Srinath Chinnakotla, MD
Director of Living Liver Donor Program
University of Minnesota
Medicine, the technological application of scientific knowledge to the treatment of human patients with diseases or injuries, is practiced within the confines of cultural biases and financial constraints. As scientific knowledge and technology change, medicine constantly evolves.
The surgical sciences are particularly influenced by technology. Over the last two decades, advances in optics and radiologic imaging have revolutionized the practice of surgery. It continues to migrate to progressively less invasive approaches: minimally invasive surgery and interventional radiology have redefined treatment for many common diseases. As an example, the treatment of choice for malignant liver tumors was, for decades, open surgical resection, which conferred a 40% chance of five-year survival and a 20% chance of cure for patients with primary hepatocellular carcinoma or metastatic colorectal cancer. But in the last decade, many improvements, including laparoscopic liver resection, have been developed. At first, only superficial and peripheral lesions in anterolateral segments were selected for the laparoscopic approach. More recently, however, centers with extensive experience in laparoscopy and hepatic surgery have also performed major hepatic resections laparoscopically—with satisfactory outcomes. Importantly, no evidence of compromised oncologic clearance has been found in patients who undergo laparoscopic liver resection.
Other new surgical strategies for safer resection include two-stage hepatectomies with portal vein embolization. For patients with unresectable liver metastases, thermal ablation is an option. The percentage of patients who can now be considered for liver resection has jumped to almost 30%. In recent years, better survival rates for patients with primary or metastatic liver cancer have been reported.
Of course, with the development of all these new therapies, academic surgeons face a number of challenges. First and foremost is how to train future surgeons to perform advanced hepatobiliary procedures with competence.
In the last decade, the number of general surgery residents seeking fellowship training has markedly increased. More than 80% of them now pursue subspecialty training after their general surgery residency.1 In particular, interest in complex general surgery has risen, because residents often do not feel prepared for independent practice after graduation. In fact, in the field of hepatobiliary surgery, the typical graduating general surgery resident in the United States in 2012 had performed a mean of only 11.3 ± 4.3 pancreas procedures, 9.4 ± 3.4 liver procedures, and 3.8 ± 2.1 biliary procedures, excluding cholecystectomy.2 Moreover, the Surgical Council on Resident Education (SCORE) curriculum has identified essentially all hepatobiliary procedures as complex, except for cholecystectomy, common bile duct exploration, liver biopsy, and liver abscess drainage. The SCORE curriculum’s definition of complex denotes procedures that are not consistently performed by general surgeons in training and that are not typically performed in general surgery practice. Thus, exposure—but not proficiency—is required; consequently, additional hepatobiliary training after the general surgery residency has become the norm.
In the United States, that additional hepatobiliary training is primarily accredited by the fellowship council of the Americas Hepato-Pancreato-Biliary Association (AHPBA). More than 21 AHPBA-accredited, standalone fellowship programs now offer hepatobiliary surgery training; half are one-year programs, and half are two-year programs. Program requirements include performing, per year, 100 hepatobiliary procedures (including at least 25 liver, 25 pancreas, and 15 biliary procedures). The fellow is expected to be a primary surgeon in at least 70 of those procedures; no more than 20% of them can be transplants.
Other societies accrediting hepatobiliary fellows include the Society of Surgical Oncology (SSO) and the American Society of Transplant Surgeons (ASTS). The SSO offers certification in complex general surgical oncology. Typically, SSO trainees perform more than 150 surgical oncology procedures (including at least 15 complex upper gastrointestinal procedures). According to SSO data, graduates have participated in a median of 35 hepatic procedures, 20 Whipple operations, and 17 pancreatectomies. The SSO also requires its trainees to facilitate multidisciplinary cancer care and to enroll patients in clinical trials.
ASTS requirements for hepatobiliary certification include 35 hepatobiliary procedures (at least 12 hemihepatectomies and 15 biliary procedures); for hepatopancreatobiliary certification, an additional 15 nontransplant major pancreas procedures are required.
As transplant surgeons, we have several skill sets that are required for hepatobiliary procedures. About 20% to 30% of liver transplants are in patients with hepatocellular carcinoma. Pretransplant, we are very involved in the management of those tumors and regularly attend multidisciplinary tumor conferences. We actively collaborate with medical oncologists in delivering chemo-embolization and adjuvant therapies. We are engaged in providing ablation and liver resections. We perform split-liver transplants and living donor liver transplants. Our experience with implanting and explanting livers translates well to ex vivo resections. Our adroitness with various vascular anastomoses (which are necessary during transplants) also translates well to such hepatobiliary procedures as portal vein resections for pancreatic cancer during Whipple operations. And we are deeply familiar with the management of liver failure and portal hypertension, closely collaborating with medical hepatologists to care for such patients.
Obviously, transplant surgery can and should be included as a core element of hepatobiliary surgery training programs (such as those accredited by the AHPBA and SSO). The two main implications of this approach are far-reaching. First, it will provide core transplant experience to future surgeons. Second, it will foster more collaboration between hepatobiliary surgeons and transplant surgeons, so that we can learn from each other and ultimately provide better care to our patients. A key step in the right direction was the recent joint conference (conducted at San Francisco on October 27, 2014, by the AHPBA, SSO, and ASTS) to develop a consensus on hepatobiliary surgery training guidelines.
In conclusion, every academic transplant program should have a hepatobiliary surgery portfolio and needs to understand the critical need for hepatobiliary surgery training, both during and especially after the general surgery residency. We must collaborate even more closely with our AHPBA and SSO colleagues to have the greatest impact on patient care and on the next generation of surgeon-scientists.
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- Borman KR, Vick LR, Biester TW et al. changing demographics of residents choosing fellowships: longterm data from the American Board of Surgery. J Am Coll Surg.2008; 206:782-788; discussion 788-789
- Sachs TE, Ejaz A, Weiss M et al. Assessing the experience in complex hepatopancreatobiliary surgery among graduating chief residents: is the operative experience enough? Surgery 2014;156:385-393.
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