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01-04-2020 | Basic Surgery | Original Article

Resident Operative Experience in Hepatopancreatobiliary Surgery: Exposing the Divide

Authors: Alexander R. Cortez, Leah K. Winer, Gianna D. Katsaros, Al-Faraaz Kassam, Shimul A. Shah, Tayyab S. Diwan, R. Cutler Quillin III

Published in: Journal of Gastrointestinal Surgery | Issue 4/2020

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.

McKenna DT, Mattar SG. What is wrong with the training of general surgery? Adv Surg. 2014;48:201-10. doi:https://doi.org/10.1016/j.yasu.2014.05.010.CrossRefPubMed

Drake FT, Aarabi S, Garland BT, Huntington CR, McAteer JP, Richards MK et al. Accreditation Council for Graduate Medical Education (ACGME) Surgery Resident Operative Logs: The Last Quarter Century. Ann Surg. 2017;265(5):923-9. doi:https://doi.org/10.1097/SLA.0000000000001738.CrossRefPubMed

Drake FT, Horvath KD, Goldin AB, Gow KW. The general surgery chief resident operative experience: 23 years of national ACGME case logs. JAMA Surg. 2013;148(9):841-7. doi:https://doi.org/10.1001/jamasurg.2013.2919.CrossRefPubMedPubMedCentral

Quillin RC, 3rd, Cortez AR, Pritts TA, Hanseman DJ, Edwards MJ, Davis BR. Operative Variability Among Residents Has Increased Since Implementation of the 80-Hour Workweek. J Am Coll Surg. 2016;222(6):1201-10. doi:https://doi.org/10.1016/j.jamcollsurg.2016.03.004.CrossRefPubMed

Malangoni MA, Biester TW, Jones AT, Klingensmith ME, Lewis FR, Jr. Operative experience of surgery residents: trends and challenges. J Surg Educ. 2013;70(6):783-8. doi:https://doi.org/10.1016/j.jsurg.2013.09.015.

Cortez AR, Katsaros GD, Dhar VK, Drake FT, Pritts TA, Sussman JJ et al. Narrowing of the surgical resident operative experience: A 27-year analysis of national ACGME case logs. Surgery. 2018. doi:https://doi.org/10.1016/j.surg.2018.04.037.

Mattar SG, Alseidi AA, Jones DB, Jeyarajah DR, Swanstrom LL, Aye RW et al. General surgery residency inadequately prepares trainees for fellowship: results of a survey of fellowship program directors. Ann Surg. 2013;258(3):440-9. doi:https://doi.org/10.1097/SLA.0b013e3182a191ca.CrossRefPubMed

Coleman JJ, Esposito TJ, Rozycki GS, Feliciano DV. Early subspecialization and perceived competence in surgical training: are residents ready? J Am Coll Surg. 2013;216(4):764-71; discussion 71-3. doi:https://doi.org/10.1016/j.jamcollsurg.2012.12.045.CrossRefPubMed

Chang YJ, Mittal VK. Hepato-pancreato-biliary training in general surgery residency: is it enough for the real world? Am J Surg. 2009;197(3):291-5. doi:https://doi.org/10.1016/j.amjsurg.2008.10.005.CrossRefPubMed

10.

de Santibanes M, de Santibanes E, Pekolj J. Training in hepato-pancreato-biliary surgery during residency: past, present and future perspectives. J Hepatobiliary Pancreat Sci. 2016;23(12):741-4. doi:https://doi.org/10.1002/jhbp.403.CrossRefPubMed

11.

Sachs TE, Ejaz A, Weiss M, Spolverato G, Ahuja N, Makary MA et al. Assessing the experience in complex hepatopancreatobiliary surgery among graduating chief residents: is the operative experience enough? Surgery. 2014;156(2):385-93. doi:https://doi.org/10.1016/j.surg.2014.03.006.CrossRefPubMedPubMedCentral

12.

ACGME. Defined Category Minimum Numbers: General Surgery. 2017. https://www.acgme.org/Portals/0/UPDATED_DEFINED_CATEGORY_MINIMUM_NUMBERS_EFFECTIVE_ACADEMIC_YEAR_2017-2018_GENERAL_SURGERY.pdf. Accessed December 12 2017.

13.

D'Angelica MI, Chapman WC. HPB Surgery: The Specialty is Here to Stay, but the Training is in Evolution. Ann Surg Oncol. 2016;23(7):2123-5. doi:https://doi.org/10.1245/s10434-016-5230-3.CrossRefPubMed

14.

Curriculum Outline for General Surgery. Surgical Council on Resident Education, Philadelphia, PA. 2017. http://www.absurgery.org/xfer/curriculumoutline2017-18_book.pdf. Accessed December 18 2017.

15.

Schmidt CM, Turrini O, Parikh P, House MG, Zyromski NJ, Nakeeb A et al. Effect of hospital volume, surgeon experience, and surgeon volume on patient outcomes after pancreaticoduodenectomy: a single-institution experience. Arch Surg. 2010;145(7):634-40. doi:https://doi.org/10.1001/archsurg.2010.118.CrossRefPubMed

16.

Helling TS, Khandelwal A. The challenges of resident training in complex hepatic, pancreatic, and biliary procedures. J Gastrointest Surg. 2008;12(1):153-8. doi:https://doi.org/10.1007/s11605-007-0378-6.CrossRefPubMed

17.

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(12):1010-5. doi:https://doi.org/10.1111/hpb.12088.CrossRefPubMedPubMedCentral

18.

Cortez AR, Dhar VK, Sussman JJ, Pritts TA, Edwards MJ, Quillin RC. Not all operative experiences are created equal: a 19-year analysis of a single center's case logs. Journal of Surgical Research. 2018;229:127-33. doi:https://doi.org/10.1016/j.jss.2018.03.070.CrossRefPubMed

19.

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(2):123-8. doi:https://doi.org/10.1111/j.1477-2574.2009.00146.x.CrossRefPubMedPubMedCentral

20.

Livingston EH, Rege RV. Technical complications are rising as common duct exploration is becoming rare. J Am Coll Surg. 2005;201(3):426-33. doi:https://doi.org/10.1016/j.jamcollsurg.2005.04.029.CrossRefPubMed

21.

Fonseca AL, Reddy V, Longo WE, Gusberg RJ. Graduating general surgery resident operative confidence: perspective from a national survey. J Surg Res. 2014;190(2):419-28. doi:https://doi.org/10.1016/j.jss.2014.05.014.CrossRefPubMed

22.

Birkmeyer JD, Stukel TA, Siewers AE, Goodney PP, Wennberg DE, Lucas FL. Surgeon volume and operative mortality in the United States. N Engl J Med. 2003;349(22):2117-27. doi:https://doi.org/10.1056/NEJMsa035205.CrossRefPubMed

23.

Klingensmith ME, Potts JR, Merrill WH, Eberlein TJ, Rhodes RS, Ashley SW et al. Surgical Training and the Early Specialization Program: Analysis of a National Program. J Am Coll Surg. 2016;222(4):410-6. doi:https://doi.org/10.1016/j.jamcollsurg.2015.12.035.CrossRefPubMed

24.

Birkmeyer JD, Siewers AE, Finlayson EV, Stukel TA, Lucas FL, Batista I et al. Hospital volume and surgical mortality in the United States. N Engl J Med. 2002;346(15):1128-37. doi:https://doi.org/10.1056/NEJMsa012337.CrossRefPubMed

Title: Resident Operative Experience in Hepatopancreatobiliary Surgery: Exposing the Divide
Authors: Alexander R. Cortez
Leah K. Winer
Gianna D. Katsaros
Al-Faraaz Kassam
Shimul A. Shah
Tayyab S. Diwan
R. Cutler Quillin III
Publication date: 01-04-2020
Publisher: Springer US
Keywords: Basic Surgery
Cholecystectomy
Published in: Journal of Gastrointestinal Surgery / Issue 4/2020
Print ISSN: 1091-255X
Electronic ISSN: 1873-4626
DOI: https://doi.org/10.1007/s11605-019-04226-9

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Resident Operative Experience in Hepatopancreatobiliary Surgery: Exposing the Divide

Abstract

Background

Methods

Results

Conclusions

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

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