- Email: [email protected]
Simulation training to acquire expertise in low volume laparoscopic liver surgery centers
Electronic Poster Abstracts About half the surgeons (48%) are HPB fellowship trained; and only 1/3 of them have been out in practice for >10 years. Majority (70%) of them are practicing in academic centers. Only a fraction (7.32%) of the surveyors have a “HPB only” practice; majority supplement their practice with general surgery (34%), surgical oncology (24%) or transplant (21%). 2/3 of the surveyors perform less than 30 pancreatic and less than 30 liver cases annually. Only a quarter of the surgeons use minimally invasive techniques. 68% of the surgeons did not have any specific HPB credentialing requirements from their institutions, beyond general surgery privileges. Conclusion: The responses highlight the challenges faced in order to run a solo HPB practice, given the limited number of cases encountered annually and the need to maintain financial stability. Changes may be needed with respect to HPB training across HPB, transplant and surgical oncology, in order to provide uniformity and enhance the scope of practice for upcoming HPB surgeons.
FP18-04 THE INFLUENCE OF HPB FELLOWSHIP TRAINING ON THE PRACTICE OF PANCREATODUODENECTOMY 1
2
3
4
M. McMillan , C. Bassi , P. Greig , P. Hansen , D. Jeyarajah5, T. Kent6, G. Malleo2, R. Minter7, M. Sprys1 and C. Vollmer1 1 Surgery, University of Pennsylvania Perelman School of Medicine, United States, 2Surgery, University of Verona, Italy, 3Surgery, University Health Network, Canada, 4 Surgery, The Oregon Clinic, 5Surgery, Methodist Dallas Medical Center, 6Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, and 7Surgery, UT Southwestern Medical Center, United States Introduction: Increased competition and an emphasis on sub-specialization have led to the proliferation of gastrointestinal surgical fellowships; however, little is known regarding their association with surgical volume and management approaches. Methods: Surveys were distributed to members of 22 international GI surgical societies, including the IHPBA. Responses were evaluated to define relationships between fellowship training and surgical practice with pancreatoduodenectomy (PD), a cornerstone of HPB surgery. Results: Surveys were completed by 889 surgeons. Fellowship training was indicated by 84.1% of respondents, of which, 61.2% obtained a HPB fellowship. Annual PD volume was greater for surgeons who completed fellowship training (median: 13 vs. 10, P = 0.030), with the greatest difference among surgeons with 10 years of experience (12 vs. 8, P = 0.009). Annual PD volume and clinical-management varied by fellowship. Any transplant training was associated with the highest annual PD volume (median: 15 vs. 11, P = 0.007); however, when controlling for experience, this difference remained significant only among surgeons
HPB 2016, 18 (S1), e1ee384
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with 11e20 years experience as an attending (median: 20 vs. 14, P = 0.013). HPB fellowship training was associated with a unique practice profile, including the completion of other classical GI fellowships (Table). When performing PD, surgeons with HPB fellowship training were more likely to remove drains early (POD3), as well as use prophylactic somatostatin analogues, internal trans-anastomotic stents, and dunking/ invagination (P0.01 for each). Conclusions: Completion of an HPB fellowship correlated with differences in PD volume, HPB-only practice, and completion of other fellowships. HPB-trained surgeons appear to approach the management of PD differently from non-HPB trained surgeons.
Variable, N (%) or median (IQR)
No HPB Fellowship Training (N [ 431)
HPB Fellowship Training (N [ 458)
p-value
Age
48 (40-55)
45 (38-52)
0.001
Years experience as an attending
14.5 (7-24)
10 (5-20)
< 0.001
PDs during last calendar year
11 (5-24)
15 (8-25)
< 0.001
PDs during career as an attending
90 (25-206.5)
70 (30-181.3)
0.327
Practice HPB exclusively
165 (38.5%)
341 (74.5%)
< 0.001
Surgical Oncology
167 (38.7%)
103 (22.5%)
< 0.001
Transplant
64 (14.8%)
130 (28.4%)
< 0.001
Upper GI
43 (10.0%)
80 (17.5%)
0.001
Classical GI fellowships obtained
[Characteristics of HPB fellowship-trained surgeons]
FP18-05 SIMULATION TRAINING TO ACQUIRE EXPERTISE IN LOW VOLUME LAPAROSCOPIC LIVER SURGERY CENTERS P. Achurra, M. Sanhueza, J. Varas, R. Rebolledo, J. F. Guerra, J. Martinez and N. Jarufe Digestive Surgery, Hospital Clínico Pontificia Universidad Católica de Chile, Chile Introduction: Simulation may provide the necessary training volume needed to complete the complex learning curve for advanced laparoscopic liver surgery in low-tomoderate volume centers. Aim: To present an advanced liver surgery simulation program and to assess the transfer of skills to the operating room (OR). Methods: Phase-1: Two HPB expert surgeons performed 12 totally laparoscopic left hepatectomy (TLLH) on a live sheep
e64
Electronic Poster Abstracts
model. LC-CUSUM methodology was used to assess learning curves based on intraoperative outcomes: mortality, blood loss, vascular control, hepatic transection and operative time. Each procedure was recorded and analyzed by 2-blinded experts using global and specific rating scales (GRS and SRS). Phase-2: An HBP-Fellow was trained by one of phase-1 HBP surgeons in 8-sessions using the same educational methodology. Phase-3: After completing simulation, the HBP-Fellow performed a TLLH in the OR (patient with colorectal metastasis). Wilcoxon and McNemar tests were used for analysis. This study reckon with the patient and animal ethics committee consent. Results: LC-CUSUM learning curves indicated competency and a learning trend since the 7th-session in phase-1. GRS and SRS improved from the first to the last procedure (p < 0,01). In phase-2, the HBP-fellow under expert supervision, showed competency after session 7 with significant improvement in GRS and SRS. In phase-3, the fellow completed a TLLH in the OR achieving perfect GRS and SRS with no expert takeovers. The patient had an uneventful postoperative course. Conclusion: Ovine-model simulation training allowed competency acquisition in HBP-surgeons and HBP-Fellows. The acquired surgical skills obtained were transferred to the OR.
FP18-06 PANCREATIC SURGERY PRACTICE PATTERNS BASED ON TRAINING e ARE WE REALLY THE SAME? M. U. Butt1, H. Osman2, H. Aderianwalla2, R. Hellums2, S. Furlough2 and D. R. Jeyarajah2 1 Hepatopancreatobiliary, Methodist Dallas Medical Center, and 2Methodist Dallas Medical Center, United States Introduction: High volume centers for pancreatic surgery in the United States have dedicated fellowship training programs and are sponsored by Americas HepatoPancreato-Biliary Association (AHPBA) and society of surgical oncology (SSO). Our goal was to determine the differences in pancreatic surgery techniques specifically identifying how the specimen margin was inked and assessed. Method: This survey targeted program directors (PD’s) participating in the 18 AHPBA and 22 SSO accredited fellowships. Results: The response rate was 83% for AHPBA PD’s (15/18) and 50% for SSO PD’s (11/22). Seventy percent placed nasogastric tubes, drains, and removed them based on amylase level in both groups. 40% of SSO PD’s sent no margin for frozen section compared to 21% for AHPBA PD’s. Superior mesenteric artery margin was specifically inked in more than 80% of specimens. The margin was inked mostly by surgeons (46%) in the AHPBA groups compared to pathologist PA (60%) in the SSO group.
Table 1
AHPBA
SSO
>50 Pancreaticoduodenectomies
100%
73%
Routine Diagnostic Laparoscopy
53%
60%
Pancreas Reconstruction – Most common (duct to mucosa/ no stent)
53%
60%
Bile Duct Anastamosis Most Common (Interrupted absorbable suture)
70%
70%
Conclusion: Our data shows AHPBA and SSO training programs have similar technical approach to pancreatic surgery, but higher volume for the AHPBA programs. There was significant differences in how the specimen was handled for frozen section and who inked the margin. National standardized guidelines should be developed for optimal specimen handling.
FP19 e Free Papers 19 (long oral) e Pancreas: Tumors 3
FP19-01 WHOLE GENOME SEQUENCING REVEALS MECHANISMS OF CARCINOGENESIS IN PANCREATIC DUCTAL ADENOCARCINOMA A. Connor, L. Stein, J. McPherson, S. Cleary and S. Gallinger University of Toronto, Canada Background: To better understand the carcinogenesis of pancreatic ductal adenocarcinoma (PDAC), establish subtypes and identify actionable alterations, we performed whole genome sequencing of 148 resected PDAC and normal pairs. Methods: Following tumour cellularity enrichment, whole genome sequencing was performed on Illumina HiSeq 2000/2500, and simple somatic, structural and copy number variations were called and annotated. Associations of clinical, pathologic and molecular covariates with overall survival and association of DSBR deficiency with response to palliative platinum chemotherapy were determined by Cox models. Results: We identified 9 driver genes, 10 driver pathways, and unprecedented rates of chromothripsis and polyploidization. There were three predominant, exclusive mutational signatures: “Typical”, “DSBR” and “MMR”. These aligned with germline HPCS mutations. Eleven of 27 DSBR cases had biallelic inactivation of BRCA1, BRCA2 or PALB2. Though 21 genes were exclusively inactivated in 16 DSBR cases without attributable cause, none reached statistical significance. Median progression-free survival was not greater on platinum chemotherapy in “DSBR” relative to “Typical” patients. Lack of adjuvant therapy, positive margin status, positive N stage, deletions of 18q21 and 9p24.1, amplifications of 12q14.1 and mutation of TP53 were negatively prognostic.
HPB 2016, 18 (S1), e1ee384
FP18-04 THE INFLUENCE OF HPB FELLOWSHIP TRAINING ON THE PRACTICE OF PANCREATODUODENECTOMY 1
2
3
4
M. McMillan , C. Bassi , P. Greig , P. Hansen , D. Jeyarajah5, T. Kent6, G. Malleo2, R. Minter7, M. Sprys1 and C. Vollmer1 1 Surgery, University of Pennsylvania Perelman School of Medicine, United States, 2Surgery, University of Verona, Italy, 3Surgery, University Health Network, Canada, 4 Surgery, The Oregon Clinic, 5Surgery, Methodist Dallas Medical Center, 6Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, and 7Surgery, UT Southwestern Medical Center, United States Introduction: Increased competition and an emphasis on sub-specialization have led to the proliferation of gastrointestinal surgical fellowships; however, little is known regarding their association with surgical volume and management approaches. Methods: Surveys were distributed to members of 22 international GI surgical societies, including the IHPBA. Responses were evaluated to define relationships between fellowship training and surgical practice with pancreatoduodenectomy (PD), a cornerstone of HPB surgery. Results: Surveys were completed by 889 surgeons. Fellowship training was indicated by 84.1% of respondents, of which, 61.2% obtained a HPB fellowship. Annual PD volume was greater for surgeons who completed fellowship training (median: 13 vs. 10, P = 0.030), with the greatest difference among surgeons with 10 years of experience (12 vs. 8, P = 0.009). Annual PD volume and clinical-management varied by fellowship. Any transplant training was associated with the highest annual PD volume (median: 15 vs. 11, P = 0.007); however, when controlling for experience, this difference remained significant only among surgeons
HPB 2016, 18 (S1), e1ee384
e63
with 11e20 years experience as an attending (median: 20 vs. 14, P = 0.013). HPB fellowship training was associated with a unique practice profile, including the completion of other classical GI fellowships (Table). When performing PD, surgeons with HPB fellowship training were more likely to remove drains early (POD3), as well as use prophylactic somatostatin analogues, internal trans-anastomotic stents, and dunking/ invagination (P0.01 for each). Conclusions: Completion of an HPB fellowship correlated with differences in PD volume, HPB-only practice, and completion of other fellowships. HPB-trained surgeons appear to approach the management of PD differently from non-HPB trained surgeons.
Variable, N (%) or median (IQR)
No HPB Fellowship Training (N [ 431)
HPB Fellowship Training (N [ 458)
p-value
Age
48 (40-55)
45 (38-52)
0.001
Years experience as an attending
14.5 (7-24)
10 (5-20)
< 0.001
PDs during last calendar year
11 (5-24)
15 (8-25)
< 0.001
PDs during career as an attending
90 (25-206.5)
70 (30-181.3)
0.327
Practice HPB exclusively
165 (38.5%)
341 (74.5%)
< 0.001
Surgical Oncology
167 (38.7%)
103 (22.5%)
< 0.001
Transplant
64 (14.8%)
130 (28.4%)
< 0.001
Upper GI
43 (10.0%)
80 (17.5%)
0.001
Classical GI fellowships obtained
[Characteristics of HPB fellowship-trained surgeons]
FP18-05 SIMULATION TRAINING TO ACQUIRE EXPERTISE IN LOW VOLUME LAPAROSCOPIC LIVER SURGERY CENTERS P. Achurra, M. Sanhueza, J. Varas, R. Rebolledo, J. F. Guerra, J. Martinez and N. Jarufe Digestive Surgery, Hospital Clínico Pontificia Universidad Católica de Chile, Chile Introduction: Simulation may provide the necessary training volume needed to complete the complex learning curve for advanced laparoscopic liver surgery in low-tomoderate volume centers. Aim: To present an advanced liver surgery simulation program and to assess the transfer of skills to the operating room (OR). Methods: Phase-1: Two HPB expert surgeons performed 12 totally laparoscopic left hepatectomy (TLLH) on a live sheep
e64
Electronic Poster Abstracts
model. LC-CUSUM methodology was used to assess learning curves based on intraoperative outcomes: mortality, blood loss, vascular control, hepatic transection and operative time. Each procedure was recorded and analyzed by 2-blinded experts using global and specific rating scales (GRS and SRS). Phase-2: An HBP-Fellow was trained by one of phase-1 HBP surgeons in 8-sessions using the same educational methodology. Phase-3: After completing simulation, the HBP-Fellow performed a TLLH in the OR (patient with colorectal metastasis). Wilcoxon and McNemar tests were used for analysis. This study reckon with the patient and animal ethics committee consent. Results: LC-CUSUM learning curves indicated competency and a learning trend since the 7th-session in phase-1. GRS and SRS improved from the first to the last procedure (p < 0,01). In phase-2, the HBP-fellow under expert supervision, showed competency after session 7 with significant improvement in GRS and SRS. In phase-3, the fellow completed a TLLH in the OR achieving perfect GRS and SRS with no expert takeovers. The patient had an uneventful postoperative course. Conclusion: Ovine-model simulation training allowed competency acquisition in HBP-surgeons and HBP-Fellows. The acquired surgical skills obtained were transferred to the OR.
FP18-06 PANCREATIC SURGERY PRACTICE PATTERNS BASED ON TRAINING e ARE WE REALLY THE SAME? M. U. Butt1, H. Osman2, H. Aderianwalla2, R. Hellums2, S. Furlough2 and D. R. Jeyarajah2 1 Hepatopancreatobiliary, Methodist Dallas Medical Center, and 2Methodist Dallas Medical Center, United States Introduction: High volume centers for pancreatic surgery in the United States have dedicated fellowship training programs and are sponsored by Americas HepatoPancreato-Biliary Association (AHPBA) and society of surgical oncology (SSO). Our goal was to determine the differences in pancreatic surgery techniques specifically identifying how the specimen margin was inked and assessed. Method: This survey targeted program directors (PD’s) participating in the 18 AHPBA and 22 SSO accredited fellowships. Results: The response rate was 83% for AHPBA PD’s (15/18) and 50% for SSO PD’s (11/22). Seventy percent placed nasogastric tubes, drains, and removed them based on amylase level in both groups. 40% of SSO PD’s sent no margin for frozen section compared to 21% for AHPBA PD’s. Superior mesenteric artery margin was specifically inked in more than 80% of specimens. The margin was inked mostly by surgeons (46%) in the AHPBA groups compared to pathologist PA (60%) in the SSO group.
Table 1
AHPBA
SSO
>50 Pancreaticoduodenectomies
100%
73%
Routine Diagnostic Laparoscopy
53%
60%
Pancreas Reconstruction – Most common (duct to mucosa/ no stent)
53%
60%
Bile Duct Anastamosis Most Common (Interrupted absorbable suture)
70%
70%
Conclusion: Our data shows AHPBA and SSO training programs have similar technical approach to pancreatic surgery, but higher volume for the AHPBA programs. There was significant differences in how the specimen was handled for frozen section and who inked the margin. National standardized guidelines should be developed for optimal specimen handling.
FP19 e Free Papers 19 (long oral) e Pancreas: Tumors 3
FP19-01 WHOLE GENOME SEQUENCING REVEALS MECHANISMS OF CARCINOGENESIS IN PANCREATIC DUCTAL ADENOCARCINOMA A. Connor, L. Stein, J. McPherson, S. Cleary and S. Gallinger University of Toronto, Canada Background: To better understand the carcinogenesis of pancreatic ductal adenocarcinoma (PDAC), establish subtypes and identify actionable alterations, we performed whole genome sequencing of 148 resected PDAC and normal pairs. Methods: Following tumour cellularity enrichment, whole genome sequencing was performed on Illumina HiSeq 2000/2500, and simple somatic, structural and copy number variations were called and annotated. Associations of clinical, pathologic and molecular covariates with overall survival and association of DSBR deficiency with response to palliative platinum chemotherapy were determined by Cox models. Results: We identified 9 driver genes, 10 driver pathways, and unprecedented rates of chromothripsis and polyploidization. There were three predominant, exclusive mutational signatures: “Typical”, “DSBR” and “MMR”. These aligned with germline HPCS mutations. Eleven of 27 DSBR cases had biallelic inactivation of BRCA1, BRCA2 or PALB2. Though 21 genes were exclusively inactivated in 16 DSBR cases without attributable cause, none reached statistical significance. Median progression-free survival was not greater on platinum chemotherapy in “DSBR” relative to “Typical” patients. Lack of adjuvant therapy, positive margin status, positive N stage, deletions of 18q21 and 9p24.1, amplifications of 12q14.1 and mutation of TP53 were negatively prognostic.
HPB 2016, 18 (S1), e1ee384