Hepato-Bilio-Pancreatic Surgery Specialty - Current Trends and Perspectives

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Hepato-Bilio-Pancreatic Surgery Specialty
-Current Trends and Perspectives
Irinel Popescu, MD, FACS, FEBS Professor of
Surgery
Center of General Surgery and Liver
Transplantation Fundeni Clinical Institute,
Bucharest, Romania
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• 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

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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

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From General Surgery to HBP Surgery

• 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

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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

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How should we train the HBP surgeon?
and
What Is the Current Status of Postgraduate
Training in HBP Surgery?
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. By definition, HBP surgeons had to have one
full year of training in HPB surgery with or
without training in liver transplantation
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EBSQ Examinations in HPB Surgery
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at least 50 major HBP procedures
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henri.bismuth_at_pbr.aphp.fr .ihb2.org www

• The Hepatobiliary Institutes objective
• to set up a HBP specialty and
• to train specialized surgeons through a 12-month
  or 24-month program.
• The program is open to surgeons trained in
  digestive surgery with a minimum of two years
  experience in this field  six years of Residency
  and Senior Residency.

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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

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Romanian Model of the Hepato-Bilio-Pancreatic
Surgery Training
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Aims

• 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

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• The fellowship was set as two-year duration
• 6 Training Centers

BUCHAREST 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
Spitalul Clinic Judetean de Urgenta Sf. Spiridon VIOREL SCRIPCARIU
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• Ord. 418/2005 liver surgery and liver
  transplantation fellowship
• Ref. 102224/2007 hepato-bilio-pancreatic
  surgery fellowship (one-year duration)
• Ord. 183/2012 new curricula and duration
  according to UEMS

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Fundeni Clinical Institute
High volume center
983 HBP SURGICAL PROCEDURES
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Surgical Training Model
6 years medical school
6 years residency in general surgery
Inadequate exposure to HBP surgical procedures
Attending surgeon
Large academic institutions
2 years fellowship in HBP surgery
nonacademic and geographically remote areas
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Who Should Attend?

• The applicant- Board Certified General Surgeon
• - Board Certified Pediatric Surgeon

• CANDIDATE SELECTION by

• Letter of intention
• Letters of recommendations
• Oral interview

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The 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

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Educational training

• proficiency in medical knowledge
• patient care skills
• self-reflection and assessment
• interpersonal skills and communication
• professionalism
• ability to practice

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TOPICS

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

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A typical day for HBP fellow

• Morning ward round - begin at 08.00 am
• OR- attending HBP surgery
• Hepatic resections, Whipple procedure, Distal
  Pancreatectomy, Hepaticoenterostomy
• Minimally Invasive HBP Surgery ( laparoscopic,
  robotic)
• Liver Transplantation
• Afternoon attending ward round
• Weekly multidisciplinary board meeting
• Liver transplantation
• Oncology

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CLINICAL RESEARCH

• 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

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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

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2005
Romanian Association of Hepato-Bilio-Pancreatic
Surgery and Liver Transplantation

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

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4 HBP Romanian Fellows attended the 2008-2009
courses for
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Take home message..

• 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