Hepato-Bilio-Pancreatic Surgery Specialty -

Current Trends and Perspectives

Hepato-Bilio-Pancreatic Surgery Specialty -

Current Trends and Perspectives

Center of General Surgery and Liver Transplantation

Fundeni Clinical Institute, Bucharest, Romania

Irinel Popescu, MD, FACS, FEBS

Professor of Surgery

“We need a system, and we shall surely have it, which will produce not only surgeons, but surgeons of the highest type, men who will stimulate the first youths of our country to study surgery and to devote their energies and their lives to raising the standard of surgical science.”

William Stewart Halsted, MD

“We need a system, and we shall surely have it, which will produce not only surgeons, but surgeons of the highest type, men who will stimulate the first youths of our country to study surgery and to devote their energies and their lives to raising the standard of surgical science.”

William Stewart Halsted, MD

From General Surgery to HBP Surgery

From General Surgery to HBP Surgery

• Many large academic institutions now deal with many of the diseases historically managed by general surgeons in “organ- based” specialty units or “discipline-specific” units

• ……..the move toward specialization has a lesser degree in nonacademic and geographically remote areas

• The operations on the liver and pancreas have fallen within the domain of the general surgery

• The number of complex HBP procedures increased dramatically

• The experience of general surgery residency is limited in the HBP domain

From General Surgery to HBP Surgery

From General Surgery to HBP Surgery

THE NEED FOR HBP TRAINING

Surgeon training : was associated with improved outcomes after hepatic resections significant predictor of postoperative complications, no impact on in-hospital mortality

From General Surgery to HBP Surgery

From General Surgery to HBP Surgery

How should we train the HBP surgeon?How should we train the HBP surgeon?

What Is the Current Status of

Postgraduate Training in HBP Surgery?

and

…….” By definition, HBP surgeons had to have .” By definition, HBP surgeons had to have one one full yearfull year of of

training in HPB surgery with or without training in training in HPB surgery with or without training in liver transplantation”liver transplantation”

EBSQ Examinations in HPB SurgeryEBSQ Examinations in HPB Surgery

…………at least 50 major at least 50 major HBP proceduresHBP procedures

•The Hepatobiliary Institute’s objective :The Hepatobiliary Institute’s objective :

•to set up a to set up a HBP specialty HBP specialty and and

•to train specialized surgeons through a to train specialized surgeons through a 12-month or 24-month progra12-month or 24-month program.m.

•The program is open to surgeons trained in The program is open to surgeons trained in digestive surgery with a minimum of two digestive surgery with a minimum of two years’ experience in this field : six years of years’ experience in this field : six years of Residency and Senior Residency.Residency and Senior Residency.

henri.bismuth@pbr.aphp.fr.ihb2.org www

What Is the Current Status of Postgraduate Training in HPB

Surgery?

University of Toronto model:

•The two-year HBP Fellowship is designed as follows:

- Year 1 – Combined HPB Surgery and Liver Transplant Year

- Year 2 – HBP Surgical Oncology & Research

Romanian Model of the Hepato-Bilio-Pancreatic

Surgery Training

Romanian Model of the Hepato-Bilio-Pancreatic

Surgery Training

• Increase of training time dedicated primarily to HBP surgery

• Increase the sample size of the HBP procedures performed by HBP fellows in a high-volume hospital

AimsAims

TThe fellowship was set as he fellowship was set as two-yeartwo-year durationduration

6 Training CentersBUCHAREST Institutul Clinic Fundeni IRINEL POPESCU

Spitalul Clinic de Urgenta MIRCEA BEURAN

CLUJ Spitalul Clinic Judetean C-TIN CIUCE

Institutul Regional de Gatroenterologie si Hepatologie “Prof. Dr. O. Fodor”

CORNEL IANCU

IASI Spitalul Clinic Judetean de Urgenta “Sf. Spiridon”

EUGEN TARCOVEANU

VIOREL SCRIPCARIU

Ord. 418/2005 – liver surgery and liver Ord. 418/2005 – liver surgery and liver transplantation fellowshiptransplantation fellowship

Ref. 102224/2007 – hepato-bilio-Ref. 102224/2007 – hepato-bilio-pancreatic surgery fellowship (one-year pancreatic surgery fellowship (one-year duration)duration)

Ord. 183/2012 – new curricula and Ord. 183/2012 – new curricula and duration according to UEMSduration according to UEMS

99570

8119

14965

0 200 400 600

Liver Tx

Hepatectomy

RFA

Hydatic Cyst treat

Biliary tract op

Pancreatectomy

Fundeni Clinical InstituteFundeni Clinical Institute

High High volume volume centercenter

Surgical procedures2251

2058

1703

1679

1832 2231 2732 3016

3066

3045

2902 3471

3591

3600

3671 3977

4095

4018

3909

3965

3307

2980

0

1000

2000

3000

4000

5000

1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010

983 HBP SURGICAL

PROCEDURES

Surgical Training ModelSurgical Training Model

6 years medical school6 years medical school

6 years residency in general surgery

6 years residency in general surgery

Attending surgeonAttending surgeon

Large academic

institutions

nonacademic and

geographically remote areas

2 years fellowship in HBP surgery

Inadequate exposure to HBP surgical

procedures

Who Should Attend? Who Should Attend?

Letter of intentionLetters of recommendationsOral interview

The applicant- Board Certified General Surgeon

- Board Certified Pediatric Surgeon

CANDIDATE SELECTION by:

The way of trainingThe way of training

• KNOWLEDGE

• lectures/course/didactic conferences

• case reports presentation

• discussion of relevant papers

• CLINICAL SKILLS – WARDS, OR

• EXPERIMENTAL SKILLS – pig model

• EDUCATIONAL TRAINING

• proficiency in medical knowledge

• patient care skills

• self-reflection and assessment

• interpersonal skills and communication

• professionalism

• ability to practice

Educational training

24

1. Liver Resections

2. Biliary Tract Surgery

3. Liver Vascular Reconstruction

4. Pancreatic Surgery

5. Multidisciplinary Oncological Approach of HBP Pathology

6. Organ Transplantation - LT

24

TOPICSTOPICS

1. Morning ward round - begin at 08.00 am

2. OR- attending HBP surgery • Hepatic resections, Whipple procedure, Distal Pancreatectomy,

Hepaticoenterostomy

• Minimally Invasive HBP Surgery ( laparoscopic, robotic)

• Liver Transplantation

3. Afternoon attending ward round

4. Weekly multidisciplinary board meeting

• Liver transplantation

• Oncology

A typical day for HBP fellowA typical day for HBP fellow

• Many available opportunities to become involved in clinical research in HBP field:

• Patient recruitment into existing trials

• Access to new therapy / clinical trials

• The fellow participate in publication work: abstract and manuscript submission

CLINICAL RESEARCH

Liver Transplantation

• closely related to HBP surgery – detailed understanding of the local anatomy, biliary surgery and techniques of reduced or split liver transplantation

• different modules concerning– organ procurement– recipient hepatectomy – graft implant

Romanian Association of Hepato-Bilio-Pancreatic Surgery and Liver Transplantation

2005

•main objectives:–training in HBP surgery;–CME in HBP surgery;–collaboration with similar associations;–national and international conferences;–support and publication of HBP articles;

29

4 HBP Romanian Fellows attended the 2008-2009 courses for

30

- “learning by doing” – the best approach

- the HBP subspecialty is the way for improving the

outcomes in HBP surgery

- the national HBP surgery program must follow the

UEMS rules

Take home message…..Take home message…..