Investigating Factors at Play in Hepatopancreatobiliary Fellowship Selection: Beliefs versus Reality.

BACKGROUND: Selection biases affecting candidate matches to fellowship programs directly influence diversity within the surgical community. The review of selection bias has never been distinctively investigated in the Hepatopancreatobiliary (HPB) surgery community. This study seeks to (i) evaluate factors affecting selection of candidates to HPB fellowships, (ii) examine explicit biases among program directors and faculty of HPB programs in North America, and (iii) compare the demography of the HPB faculty and recently graduated fellows to general surgery residents. STUDY DESIGN: An anonymous, self-reported survey consisting of 10 sets of fictional applications was distributed to 52 faculty members, including program directors, of AHPBA-affiliated HPB fellowships in North America. The respondents had to pick a preferred candidate between two abridged, fictional HPB fellow applications and give an open-ended response as to why they picked that candidate. The applications were nearly identical with one notable characteristic of interest. Demographic information of both faculty and their recent fellows was also collected. This survey was administered and collected between February and April, 2020. RESULTS: A total of 29 fully completed responses were received, comprising a 55.7% response rate. Respondents were 72.4% male, 69.0% Caucasian, and 79.3% held US medical degrees (MD). 50.0% of respondents preferred an MD candidate to a DO candidate, and 37% preferred US graduates to foreign-trained candidates. The respondents were unanimous in stating that gender, race, and family status were not a factor in their selection process. 5.0% said they would support an LGBTQ candidate when faced with otherwise similar applicants. Seventy-six HPB fellows from the past 5 years were 76.3% male, 56.6% Caucasian, and 51.3% US graduated Doctor of Medicine (US MD). CONCLUSION: This is the first study explicitly exploring the impact of demographic factors in the HPB fellowship selection process. The respondents unanimously and explicitly stated that race and gender do not play any role in their selection process. Yet, there is stark discordance between general surgery resident demographics and HPB fellow demographics. A greater effort to promote a more diverse HPB surgery community may be needed.

Overcoming the Arduous Transition for Robotic Hepatopancreatobiliary Cases: A Multi-Procedure Learning Curve Study Utilizing CUSUM Analysis.

BACKGROUND/OBJECTIVE: Quick optimization and mastery of a new technique is an important part of procedural medicine, especially in the field of minimally invasive surgery. Complex surgeries such as robotic pancreaticoduodenectomies (RPD) and robotic distal pancreatectomies (RDP) have a steep learning curve; therefore, findings that can help expedite the burdensome learning process are extremely beneficial. This single-surgeon study aims to report the learning curves of RDP, RPD, and robotic Heller myotomy (RHM) and to review the results' implications for the current state of robotic hepatopancreaticobiliary (HPB) surgery. STUDY DESIGN: This is a retrospective case series of a prospectively maintained database at a non-university tertiary care center. Total of 175 patients underwent either RDP, RPD, or RHM with the surgeon (DRJ) from January 2014 to January 2020. RESULTS: Statistical significance of operating room time (ORT) was noted after 47 cases for RDP (p < 0.05), 51 cases for RPD (p < 0.0001), and 18 cases for RHM (p < 0.05). Mean ORT after the statistical mastery of the procedure for RDP, RPD, and RHM was 124, 232, 93 min, respectively. No statistical significance was noted for estimated blood loss or length of stay. CONCLUSIONS: Robotic HPB procedures have significantly higher learning curves compared to non-HPB procedures, even for an experienced HPB surgeon with extensive laparoscopic experience. Our RPD curve, however, is quicker than the literature average. We suggest that this is because of the simultaneous implementation of HPB (RDP and RPD) and non-HPB robotic surgeries with a shorter learning curve-especially foregut procedures such as RHM-into an experienced surgeon's practice. This may accelerate the learning process without compromising patient safety and outcomes.

Incipient Intracholecystic Papillary Neoplasm of the Gallbladder Without Dysplasia.

Intracholecystic papillary neoplasm (ICPN) of the gallbladder is a rare tumor described as a mucosal exophytic neoplastic lesion that projects into the gallbladder lumen. In regards to the size, lesions that did not make the arbitrary 1cm cutoff are described as "incipient" ICPN. Not much is known about these incipient ICPNs, as they are often excluded in ICPN studies, given the attempted adherence to the traditional 1cm cutoff. We present the youngest reported case of incipient, non-mucinous gastric-pylorus type ICPN who underwent cholecystectomy. Resection with negative margin for ICPN appears to be sufficient treatment and post resection imaging surveillance could be of value but further studies are required.

Hepatopancreatobiliary Fellowship Graduates: Where Do They Stand today?

BACKGROUND: The Americas Hepato-Pancreato-Biliary Association (AHPBA) Education and Training Committee standardized a Hepatopancreatobiliary (HPB) Surgery Fellowship certification process in 2010. Several classes of fellows have since graduated from HPB, combined Society of Surgical Oncology/AHPBA, and combined American Society of Transplant Surgeons/AHPBA fellowships, but there is little information on their career outcomes. We seek to offer long-term data on the careers of HPB fellowship graduates. METHODS: A 26-question anonymous survey was distributed among graduates of accredited programs for the last 10 years. We generated descriptive statistics from the responses. RESULTS: The respondents were evenly distributed in terms of graduation years between 2010 and 2019. Fifty-eight percent of fellows had completed a prior fellowship, 82% received 1 to 3 job offers during the fellowship, and 75% of respondents were still at their first job. The majority of graduates (>60%) were able to secure a job with a >50% HPB practice and >40 HPB cases per year within 3 years of graduation. Overall, >90% candidates rated their satisfaction with fellowship training greater than 8 out of 10. DISCUSSION: This survey helps shed light on the early formative years in the practices of HPB fellowship graduates. These data show that HPB fellowship training is essential and effective in providing job security and helps fellowship graduates develop a gratifying practice.

Minimally Invasive Lower Anterior Resections - Better than Open But Not All the Same.

Background/Objective: Optimal approach for lower anterior resection has been closely debated. The relatively new addition of the robotic approach adds a layer of complexity to this topic. The majority of the literature has compared the possible approaches between two techniques; however, only a few studies have comprehensively compared all 3 approaches at the same time, especially in a non-academic center.Study Design: This is a retrospective cohort study of a prospectively maintained database of data from a large group of private-practice colorectal surgeons in a large metropolitan area. Specifically, rectal resections using open, laparoscopic, and robotic approaches were queried. A total of 130 patients underwent open, laparoscopic, or robotic oncological lower anterior resection from 2016 to January 2020.Results: Statistical significance of length of stay was noted between the three approaches with the mean length of stay for open being 8.08 days, laparoscopic being 7.04 days, and robotic being 4.96 days (P < .005). No statistical significance was noted for estimated blood loss, operating time, or postoperative complications including anastomotic leak, ileus, pneumonia, pulmonary embolism, surgical site infection, and urinary tract infection. When directly comparing any minimally invasive surgery approach to open, estimated blood loss was decreased in addition to the shortened length of stay (P < .05).Conclusions: This study demonstrates that MIS LAR has significant benefit over the open approach. However, finding that robotic surgery had was superior to laparoscopic LAR which was surprising and important. This experience in the private world raises the question as to whether robotic LAR should be considered the standard of care.