Berjot L. Development of a novel educational tool to assess skills in laparoscopic liver surgery using the Delphi methodology: the laparoscopic liver skills scale (LLSS). Surg Endosc 2021; 36:2321-2333. [PMID: 33871719 DOI: 10.1007/s00464-021-08507-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 04/07/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND No specific performance assessment scales have been reported in laparoscopic liver resection. This study aimed at developing an objective scale specific for the assessment of technical skills for wedge resection in anterior segments (WRAS) and left lateral sectionectomy (LLS). METHODS A laparoscopic liver skills scale (LLSS) was developed using a hierarchical task analysis. A Delphi method obtained consensus among five international experts on relevant steps that should be included into the LLSS for assessment of operative performances. The consensus was predefined using Cronbach's alpha > 0.80. RESULTS A semi-structured review extracted 15 essential subtasks for full laparoscopic WRAS and LLS for evaluation in the Delphi survey. Two rounds of the survey were conducted. Three over 15 subtasks did not reach the predefined level of consensus. Based on the expert's comments, 13 subtasks were reformulated, 4 subtasks were added, and a revised skills scale was developed. After the 2nd round survey (Cronbach's alpha 0.84), 19 subtasks were adopted. The LLSS was composed of three main parts: patient positioning and intraoperative preparation (task 1 to 8), the core part of the WRAS and LLS procedure (tasks 9 to 14), and completion of procedure (task 15 to 19). CONCLUSIONS The LLSS was developed for measuring the skill set for the education of safe and secure laparoscopic WRAS and LLS procedures in a dedicated training program. After validation, this scale could be also used as an assessment tool in the operating room and extrapolated as an operative roadmap to other complex procedures.
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Affiliation(s)
- Théophile Guilbaud
- Department of Digestive Surgery, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille Université, Chemin Des Bourrely, 13015, Marseille, France. .,Center for Surgical Teaching and Research (CERC), Aix-Marseille University, Marseille, France.
| | - David Fuks
- Department of Digestive, Oncological and Metabolic Surgery, Institut Mutualiste Montsouris, Université Paris Descartes, 42 Boulevard Jourdan, 75014, Paris, France
| | - Stéphane Berdah
- Department of Digestive Surgery, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille Université, Chemin Des Bourrely, 13015, Marseille, France.,Center for Surgical Teaching and Research (CERC), Aix-Marseille University, Marseille, France
| | - David Jérémie Birnbaum
- Department of Digestive Surgery, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille Université, Chemin Des Bourrely, 13015, Marseille, France.,Center for Surgical Teaching and Research (CERC), Aix-Marseille University, Marseille, France
| | - Laura Beyer Berjot
- Department of Digestive Surgery, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille Université, Chemin Des Bourrely, 13015, Marseille, France.,Center for Surgical Teaching and Research (CERC), Aix-Marseille University, Marseille, France
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Rowcroft A, Joh D, Pandanaboyana S, Loveday B. Hepato-pancreato-biliary and transplant surgery experience among New Zealand general surgery trainees. ANZ J Surg 2021; 91:1125-1130. [PMID: 33682311 DOI: 10.1111/ans.16714] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 02/16/2021] [Accepted: 02/16/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND Subspecialty surgery experience during general surgery training in Australasia is influenced by many factors, including duration of training, training location and the introduction of post-fellowship training programmes. Experience in hepato-pancreato-biliary (HPB) and transplant surgery is part of the general surgery curriculum, although trainee experience in these subspecialties has not been quantified in this region, which is relevant to post-fellowship training programmes. Therefore, the aim of this study was to quantify the HPB and transplant operative experience of New Zealand (NZ) general surgery trainees. METHODS Operative logbook data were analysed for all NZ trainees from 2013 to 2017, including procedures categorized as pancreatic, biliary, hepatic and transplant surgery only. The number of cases within each category was used to model the cumulative operative experience over a 5-year training programme. RESULTS During the study period, 118 trainees (303 trainee years) recorded 15 662 HPB and transplant procedures. Of these, 13 838 (88.4%) were cholecystectomies (mean cumulative experience 219.3 cases). Excluding cholecystectomy, trainees had a mean cumulative experience of 5.7 biliary, 7.5 pancreatic, 8.1 liver and 4.2 transplant procedures during their training. Transplant experience was predominantly access for peritoneal dialysis (228/260, 86.7%), with cumulative transplant experience otherwise reaching 0.47 procedures over 5 years. CONCLUSION Exposure to HPB and transplant surgery during general surgery training in NZ is limited beyond cholecystectomy. Additional exposure during post-fellowship training is likely required for general surgeons to practice in these subspecialties.
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Affiliation(s)
- Alistair Rowcroft
- Department of Surgery, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Daniel Joh
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Sanjay Pandanaboyana
- Department of Surgery, University of Auckland, Auckland, New Zealand.,HPB and Transplant Unit, Freeman Hospital, Newcastle Upon Tyne, UK
| | - Benjamin Loveday
- Department of Surgery, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Surgery, University of Auckland, Auckland, New Zealand.,Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
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10
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Brewer JO, Navaratne L, Marchington SW, Martínez Cecilia D, Quiñones Sampedro J, Muñoz Bellvis L, Isla AM. Porcine Aorto-Renal Artery (PARA) model for laparoscopic transcystic common bile duct exploration: the evolution of a training model to meet new clinical needs. Langenbecks Arch Surg 2021; 406:1149-1154. [PMID: 33595704 PMCID: PMC8208912 DOI: 10.1007/s00423-020-02045-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 11/25/2020] [Indexed: 10/29/2022]
Abstract
BACKGROUND The transcystic approach to laparoscopic common bile duct exploration has gained popularity for the single-stage management of choledocholithiasis with concomitant gallstones. Our team previously described the use of a porcine aorta segment to simulate the common bile duct during laparoscopic skill training. METHODS With the advent of the transcystic approach as a contender for the first-line technique of accessing the common bile duct, we present an evolution of the laparoscopic training model using a Porcine Aorta-Renal Artery (PARA) specimen to simulate the structural integrity, dimensions and spatial distribution of both the human cystic and common bile ducts. RESULTS This training model allows the use of a choledochoscope for transcystic exploration of the biliary tree. It combines fidelity and reproducibility required for a simulated training model to offer experience in laparoscopic transcystic common bile duct exploration. Validation of the model was demonstrated by 21 surgeons who completed a questionnaire after performing the simulated procedure. In all sections assessing reliability, face validity and content validity of the model, mean rating scores were between 4 and 5 out of five (good or excellent). CONCLUSIONS We present the evolution of an established training model for laparoscopic common bile duct exploration which focusses the attention on the transcystic approach to the common bile duct and the use of lithotripsy techniques. The need for such a model reflects the shift in the current practice of the laparoendoscopic management of choledocholithiasis with concomitant gallstones from transductal to transcystic approach.
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Affiliation(s)
- James O Brewer
- Department of Upper Gastrointestinal Surgery, Northwick Park Hospital, London North West University Healthcare NHS Trust, Watford Road, Harrow, London, HA1 3UJ, UK
| | - Lalin Navaratne
- Department of Upper Gastrointestinal Surgery, Northwick Park Hospital, London North West University Healthcare NHS Trust, Watford Road, Harrow, London, HA1 3UJ, UK.,Defence Medical Services, Birmingham, UK
| | | | | | | | | | - Alberto Martínez Isla
- Department of Upper Gastrointestinal Surgery, Northwick Park Hospital, London North West University Healthcare NHS Trust, Watford Road, Harrow, London, HA1 3UJ, UK. .,Department of Surgery and Cancer, Imperial College London, London, UK.
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11
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Rashidian N, Willaert W, Van Herzeele I, Morise Z, Alseidi A, Troisi RI, Doyle MB, Briceño-Delgado J, Calise F, Ceppa EP, Chen KH, Cherqui D, Cheung TT, Lin CCW, Cleary S, David Kwon CH, Dominguez-Rosado I, Ferrero A, Warner SG, Grazi GL, Hammill C, Han HS, Hansen P, Helton S, Itano O, Jafarian A, Jeyarajah R, Kaneko H, Kato Y, Kubo S, Li J, Lucidi V, Majno P, Maynard E, Montalti R, Nadalin S, Nitta H, Otsuka Y, Rotellar F, Samstein B, Soubrane O, Sugioka A, Tanabe M, Torzilli G, Vanlander A, Wakabayashi G. Key components of a hepatobiliary surgery curriculum for general surgery residents: results of the FULCRUM International Delphi consensus. HPB (Oxford) 2020; 22:1429-1441. [PMID: 32060009 DOI: 10.1016/j.hpb.2020.01.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 01/13/2020] [Accepted: 01/19/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND In general surgery residency, hepatobiliary training varies significantly across the world. The aim of this study was to establish an international consensus among hepatobiliary surgeons on components of a hepatobiliary curriculum for general surgery residents. METHODS A three-round modified Delphi technique was employed. Fifty-two hepatobiliary surgeons involved in general surgery training programs were invited. An initial questionnaire was developed by a group of experts in hepatobiliary and educational research after a systematic literature review. It comprised 90 statements about knowledge, technical skills, attitudes, and postoperative care. Panelists could add or alter items. The survey was delivered electronically and the panel was instructed to score the items based on 5-point Likert scale. Consensus was reached when at least 80% of panelists agreed on a statement with Cronbach's alpha value >0.8. RESULTS Forty-one (79%) experts have participated. Sixteen panelists are based in Asia, 14 in Europe, and 11 in the Americas. Eighty percent of all proposed skills (81/101) were considered fundamental including knowledge (39/43), technical skills (16/32), attitude (15/15), and postoperative care (11/11). CONCLUSION An international consensus was achieved on components of a hepatobiliary curriculum. Acquiring broad knowledge is fundamental during residency. Advanced liver resection techniques require specialized hepatobiliary training.
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Affiliation(s)
- Nikdokht Rashidian
- Department of Human Structure and Repair, Ghent University Faculty of Medicine, Belgium; Department of Gastrointestinal Surgery, Ghent University Hospital, Belgium
| | - Wouter Willaert
- Department of Human Structure and Repair, Ghent University Faculty of Medicine, Belgium; Department of Gastrointestinal Surgery, Ghent University Hospital, Belgium
| | - Isabelle Van Herzeele
- Department of Human Structure and Repair, Ghent University Faculty of Medicine, Belgium; Department of Thoracic and Vascular Surgery, Ghent University Hospital, Belgium
| | - Zenichi Morise
- Department of Surgery, Fujita Health University School of Medicine, Toyoake, Japan
| | - Adnan Alseidi
- Division of Pancreas, Liver and Biliary Surgery, Virginia Mason Medical Center, Seattle, USA
| | - Roberto I Troisi
- Department of Human Structure and Repair, Ghent University Faculty of Medicine, Belgium; Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy; Organ Transplant Center, King Faisal Specialist Hospital and Research Center and Al Faisal University, Riyadh, Saudi Arabia.
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Single-stage management of choledocholithiasis: intraoperative ERCP versus laparoscopic common bile duct exploration. Surg Endosc 2020; 34:4616-4625. [PMID: 31617103 DOI: 10.1007/s00464-019-07215-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 10/09/2019] [Indexed: 01/25/2023]
Abstract
BACKGROUND Laparoscopic cholecystectomy (LC) is the criterion standard for treating patients with symptomatic gallstone disease; however, the optimal technique for extracting common bile duct stones remains unclear. Recent studies have noted improved outcomes with single-stage techniques, such as intraoperative endoscopic retrograde cholangiopancreatography (iERCP) and laparoscopic common bile duct exploration (LCBDE); however only few studies have directly compared those two single-stage techniques. OBJECTIVES Using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database, we retrospectively analyzed the postoperative outcomes of all patients who underwent single-stage LC for choledocholithiasis from 2005 to 2017. Using Current Procedural Terminology (CPT) codes, as well as International Classification of Diseases, Ninth Revision (ICD-9) and 10th Revision (ICD-10) codes, we stratified patients into two cohorts: those who underwent iERCP and LCBDE. Applying univariate techniques, we evaluated baseline characteristics and postoperative outcomes for both cohorts. Our primary outcomes of interest were 30-day morbidity and 30-day mortality; our secondary outcomes included rates of reoperation, readmission, operative time, and hospital length of stay. RESULTS Of the 1814 single-stage LC patients during our 13-year study period, 1185 (65.3%) underwent LCBDE; 629 (34.6%) underwent iERCP. Our univariate analysis showed that the two cohorts were homogeneous in terms of baseline characteristics, including demographics, preoperative comorbidities, laboratory values, and American Society of Anesthesiologists (ASA) scores. 30-day postoperative morbidity (including infectious and noninfectious complications) and overall mortality between groups were low and comparable. The mean operative time was slightly longer with LCBDE (125.1 ± 62.0 min) than iERCP (113.5 ± 65.2 min; P < 0.001), however the mean hospital length of stay, readmission rate, and reoperation rate were similar. CONCLUSION We found that both iERCP and LCBDE resulted in low, comparable rates of morbidity and mortality. Centers with readily available endoscopic expertise might favor iERCP for its ease of access and shorter operative time. However, LCBDE remains an appropriate technique for patients with choledocholithiasis, especially when immediate endoscopic intervention is unavailable.
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Learning Curve in Laparoscopic Liver Resection, Educational Value of Simulation and Training Programmes: A Systematic Review. World J Surg 2020; 43:2710-2719. [PMID: 31384997 DOI: 10.1007/s00268-019-05111-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The laparoscopic approach is widely accepted as the procedure of choice for abdominal surgery. However, laparoscopic liver resection (LLR) has advanced slowly due to the significant learning curve (LC), and only few publications have dealt with advanced training in LLR. METHODS Two reviewers conducted systematic research through MEDLINE and EMBASE with combinations of the following keywords: (learning curve OR teaching OR training OR simulation OR education) AND (liver OR hepatic) AND (laparoscopic OR laparoscopy). Robotic-assisted, hand-assisted and hybrid LLRs were excluded. RESULTS Nineteen studies were retrieved. Overall, the level of evidence was low. Thirteen articles assessed the LC during real-life LLR, and six articles focussed on simulation and training programmes in LLR. The LC in minor LLR comprised 60 cases overall, and 15 cases for standardised left lateral sectionectomy. For major LLR (MLLR), the LC was 50 cases for most studies, but was reported to be 15-20 cases in more recent studies, provided MLLR is performed progressively in selected patients. However, there was heterogeneity in the literature regarding the number of minor LLRs required before MLLR, with 60 minor LLRs reported as the minimum. Six studies showed a potential benefit of simulation and training programmes in this field. The gradual implementation of LLR combined with simulation-based training programmes could reduce the clinical impact of LC. CONCLUSIONS The LC in LLR is a long process, and MLLR should be gradually implemented under the supervision of experienced surgeons. Training outside the operating room may reduce the LC in real-life situations.
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Cortez AR, Winer LK, Katsaros GD, Kassam AF, Shah SA, Diwan TS, Cutler Quillin R. Resident Operative Experience in Hepatopancreatobiliary Surgery: Exposing the Divide. J Gastrointest Surg 2020; 24:796-803. [PMID: 31012042 DOI: 10.1007/s11605-019-04226-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 03/29/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND The Accreditation Council for Graduate Medical Education (ACGME) requires an experience in hepatopancreatobiliary (HPB) surgery as part of general surgery residency training. The composition of this experience, however, is unclear. We set out to evaluate current trends in the HPB experience of US general surgery residents. METHODS National ACGME operative case logs from 1990 to 2016 were examined with a focus on the HPB operative domains. Time-trend analysis was performed using ANOVA and linear regression analysis. RESULTS Median biliary, liver, and pancreatic operative volumes increased by 30%, 33%, and 27% over the 27-year study period (all p < 0.05). Both core and advanced HPB cases increased, but the rate of increase for core was four times greater than that of advanced. However, when cholecystectomy was excluded, this trend reversed such that HPB core operations decreased by 11 cases over the study period. Further analysis demonstrated that laparoscopic cholecystectomy comprised 90% of all biliary cases and 77% of all HPB cases for graduates in 2016. Finally, operative volume variability-the difference in case numbers between high and low volume residents-increased by 16%, 21%, and 73% for the biliary, liver, and pancreatic domains, respectively (all p < 0.05). CONCLUSIONS Despite increases in overall HPB operative volume, the HPB experience is changing for today's surgical trainees. Moreover, the HPB experience is comprised largely of a single operation-the cholecystectomy. Awareness of these trends is important for surgical educators to facilitate adequate exposure to HPB surgery among general surgery residents.
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Affiliation(s)
- Alexander R Cortez
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, 231 Albert Sabin Way, ML 0558, Cincinnati, OH, 45267-0558, USA.
| | - Leah K Winer
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, 231 Albert Sabin Way, ML 0558, Cincinnati, OH, 45267-0558, USA
| | - Gianna D Katsaros
- Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Al-Faraaz Kassam
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, 231 Albert Sabin Way, ML 0558, Cincinnati, OH, 45267-0558, USA
| | - Shimul A Shah
- Division of Transplantation, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Tayyab S Diwan
- Division of Transplantation, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - R Cutler Quillin
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, 231 Albert Sabin Way, ML 0558, Cincinnati, OH, 45267-0558, USA
- Division of Transplantation, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
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Simpson RE, Carpenter KL, Wang CY, Schmidt CM, Kilbane EM, Colgate CL, House MG, Zyromski NJ, Schmidt CM, Nakeeb A, Ceppa EP. Is resident assistance equivalent to fellows during hepatectomy? Surg Endosc 2020; 35:260-269. [PMID: 31993809 DOI: 10.1007/s00464-020-07388-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 01/10/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Hepatectomy is a complex operative procedure frequently performed at academic institutions with trainee participation. The aim of this study was to determine the effect of assistant's training level on outcomes following hepatectomy. METHODS A retrospective review of a prospective, single-institution ACS-NSQIP database was performed for patients that underwent hepatectomy (2013-2016). Patients were divided by trainee assistant level: hepatopancreatobiliary (HPB) fellow versus general surgery resident (PGY 4-5). Demographic, perioperative, and 30-day outcome variables were compared using Chi-Square/Fisher's exact, Mann-Whitney U test, and multivariable regression. Cases involving a senior-level general surgery resident or HPB fellow as first assistant were included (n = 352). Those with a second attending, junior-level resident, or no documented assistant were excluded (n = 39). RESULTS Patients undergoing hepatectomy with an HPB fellow as primary assistant had more frequent preoperative biliary stenting, longer operative time, and more concomitant procedures including biliary reconstruction, resulting in a higher rate of post-hepatectomy liver failure (PHLF) (15% vs. 8%, P = 0.044). However, trainee level did not impact PHLF on multivariable analysis (OR 0.60, 95% CI [0.29-1.25], P = 0.173). Fellows assisted with proportionally more major hepatectomies (45% vs. 31%; P = 0.010) and resections for hepatobiliary cancers (31% vs. 19%, P = 0.014). On stratified analysis of major and minor hepatectomies, outcomes were similar between trainee groups. CONCLUSION Fellows performed higher complexity cases with longer operative time. Despite these differences, outcomes were similar regardless of assistant training level. Resident and HPB fellow participation in operations requiring liver resection provide comparable quality of care.
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Affiliation(s)
- Rachel E Simpson
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., Emerson Hall 541, Indianapolis, IN, 46202, USA
| | - Kyle L Carpenter
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., Emerson Hall 541, Indianapolis, IN, 46202, USA
| | - Christine Y Wang
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., Emerson Hall 541, Indianapolis, IN, 46202, USA
| | - Christian M Schmidt
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., Emerson Hall 541, Indianapolis, IN, 46202, USA
| | - E Molly Kilbane
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., Emerson Hall 541, Indianapolis, IN, 46202, USA
| | - Cameron L Colgate
- Center for Outcomes Research in Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Michael G House
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., Emerson Hall 541, Indianapolis, IN, 46202, USA
| | - Nicholas J Zyromski
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., Emerson Hall 541, Indianapolis, IN, 46202, USA
| | - C Max Schmidt
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., Emerson Hall 541, Indianapolis, IN, 46202, USA
| | - Attila Nakeeb
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., Emerson Hall 541, Indianapolis, IN, 46202, USA
| | - Eugene P Ceppa
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., Emerson Hall 541, Indianapolis, IN, 46202, USA.
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Teitelbaum EN, Barsness KA, Hungness ES. Mastery Learning of Surgical Skills. COMPREHENSIVE HEALTHCARE SIMULATION: MASTERY LEARNING IN HEALTH PROFESSIONS EDUCATION 2020. [DOI: 10.1007/978-3-030-34811-3_12] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Gimm O, Barczyński M, Mihai R, Raffaelli M. Training in endocrine surgery. Langenbecks Arch Surg 2019; 404:929-944. [PMID: 31701231 PMCID: PMC6935392 DOI: 10.1007/s00423-019-01828-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 09/20/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND/PURPOSE In Europe, the Division of Endocrine Surgery (DES) determines the number of operations (thyroid, neck dissection, parathyroids, adrenals, neuroendocrine tumors of the gastro-entero-pancreatic tract (GEP-NETs)) to be required for the European Board of Surgery Qualification in (neck) endocrine surgery. However, it is the national surgical boards that determine how surgical training is delivered in their respective countries. There is a lack of knowledge on the current situation concerning the training of surgical residents and fellows with regard to (neck) endocrine surgery in Europe. METHODS A survey was sent out to all 28 current national delegates of the DES. One questionnaire was addressing the training of surgical residents while the other was addressing the training of fellows in endocrine surgery. Particular focus was put on the numbers of operations considered appropriate. RESULTS For most of the operations, the overall number as defined by national surgical boards matched quite well the views of the national delegates even though differences exist between countries. In addition, the current numbers required for the EBSQ exam are well within this range for thyroid and parathyroid procedures but below for neck dissections as well as operations on the adrenals and GEP-NETs. CONCLUSIONS Training in endocrine surgery should be performed in units that perform a minimum of 100 thyroid, 50 parathyroid, 15 adrenal, and/or 10 GEP-NET operations yearly. Fellows should be expected to have been the performing surgeon of a minimum of 50 thyroid operations, 10 (central or lateral) lymph node dissections, 15 parathyroid, 5 adrenal, and 5 GEP-NET operations.
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Affiliation(s)
- Oliver Gimm
- Department of Surgery and Department of Clinical and Experimental Medicine (IKE), Linköping University, 58183 Linköping, Sweden
| | - Marcin Barczyński
- Department of Endocrine Surgery, Third Chair of Surgery, Jagiellonian University Medical College, 37 Prądnicka Street, 31-202 Kraków, Poland
| | - Radu Mihai
- Department of Endocrine Surgery, Churchill Cancer Centre, Oxford University Hospital NHS Foundation Trust, Oxford, OX3 7DU United Kingdom
| | - Marco Raffaelli
- U.O. Chirurgia Endocrina e Metabolica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Semeiotica Chirurgica, Università Cattolica del Sacro Cuore, Rome, Italy
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Abstract
While adrenal tumors are common, adrenalectomy is rather uncommon. This is one reason for the many challenges regarding the training of adrenal surgery. Here we focus on issues that are most pertinent regarding training of the young surgeons performing adrenalectomy. Due to the very limited literature, what is presented is mainly based on personal experience and/or from the literature published for other surgical operations and subspecialties. The discussed challenges include indications for surgery, surgical approaches and extent, and intraoperative complications. With advances in adrenal surgery, we expect some old challenges to be resolved, and some new challenges to arise. These challenges will be faced in order to continue to help our younger trainee acquire the knowledge and skills to best care for our patients with adrenal diseases.
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Affiliation(s)
- Oliver Gimm
- Department of Surgery and Department of Clinical and Experimental Medicine, Medical Faculty, Linköping University, Linköping, Sweden
| | - Quan-Yang Duh
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco, CA, USA
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Khan AA, Rakinic J, Kim RH, Mellinger JD, Ganai S. National Trends in General Surgery Resident Exposure to Complex Oncology-Relevant Cases. JOURNAL OF SURGICAL EDUCATION 2019; 76:378-386. [PMID: 30253983 DOI: 10.1016/j.jsurg.2018.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 07/19/2018] [Accepted: 09/01/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To evaluate trends in surgical resident exposure to complex oncologic procedures in order to determine whether additional fellowship training is necessary. DESIGN An observational study of national Accreditation Council for Graduate Medical Education case log statistical reports was conducted to determine the average number of cases for selected oncology-relevant procedures completed during training. Linear regression and Cusick trend tests were used to assess temporal trends with the null hypothesis assuming an estimated slope of zero. Instrumental variable estimation was used to study the effect of duty-hour restrictions on oncologic cases per year. SETTING United States general surgery residency training programs. PARTICIPANTS Graduating surgical residents completing their training between 2000 and 2016. RESULTS Across the study interval, mean case volume was 950.6 ± 29.7 (standard deviation) cases with 38.9 ± 3.1 complex oncologic cases per graduating resident. Decreasing trends were noted for average exposure to lymphadenectomies (-7.8 cases/decade; 95% confidence interval [CI] -8.8 to -6.8) and low rectal procedures (-0.9 cases/decade; 95% CI -1.2 to -0.6). There was no clinically important change in complex soft-tissue resections and foregut cases. A significant increase was seen in number of hepatopancreaticobiliary procedures (+3.9 cases/decade; 95% CI 3.1-4.7). Using instrumental variable estimation, there was a modest decline in cancer-relevant cases by 5.0 cases/decade (95% CI 4.5-5.6), while there was an increase in 38.5 total cases/decade (95% CI 10.4-66.7) associated with duty-hour restrictions. CONCLUSIONS Case numbers for several complex oncologic procedures remain low, justifying a need for further fellowship training depending on individual resident experience.
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Affiliation(s)
- Amir A Khan
- Department of Surgery, Southern Illinois University School of Medicine, Springfield, Illinois
| | - Jan Rakinic
- Department of Surgery, Southern Illinois University School of Medicine, Springfield, Illinois
| | - Roger H Kim
- Department of Surgery, Southern Illinois University School of Medicine, Springfield, Illinois
| | - John D Mellinger
- Department of Surgery, Southern Illinois University School of Medicine, Springfield, Illinois
| | - Sabha Ganai
- Department of Surgery, Southern Illinois University School of Medicine, Springfield, Illinois; Department of Population Science and Policy, Southern Illinois University School of Medicine, Springfield, Illinois.
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Ülger BV, Hatipoğlu ES, Ertuğrul Ö, Tuncer MC, Özmen CA, Gül M. Variations in the vascular and biliary structures of the liver: a comprehensive anatomical study. Acta Chir Belg 2018; 118:354-371. [PMID: 29433396 DOI: 10.1080/00015458.2018.1438565] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
PURPOSE Vascular structures of the liver and the bile ducts are crucial during liver transplantation or liver resection surgery. Here, we report on variations in the vascular structures and bile ducts of 200 patients. MATERIALS AND METHODS We reviewed magnetic resonance cholangiopancreatographic and multiple-detector computed tomographic data. RESULTS Michels type 1 was detected in 54% of the patients. The other most common variations were, respectively, Michels type 5 (13%) and type 2 (11%). Unclassified variations were defined as Michels type 11; 5% of patients were in this group. Type 1 variations in the hepatic portal vein were detected in 76% of our study group. Other common variations were type 2 (9%) and type 3 (8.5%). The left and intermediate hepatic veins united to become a single vein and then joined the inferior vena cava in 64% of the patients. The right, intermediate, and left hepatic veins joined the inferior vena cava separately in 36% of the patients. Type A, which represents the classic anatomy of the bile duct, was observed in 51.5% of our patients. Type C1 and type B were detected in 15% and 12% of patients, respectively. CONCLUSIONS We describe vascular and biliary variations in the livers of our patients.
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Affiliation(s)
- Burak Veli Ülger
- Department of General Surgery, University of Dicle, Faculty of Medicine, Diyarbakır, Turkey
| | - Eyüp Savaş Hatipoğlu
- Department of Anatomy, Faculty of Medicine, University of Dicle, Diyarbakır, Turkey
| | - Özgür Ertuğrul
- Department of Radiology, Memorial Hospital, Diyarbakır, Turkey
| | - Mehmet Cudi Tuncer
- Department of Anatomy, Faculty of Medicine, University of Dicle, Diyarbakır, Turkey
| | - Cihan Akgül Özmen
- Department of Radiology, Faculty of Medicine, University of Dicle, Diyarbakır, Turkey
| | - Mesut Gül
- Department of General Surgery, University of Dicle, Faculty of Medicine, Diyarbakır, Turkey
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Single-stage laparoscopic management of choledocholithiasis: An analysis after implementation of a mastery learning resident curriculum. Surgery 2017; 163:503-508. [PMID: 29191675 DOI: 10.1016/j.surg.2017.10.006] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 09/13/2017] [Accepted: 10/06/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Laparoscopic common bile duct exploration is an underutilized treatment for choledocholithiasis. We sought to evaluate the impact of a simulation-based mastery-learning curriculum for surgical residents on laparoscopic common bile duct exploration utilization and to compare outcomes for patients treated with laparoscopic common bile duct exploration versus endoscopic retrograde cholangiopancreatography (ERCP). METHODS The number of laparoscopic common bile duct explorations performed before and after curriculum implementation was reviewed and outcomes were compared between patients with choledocholithiasis managed with laparoscopic common bile duct exploration and endoscopic retrograde cholangiopancreatography. Based on cost savings from increased utilization of laparoscopic common bile duct exploration, the annual return on investment associated with the curriculum was calculated. RESULTS Twenty-two residents completed the curriculum. In the pre-curriculum period, an average of 1.7 laparoscopic common bile duct explorations was performed yearly, which increased to 8.4 cases per year after curriculum implementation (P < .05). Identified were 155 patients with choledocholithiasis: 31 underwent laparoscopic common bile duct exploration plus laparoscopic cholecystectomy and 124 underwent endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy. The laparoscopic common bile duct exploration and laparoscopic cholecystectomy group had a reduced duration of stay (2.5 ± 1.8 days versus 4.3 ± 2.2 days, P < .0001) and costs ($12,987 ± $3,286 versus $15,022 ± $4,613, P = .01) compared with endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy. Rates of readmission and reoperation were equivalent between groups. Cost savings were more than $38,000, resulting in a 3.8 to 1 return on investment from curriculum implementation. CONCLUSION A simulation-based mastery-learning curriculum increased institutional utilization of laparoscopic common bile duct exploration and adoption of the curriculum resulted in positive return on investment.
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Tam V, Zenati M, Novak S, Chen Y, Zureikat AH, Zeh HJ, Hogg ME. Robotic Pancreatoduodenectomy Biotissue Curriculum has Validity and Improves Technical Performance for Surgical Oncology Fellows. JOURNAL OF SURGICAL EDUCATION 2017; 74:1057-1065. [PMID: 28578981 DOI: 10.1016/j.jsurg.2017.05.016] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 04/26/2017] [Accepted: 05/21/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE Obtaining the proficiency on the robotic platform necessary to safely perform a robotic pancreatoduodenectomy is particularly challenging. We hypothesize that by instituting a proficiency-based robotic training curriculum we can enhance novice surgeons' skills outside of the operating room, leading to a shorter learning curve. DESIGN A biotissue curriculum was designed consisting of sewing artificial organs to simulate a hepaticojejunostomy (HJ), gastrojejunostomy (GJ), and pancreaticojejunostomy (PJ). Three master robotic surgeons performed each biotissue anastomosis to assess validity. Using video review, trainee performance on biotissue drills was evaluated for time, errors and objective structured assessment of technical skills (OSATS) by 2 blinded graders. SETTING This study is conducted at the University of Pittsburgh Medical Center (Pittsburgh, PA), a tertiary care academic teaching hospital. PARTICIPANTS In total, 14 surgical oncology fellows completed the biotissue curriculum. RESULTS Fourteen fellows performed 196 anastomotic drills during the first year: 66 (HJ), 64 (GJ), and 66 (PJ). The fellows' performances were analyzed as a group by attempt. The attendings' first attempt outperformed the fellows' first attempt in all metrics for every drill (all p < 0.05). More than 5 analyzed attempts of the HJ, there was improvement in time, errors, and OSATS (all p < 0.01); however, no metric reached attending performance. For the GJ, time, errors, and OSATS all improved more than 5 attempts (all p < 0.01), whereas only errors and OSATS reached proficiency. For the PJ, errors and OSATS both improved over attempts (p < 0.01) and reached proficiency; however, time did not statistically improve nor reach proficiency. The graders scoring correlated for errors and OSATS (p < 0.0001). CONCLUSION A pancreatoduodenectomy biotissue curriculum has face and construct validity. The curriculum is feasible and improves errors and technical performance. Time is the most difficult technical parameter to improve. This curriculum is a valid tool for teaching robotic pancreatoduodenectomies with established milestones for reaching optimum performance.
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Affiliation(s)
- Vernissia Tam
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Mazen Zenati
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Stephanie Novak
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Yong Chen
- Hepatobiliary Surgery Department, Chongqing Medical University Affiliated First Hospital, Chongqing, China
| | - Amer H Zureikat
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Herbert J Zeh
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Melissa E Hogg
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
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Schwab B, Hungness E, Barsness KA, McGaghie WC. The Role of Simulation in Surgical Education. J Laparoendosc Adv Surg Tech A 2017; 27:450-454. [DOI: 10.1089/lap.2016.0644] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Ben Schwab
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Eric Hungness
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Katherine Ann Barsness
- Division of Pediatric Surgery, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - William Craig McGaghie
- Department of Medical Education, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Schwab B, Rooney DM, Hungness ES, Barsness KA. Preliminary Evaluation of a Laparoscopic Common Bile Duct Simulator for Pediatric Surgical Education. J Laparoendosc Adv Surg Tech A 2016; 26:831-835. [PMID: 27607145 DOI: 10.1089/lap.2016.0248] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
PURPOSE Laparoscopic common bile duct exploration (LCBDE) decreases overall costs and length of stay in patients with choledocolithiasis. However, utilization of LCBDE remains low. We sought to evaluate a previously developed general surgery LCBDE simulator among a cohort of pediatric surgical trainees. The study purpose was to evaluate the content validity of an LCBDE simulator to support or refute its use in pediatric surgery education. MATERIALS AND METHODS After IRB exempt determination, 30 participants performed a transcystic LCBDE using a previously developed simulator and evaluated the simulator using a self-reported 28-item instrument. The instrument consisted of two primary domains (Quality and Ability to Perform) that were rated using twenty-five 4-point rating scales and one 4-point global rating scale. Validity evidence relevant to test content was evaluated using a many-facet Rasch model. Interitem consistency was estimated using Cronbach's alpha. P < .05 was considered statistically significant. RESULTS The highest combined observed averages were for the Value subdomain (OA = 3.79), whereas the lowest ratings were for the Physical/visual attributes subdomain (OA = 3.19). The averaged global rating was 3.14, consistent with this simulator can be considered for use in pediatric LCBDE training, but could be improved slightly. Rasch indices were favorable and supported evidence relevant to test content. Interitem consistency estimates were also favorable, with α values of 0.94 and 0.56 for Qualities and Ability, respectively. CONCLUSIONS Overall, participants rated the LCBDE simulator highly valuable for pediatric surgical education and felt that it could be used as an educational tool with minor modifications.
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Affiliation(s)
- Ben Schwab
- 1 Department of Surgery and Medical Education, Northwestern University Feinberg School of Medicine , Chicago, Illinois
| | - Deborah M Rooney
- 2 Department of Learning Health Sciences, University of Michigan Medical School , Ann Arbor, Michigan
| | - Eric S Hungness
- 1 Department of Surgery and Medical Education, Northwestern University Feinberg School of Medicine , Chicago, Illinois
| | - Katherine A Barsness
- 3 Department of Surgery and Medical Education, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine , Chicago, Illinois
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Zheng YX, Yu DF, Zhao JG, Wu YL, Zheng B. 3D Printout Models vs. 3D-Rendered Images: Which Is Better for Preoperative Planning? JOURNAL OF SURGICAL EDUCATION 2016; 73:518-523. [PMID: 26861582 DOI: 10.1016/j.jsurg.2016.01.003] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2015] [Revised: 11/08/2015] [Accepted: 01/05/2016] [Indexed: 06/05/2023]
Abstract
INTRODUCTION Correct interpretation of a patient's anatomy and changes that occurs secondary to a disease process are crucial in the preoperative process to ensure optimal surgical treatment. In this study, we presented 3 different pancreatic cancer cases to surgical residents in the form of 3D-rendered images and 3D-printed models to investigate which modality resulted in the most appropriate preoperative plan. METHODS We selected 3 cases that would require significantly different preoperative plans based on key features identifiable in the preoperative computed tomography imaging. 3D volume rendering and 3D printing were performed respectively to create 2 different training ways. A total of 30, year 1 surgical residents were randomly divided into 2 groups. Besides traditional 2D computed tomography images, residents in group A (n = 15) reviewed 3D computer models, whereas in group B, residents (n = 15) reviewed 3D-printed models. Both groups subsequently completed an examination, designed in-house, to assess the appropriateness of their preoperative plan and provide a numerical score of the quality of the surgical plan. RESULTS Residents in group B showed significantly higher quality of the surgical plan scores compared with residents in group A (76.4 ± 10.5 vs. 66.5 ± 11.2, p = 0.018). This difference was due in large part to a significant difference in knowledge of key surgical steps (22.1 ± 2.9 vs. 17.4 ± 4.2, p = 0.004) between each group. All participants reported a high level of satisfaction with the exercise. CONCLUSION Results from this study support our hypothesis that 3D-printed models improve the quality of surgical trainee's preoperative plans.
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Affiliation(s)
- Yi-xiong Zheng
- Department of Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Di-fei Yu
- Department of Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Jian-gang Zhao
- Department of Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Yu-lian Wu
- Department of Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China.
| | - Bin Zheng
- Department of Surgery, Surgical Simulation Research Lab, University of Alberta, Edmonton, Alberta, Canada
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Cost Utility of Competing Strategies to Prevent Endoscopic Transmission of Carbapenem-Resistant Enterobacteriaceae. Am J Gastroenterol 2015; 110:1666-74. [PMID: 26526083 PMCID: PMC4721926 DOI: 10.1038/ajg.2015.358] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 09/02/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Prior reports have linked patient transmission of carbapenem-resistant Enterobacteriaceae (CRE, or "superbug") to endoscopes used during endoscopic retrograde cholangiopancreatography (ERCP). We performed a decision analysis to measure the cost-effectiveness of four competing strategies for CRE risk management. METHODS We used decision analysis to calculate the cost-effectiveness of four approaches to reduce the risk of CRE transmission among patients presenting to the hospital for symptomatic common bile duct stones. The strategies included the following: (1) perform ERCP followed by US Food and Drug Administration (FDA)-recommended endoscope reprocessing procedures; (2) perform ERCP followed by "endoscope culture and hold"; (3) perform ERCP followed by ethylene oxide (EtO) sterilization of the endoscope; and (4) stop performing ERCP in lieu of laparoscopic cholecystectomy (LC) with common bile duct exploration (CBDE). Our outcome was incremental cost per quality-adjusted life year (QALY) gained. RESULTS In the base-case scenario, ERCP with FDA-recommended endoscope reprocessing was the most cost-effective strategy. Both the ERCP with culture and hold ($4,228,170/QALY) and ERCP with EtO sterilization ($50,572,348/QALY) strategies had unacceptable incremental costs per QALY gained. LC with CBDE was dominated, being both more costly and marginally less effective vs. the alternatives. In sensitivity analysis, ERCP with culture and hold became the most cost-effective approach when the pretest probability of CRE exceeded 24%. CONCLUSIONS In institutions with a low CRE prevalence, ERCP with FDA-recommended reprocessing is the most cost-effective approach for mitigating CRE transmission risk. Only in settings with an extremely high CRE prevalence did ERCP with culture and hold become cost-effective.
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Seshadri RM, Ali N, Warner S, Cochran A, Vrochides D, Iannitti D, Rohan Jeyarajah D. Training and practice of the next generation HPB surgeon: analysis of the 2014 AHPBA residents' and fellows' symposium survey. HPB (Oxford) 2015; 17:1096-104. [PMID: 26355495 PMCID: PMC4644361 DOI: 10.1111/hpb.12498] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Accepted: 07/16/2015] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
| | - Noaman Ali
- Akron General Medical CenterAkron, OH, USA
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Ali N, O'Rourke C, El-Hayek K, Chalikonda S, Jeyarajah DR, Walsh RM. Estimating the need for hepato-pancreatico-biliary surgeons in the USA. HPB (Oxford) 2015; 17:352-6. [PMID: 25545141 PMCID: PMC4368400 DOI: 10.1111/hpb.12370] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Accepted: 11/02/2014] [Indexed: 12/12/2022]
Abstract
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 state's 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.
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Affiliation(s)
- Noaman Ali
- Digestive Disease Institute, Cleveland ClinicCleveland, OH, USA,Correspondence, Noaman Ali, 9500 Euclid Avenue, Mail code A100, Cleveland, OH 44195, USA. Tel: + 1 216 445 7576. Fax: + 1 216 445 7653. E-mail:
| | - Colin O'Rourke
- Digestive Disease Institute, Cleveland ClinicCleveland, OH, USA
| | - Kevin El-Hayek
- Digestive Disease Institute, Cleveland ClinicCleveland, OH, USA
| | | | | | - R Matthew Walsh
- Digestive Disease Institute, Cleveland ClinicCleveland, OH, USA
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Teitelbaum EN, Soper NJ, Santos BF, Rooney DM, Patel P, Nagle AP, Hungness ES. A simulator-based resident curriculum for laparoscopic common bile duct exploration. Surgery 2014; 156:880-7, 890-3. [DOI: 10.1016/j.surg.2014.06.020] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Accepted: 06/20/2014] [Indexed: 10/24/2022]
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Abstract
BACKGROUND There has been a trend toward subspecialization among general surgery graduates, and many subspecialists are reticent to participate in trauma care. This has resulted in a gap in the provision of emergency surgical care. The Acute Care Surgery (ACS) fellowship, incorporating trauma, critical care, and emergency general surgery, was developed to address this need. One of the most important aspects in establishing these ACS fellowships is that they do not detract from the existing general surgery residents' experience. METHODS The operative case logs for residents and fellows were compared for the number of resident cases during the 3 years before the ACS fellowship and during the 3 years after the fellowship was established. Surveys were distributed to the general surgery residents addressing the impact of the fellows from the resident's perspective at the end of the 2011 to 2012 academic year. RESULTS There was no significant change in the number of total cases; total chief resident cases; and trauma, thoracic, or vascular procedures done per graduate. A decrease in the number of liver cases performed by the residents was noted but includes the increase in resident complement as well as the fellowship. ACS fellow cases increased from 172 cases in the first year to 221 cases in the second year and 295 in the third year. The survey showed that the residents had a very positive response to having the fellow as a teacher and did not feel like their operative experience was compromised with the addition of the ACS fellowship. CONCLUSION The ACS fellow did not compromise general surgery resident experience and was regarded as an asset to the resident's education. An ACS fellowship can be beneficial to residents and fellows. LEVEL OF EVIDENCE Care management study, level IV.
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Juza RM, Pauli EM. Clinical and surgical anatomy of the liver: a review for clinicians. Clin Anat 2014; 27:764-9. [PMID: 24453062 DOI: 10.1002/ca.22350] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Revised: 10/22/2013] [Accepted: 10/26/2013] [Indexed: 01/20/2023]
Abstract
The liver is the largest gland in the body occupying 2.5% of total body weight and providing a host of functions necessary for maintaining normal physiological homeostasis. Despite the complexity of its functions, the liver has a homogenous appearance, making hepatic anatomy a challenging topic of discussion. To address this issue, scholars have devoted time to establishing a framework for describing hepatic anatomy to aid clinicians. Work by the anatomist Sir James Cantlie provided the first accurate division between the right and left liver in 1897. The French surgeon and anatomist Claude Couinaud provided additional insight by introducing the Couinaud segments on the basis of hepatic vasculature. These fundamental studies provided a framework for medical and surgical discussions of hepatic anatomy and were essential for the advancement of modern medicine. In this article, the authors review the normal anatomy and physiology of the liver with a view to enhancing the clinician's knowledge base. They also provide a convenient model to assist with understanding and discussion of liver anatomy.
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Affiliation(s)
- Ryan M Juza
- Department of Surgery, Penn State Hershey Medial Center, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania
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Daee SS, Flynn JC, Jacobs MJ, Mittal VK. Analysis and implications of changing hepatopancreatobiliary (HPB) case loads in general surgery residency training for HPB surgery accreditation. HPB (Oxford) 2013; 15:1010-5. [PMID: 23521184 PMCID: PMC3843621 DOI: 10.1111/hpb.12088] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2012] [Accepted: 02/04/2013] [Indexed: 12/12/2022]
Abstract
OBJECTIVE This study was conducted to determine whether residents are receiving enough hepatopancreatobiliary (HPB) training during general surgery residencies to exclude the necessity of pursuing formal fellowships in HPB surgery. METHODS Trends in HPB surgery training were examined using Accreditation Council for Graduate Medical Education (ACGME) operative log data for the academic years 1999/2000 to 2009/2010. RESULTS Of 800,000 HPB operations performed annually in the USA, the proportion of HPB procedures performed by general surgery residents increased from 15% (122,007) to 18% (143,000) between the periods under study. Numbers of pancreatic, liver and biliary procedures performed by graduating general surgery residents increased by 47% (from 8185 to 12,006), 31% (from 7468 to 9765), and 14% (from 106,354 to 121,239), respectively. The mean number of operations undertaken by a graduating resident increased from 8.3 to 11.5 (38% increase) for pancreatic surgeries, from 7.6 to 9.4 (24% increase) for liver surgeries, and from 107.5 to 116.6 (8% increase) for biliary surgeries. Total numbers of complex pancreatic, liver and biliary procedures increased by 91% (from 4768 to 9129) and 24% (from 6649 to 8233), and decreased by 29% (from 6581 to 4648), respectively. CONCLUSIONS The overall trend shows an increase in the number of HPB procedures undertaken by graduating general surgery residents. The mean number of procedures exceeds ACGME requirements, but falls short of association guidelines. However, certain residents exceed International Hepato-Pancreato-Biliary Association (IHPBA) fellowship requirements for total and complex procedures during residency. Consideration should be given to those residents to allow them to bypass fellowship training provided that they meet other IHPBA standards.
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Affiliation(s)
- Sally Sayeh Daee
- Department of Surgery, Providence Hospital and Medical CentersSouthfield, MI, USA
| | - Jeffrey C Flynn
- Department of Biomedical Research, Providence Hospital and Medical CentersSouthfield, MI, USA
| | - Michael J Jacobs
- Department of Surgery, Providence Hospital and Medical CentersSouthfield, MI, USA
| | - Vijay K Mittal
- Department of Surgery, Providence Hospital and Medical CentersSouthfield, MI, USA
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McColl RJ, Shaheen AAM, Brar B, Kaplan G, Myers R, Sutherland F, Dixon E. Survival after hepatic resection: impact of surgeon training on long-term outcome. Can J Surg 2013; 56:256-62. [PMID: 23883496 DOI: 10.1503/cjs.023611] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Mortality for liver resection has remarkably improved owing to multiple factors. We sought to determine the impact of the various types of fellowship training on patient survival after liver resection. METHODS Patients who underwent hepatic resection between 1995 and 2004 in either the Calgary or Capital health regions (Edmonton) of Alberta, Canada, were identified using ICD-9 and -10 codes. Primary outcomes included in-hospital mortality and patient survival according to surgeon volume and training type (surgical oncology v. hepatobiliary v. others). RESULTS A total of 1033 patients underwent hepatic resection. Surgeon volume was not predictive of either in-hospital mortality (adjusted odds ratio 0.63, 95% confidence interval [CI] 0.32-1.20) or patient survival (unadjusted hazard ratio 1.11, 95% CI 0.82-1.51). Nonsignificance was also demonstrated for a surgeon's type of fellowship training. CONCLUSION The various modes of fellowship training do not appear to influence inhospital mortality or patient survival after hepatic resection.
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Affiliation(s)
- Ryan J McColl
- Department of Surgery, Medicine, and Community Health Sciences, University of Calgary, Calgary, Alta
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Gillman LM, Vergis A. General surgery graduates may be ill prepared to enter rural or community surgical practice. Am J Surg 2013; 205:752-7. [DOI: 10.1016/j.amjsurg.2012.01.017] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2011] [Revised: 01/18/2012] [Accepted: 01/18/2012] [Indexed: 10/28/2022]
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Pauli EM, Staveley-O'Carroll KF, Brock MV, Efron DT, Efron G. A handy tool to teach segmental liver anatomy to surgical trainees. ACTA ACUST UNITED AC 2012; 147:692-3. [PMID: 22911067 DOI: 10.1001/archsurg.2012.689] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Eric M Pauli
- Department of Surgery, Penn State Hershey Medical Center, 500 University Dr, MCH149, Hershey, PA 17033, USA.
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Predictors of intraoperative blood loss in patients undergoing hepatectomy. Surg Today 2012; 43:485-93. [DOI: 10.1007/s00595-012-0374-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2011] [Accepted: 01/31/2012] [Indexed: 12/12/2022]
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Safavi A, Lai S, Butterworth S, Hameed M, Schiller D, Skarsgard E. Does operative experience during residency correlate with reported competency of recent general surgery graduates? Can J Surg 2012; 55:S171-7. [PMID: 22854144 PMCID: PMC3432245 DOI: 10.1503/cjs.020811] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2011] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Identification of attributes of residency training that predict competency would improve surgical education. We hypothesized that case experience during residency would correlate with self-reported competency of recent graduates. METHODS Aggregate case log data of residents enrolled in 2 general surgery programs were collected over a 12-month period and stratified into Surgical Council on Resident Education (SCORE) categories. We surveyed recent (< 5 yr) residency graduates on procedural competency. Resident case volumes were correlated with survey responses by SCORE category. RESULTS In all, 75 residents performed 11 715 operations, which were distributed by SCORE category as follows: essential-common (EC) 9935 (84.8%), essential-uncommon (EU) 889 (7.6%) and complex 891 (7.6%). Alimentary tract procedures were the most commonly performed EC (2386, 24%) and EU (504, 56.7%) procedures. The least common EC procedure was plastic surgery (4, 0.04%), and the least common EU procedure was abdomen-spleen (1, 0.1%). The questionnaire response rate was 45%. For EC procedures, self-reported competency was highest in skin and soft tissue, thoracic and head and neck (each 100%) and lowest in vascular-venous (54%), whereas for EU procedures it was highest in abdomen-general (100%) and lowest in vascular-arterial (62%). The correlation between case volume and self-reported competency was poor (R = 0.2 for EC procedures). CONCLUSION Self-reported competency correlates poorly with operative case experience during residency. Other curriculum factors, including specific rotations and timing, balance between inpatient and outpatient surgical experience and competition for cases, may contribute to procedural competency acquisition during residency.
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Affiliation(s)
- Arash Safavi
- Departments of Surgery, University of British Columbia, Vancouver BC
| | - Sarah Lai
- University of Alberta, Edmonton, Alta
| | - Sonia Butterworth
- Departments of Surgery, University of British Columbia, Vancouver BC
| | - Morad Hameed
- Departments of Surgery, University of British Columbia, Vancouver BC
| | | | - Erik Skarsgard
- Departments of Surgery, University of British Columbia, Vancouver BC
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Lengyel BI, Panizales MT, Steinberg J, Ashley SW, Tavakkoli A. Laparoscopic cholecystectomy: What is the price of conversion? Surgery 2012; 152:173-8. [PMID: 22503324 PMCID: PMC3667156 DOI: 10.1016/j.surg.2012.02.016] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2011] [Accepted: 02/13/2012] [Indexed: 01/10/2023]
Abstract
BACKGROUND Laparoscopic cholecystectomy (LC) is the gold standard procedure for gallbladder removal. Conversion to an open procedure is sometimes deemed necessary, especially in complex cases in which a prolonged laparoscopic operative time is anticipated. A prolonged LC case is thought to be associated with increased complications and cost and therefore generally discouraged. The purpose of this study was to test this assumption, and compare outcomes and cost of converted and prolonged LC cases. METHODS By using institutional National Surgical Quality Improvement Program and financial databases, we retrospectively reviewed and compared prolonged laparoscopic cases (Long-LC) with converted (CONV) procedures. Surgical times, length of stay (LOS), 30-day complications, operative room, and total hospital charges were compared between the 2 groups. RESULTS A total of 101 Long-LC and 66 CONV cases met our inclusion criteria. Long-LC cases were 19 minutes longer than CONV cases (123 vs 104 min; P < .01). No differences in postoperative complications were found between the 2 groups (P > .05). When Poisson regression was used, we found that LOS was significantly shorter in the Long-LC compared with CONV group (1 day vs 4 days; P < .01). Long-LC cases had greater operative charges ($15,278 vs $13,128; P < .01). However, hospital charges for Long-LC cases were 26% less than for CONV cases ($23,946 vs $32,446; P < .01). CONCLUSION Conversion is associated with a 3-day increase in LOS. Long-LC cases have greater operative room charges, but overall hospital charges were 26% less than CONV cases. Our data suggest that decision making regarding conversion should focus on safety and not time considerations.
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Affiliation(s)
- Balazs I. Lengyel
- Department of General Surgery, Surgical Planning Laboratory, Brigham and Women's Hospital, Boston, MA
- Department of Radiology, Surgical Planning Laboratory, Brigham and Women's Hospital, Boston, MA
| | - Maria T. Panizales
- Department of General Surgery, Surgical Planning Laboratory, Brigham and Women's Hospital, Boston, MA
| | - Jill Steinberg
- Department of General Surgery, Surgical Planning Laboratory, Brigham and Women's Hospital, Boston, MA
| | - Stanley W. Ashley
- Department of General Surgery, Surgical Planning Laboratory, Brigham and Women's Hospital, Boston, MA
| | - Ali Tavakkoli
- Department of General Surgery, Surgical Planning Laboratory, Brigham and Women's Hospital, Boston, MA
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Lee J, Miller P, Kermani R, Dao H, O’Donnell K. Gallbladder damage control: compromised procedure for compromised patients. Surg Endosc 2012; 26:2779-83. [DOI: 10.1007/s00464-012-2278-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2012] [Accepted: 03/24/2012] [Indexed: 01/11/2023]
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Increasing Complexity in the Open Surgical Repair of Abdominal Aortic Aneurysms. Ann Vasc Surg 2012; 26:10-7. [DOI: 10.1016/j.avsg.2011.11.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2011] [Revised: 11/09/2011] [Accepted: 11/13/2011] [Indexed: 11/21/2022]
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Abstract
Breast cancer treatment has changed substantially with increased specialization. Overall, the number of cases performed by residents upon completion of residency has decreased and the introduction of sentinel lymph node biopsy has reduced the number of axillary lymph node dissections being performed. Our objective was to evaluate the breast surgery education being provided by general surgery residency programs. A survey was administered to applicants to the Roswell Park Cancer Institute surgical oncology fellowship program in the fall of 2009. This survey examined the type of training program, the breast surgery exposure, and applicant comfort with the medical and surgical aspects of breast cancer. The survey was completed by 29 of 35 applicants. Of the respondents, 83 per cent were chief residents. Overall, participants had comfort levels above 8 (of 10) with breast related cases. For modified radical mastectomies and axillary lymph node dissections the comfort level dropped below 8. Participants were least comfortable discussing the medical management of breast cancer. General surgery residents completing training were less comfortable operating in the axilla compared with the breast. The study suggests careful attention should be paid to assuring adequate breast education in surgical residency.
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Affiliation(s)
- Jason P. Wilson
- Departments of Surgical Oncology, Department of Surgery, University at Buffalo, Buffalo, New York
| | - Austin Miller
- Biostatistics, Roswell Park Cancer Institute, Department of Surgery, University at Buffalo, Buffalo, New York
| | - Stephen B. Edge
- Departments of Surgical Oncology, Department of Surgery, University at Buffalo, Buffalo, New York
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Cherng N, Witkowski ET, Sneider EB, Wiseman JT, Lewis J, Litwin DEM, Santry HP, Cahan M, Shah SA. Use of cholecystostomy tubes in the management of patients with primary diagnosis of acute cholecystitis. J Am Coll Surg 2011; 214:196-201. [PMID: 22192897 DOI: 10.1016/j.jamcollsurg.2011.11.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2011] [Revised: 11/08/2011] [Accepted: 11/10/2011] [Indexed: 01/11/2023]
Abstract
BACKGROUND Management of patients with severe acute cholecystitis (AC) remains controversial. In settings where laparoscopic cholecystectomy (LC) can be technically challenging or medical risks are exceedingly high, surgeons can choose between different options, including LC conversion to open cholecystectomy or surgical cholecystostomy tube (CCT) placement, or initial percutaneous CCT. We reviewed our experience treating complicated AC with CCT at a tertiary-care academic medical center. STUDY DESIGN All adult patients (n = 185) admitted with a primary diagnosis of AC and who received CCT from 2002 to 2010 were identified retrospectively through billing and diagnosis codes. RESULTS Mean patient age was 71 years and 80% had ≥1 comorbidity (mean 2.6). Seventy-eight percent of CCTs were percutaneous CCT placement and 22% were surgical CCT placement. Median length of stay from CCT insertion to discharge was 4 days. The majority (57%) of patients eventually underwent cholecystectomy performed by 20 different surgeons in a median of 63 days post-CCT (range 3 to 1,055 days); of these, 86% underwent LC and 13% underwent open conversion or open cholecystectomy. In the radiology and surgical group, 50% and 80% underwent subsequent cholecystectomy, respectively, at a median of 63 and 60 days post-CCT. Whether surgical or percutaneous CCT placement, approximately the same proportion of patients (85% to 86%) underwent LC as definitive treatment. CONCLUSIONS This 9-year experience shows that use of CCT in complicated AC can be a desirable alternative to open cholecystectomy that allows most patients to subsequently undergo LC. Additional studies are underway to determine the differences in cost, training paradigms, and quality of life in this increasingly high-risk surgical population.
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Affiliation(s)
- Nicole Cherng
- Department of Surgery, Surgical Outcomes Analysis & Research, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA 01655, USA
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General surgery training without laparoscopic surgery fellows: The impact on residents and patients. Surgery 2011; 150:752-8. [DOI: 10.1016/j.surg.2011.07.051] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2011] [Accepted: 07/11/2011] [Indexed: 11/22/2022]
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Yamamoto Y, Shimada K, Sakamoto Y, Esaki M, Nara S, Kosuge T. Preoperative identification of intraoperative blood loss of more than 1,500 mL during elective hepatectomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2011; 18:829-38. [DOI: 10.1007/s00534-011-0399-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Yusuke Yamamoto
- Hepatobiliary and Pancreatic Surgery Division; National Cancer Center Central Hospital; 5-1-1Tsukiji, Chuo-ku Tokyo 104-0045 Japan
| | - Kazuaki Shimada
- Hepatobiliary and Pancreatic Surgery Division; National Cancer Center Central Hospital; 5-1-1Tsukiji, Chuo-ku Tokyo 104-0045 Japan
| | - Yoshihiro Sakamoto
- Hepatobiliary and Pancreatic Surgery Division; National Cancer Center Central Hospital; 5-1-1Tsukiji, Chuo-ku Tokyo 104-0045 Japan
| | - Minoru Esaki
- Hepatobiliary and Pancreatic Surgery Division; National Cancer Center Central Hospital; 5-1-1Tsukiji, Chuo-ku Tokyo 104-0045 Japan
| | - Satoshi Nara
- Hepatobiliary and Pancreatic Surgery Division; National Cancer Center Central Hospital; 5-1-1Tsukiji, Chuo-ku Tokyo 104-0045 Japan
| | - Tomoo Kosuge
- Hepatobiliary and Pancreatic Surgery Division; National Cancer Center Central Hospital; 5-1-1Tsukiji, Chuo-ku Tokyo 104-0045 Japan
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Raval MV, Bilimoria KY, Talamonti MS. Quality improvement for pancreatic cancer care: is regionalization a feasible and effective mechanism? Surg Oncol Clin N Am 2010; 19:371-90. [PMID: 20159520 DOI: 10.1016/j.soc.2009.11.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Variability exists in the quality of pancreatic cancer care provided in the United States. High-volume centers have been shown to have improved outcomes for pancreatectomy. Regionalization of pancreatic cancer care to high-volume centers has the potential to improve care and outcomes. Practical limitations such as overloading currently available high-volume centers, extending patient travel times, sharing patients within a multipayer health system, and incorporating patient preferences must be addressed for regionalization to become a reality. The benefits and limitations of regionalization of pancreatic cancer care are discussed in this review. To improve the overall quality of pancreatic cancer care at all hospitals in the United States, a combination of referral of patients with pancreatic cancer to high- and moderate-volume hospitals in conjunction with specific quality-improvement efforts at those institutions is proposed.
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Affiliation(s)
- Mehul V Raval
- Department of Surgery, Northwestern University, 251 East Huron Street, Galter 3-150, Chicago, IL 60611, USA
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Eckert M, Cuadrado D, Steele S, Brown T, Beekley A, Martin M. The changing face of the general surgeon: national and local trends in resident operative experience. Am J Surg 2010; 199:652-6. [DOI: 10.1016/j.amjsurg.2010.01.012] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2009] [Revised: 01/08/2010] [Accepted: 01/08/2010] [Indexed: 10/19/2022]
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Zyromski NJ, Torbeck L, Canal DF, Lillemoe KD, Pitt HA. Incorporating an HPB fellowship does not diminish surgical residents' HPB experience in a high-volume training centre. HPB (Oxford) 2010; 12:123-8. [PMID: 20495656 PMCID: PMC2826670 DOI: 10.1111/j.1477-2574.2009.00146.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2009] [Accepted: 10/29/2009] [Indexed: 12/12/2022]
Abstract
BACKGROUND Surgical residency training is evolving, and trainees who wish to practice hepato-pancreato-biliary (HPB) surgery in the future will be required to obtain advanced training. As this paradigm evolves, it is crucial that HPB fellowship incorporation into an established surgical residency programme does not diminish surgical residents' exposure to complex HPB procedures. We hypothesized that incorporation of a HPB fellowship in a high-volume clinical training programme would not detract from residents' HPB experience. METHODS Resident operative case logs and HPB fellow case logs were reviewed. Resident exposure to complex HPB procedures for 3 years prior to and 3 years after fellowship incorporation were compared. RESULTS No significant changes in surgical resident exposure to liver and pancreatic resection were seen between the two time periods. Surgical resident exposure to complex biliary procedures decreased in the 3 years after HPB fellowship incorporation (P= 0.003); however, exceeded the national average in each year except 2006. Graduating residents' overall HPB experience was unchanged in the 3 years prior to and after incorporating an HPB fellow. Expansion of HPB volume was a critical part of successful HPB fellowship implementation. DISCUSSION An HPB fellowship programme can be incorporated into a high-volume clinical training programme without detracting from resident HPB experience. Individual training programmes should carefully assess their capability to provide an adequate clinical experience for fellows without diminishing resident exposure to complex HPB procedures.
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Affiliation(s)
- Nicholas J Zyromski
- Department of Surgery, Indiana University School of Medicine Indianapolis, IN 46202, USA.
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The volume-outcomes effect in hepato-pancreato-biliary surgery: hospital versus surgeon contributions and specificity of the relationship. J Am Coll Surg 2009; 208:528-38. [PMID: 19476786 DOI: 10.1016/j.jamcollsurg.2009.01.007] [Citation(s) in RCA: 167] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2008] [Revised: 12/29/2008] [Accepted: 01/09/2009] [Indexed: 02/06/2023]
Abstract
BACKGROUND Although the relationship between hepato-pancreato-biliary (HPB) procedure volume and outcomes is established, the relative importance of hospital and surgeon effects and the specificity of the volume-outcomes effect remain ill-defined. We sought to comprehensively characterize the hospital and surgeon volume-outcomes relationships in high-risk HPB surgery. STUDY DESIGN The 1998 to 2005 State Inpatient Databases for Florida, Maryland, and New York were used to identify patients undergoing complex HPB surgery and to quantify hospital and surgeon procedure volumes. The effects of hospital and surgeon procedure volumes on casemix-adjusted inpatient mortality were analyzed using multilevel logistic regression models. RESULTS For hepatic resection, hospital procedure volume predicted mortality (high versus low volume, odds ratio [OR] 0.48, p=0.04), but surgeon volume did not (p=0.42). For pancreatic resection, in contrast, both hospital (OR 0.32, p < 0.001) and surgeon (OR 0.30, p < 0.001) procedure volume predicted mortality. The hospital volume effect for pancreatic resection was largely explained by surgeon volume. In both procedure groups, volume-outcomes effects were very specific. Only volumes of the primary procedure were predictive of mortality; volumes of related HPB procedures and overall HPB volume demonstrated no independent effect on mortality. CONCLUSIONS In HPB surgery, the relative contributions of hospital versus surgeon volume vary according to the specific procedure in question. In addition, the association between hospital or surgeon volume and in-hospital mortality is very specific to the procedure in question. High-volume expertise in one area of HPB surgery does not translate into improved outcomes for related procedures. These data may have implications for quality assessment and improvement, patient referral, and HPB surgical training.
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Shukla PJ, Barreto SG. Can we apply the process improvement tool Six Sigma to enhance outcomes in hepatopancreatobiliary surgery? HPB (Oxford) 2009; 11:93-5. [PMID: 19590630 PMCID: PMC2697881 DOI: 10.1111/j.1477-2574.2008.00019.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Parul J Shukla
- Department of Gastrointestinal and Hepatopancreatobiliary Surgical Oncology, Tata Memorial HospitalMumbai, India
| | - Savio G Barreto
- Department of General and Digestive Surgery, Flinders Medical CentreAdelaide, Australia
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Kairys JC, DiMuzio PJ, Crawford AG, Grabo DJ, Yeo CJ. Changes in operative case experience for general surgery residents: has the 80-hour work week decreased residents' operative experience? Adv Surg 2009; 43:73-90. [PMID: 19845170 DOI: 10.1016/j.yasu.2009.02.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Affiliation(s)
- John C Kairys
- Department of Surgery, Thomas Jefferson University, 1015 Walnut Street, Room 620, Philadelphia, PA 19107, USA.
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