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BACKGROUND: The 2022 incoming fellows' expectations for their robotics training, as well as their perceptions of the utility of the surgical robot, are not well defined. METHODS: Cross-sectional survey of 24 AHPBA fellows in 2022, analyzed with descriptive statistics and Spearman's rho. RESULTS: Of 33 current AHPBA fellows, 22 completed the survey (66.7%). Study participants had limited-to-moderate experience with robotics prior to fellowship (mean 2.5 ± SD 1.1; range 1-4). Most participants agreed that robotics influenced their fellowship choice (mean 4.14 ± SD 0.87; range 1-5), would make then more marketable (mean 4.77 ± SD 0.52; range 1-5) and improve job prospects (mean 4.68 ± SD 0.87; range 1-5). Of the study participants, 55% responded that robotics training is "essential" in fellowship, while 64% responded that it is "essential" for their careers. Fellows were only slightly satisfied with overall robotics training within their respective programs (mean 3.44 ± SD 1.17; range 1-5) The majority (73.7%) expect that robotics will comprise <25% of their training. Notably, the majority (75%) have no formal robotics training curriculum. DISCUSSION: This survey identifies potential gaps where robotics training could be improved for future incoming AHPBA fellows.
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Procedimentos Cirúrgicos Robóticos , Humanos , Bolsas de Estudo , Estudos Transversais , Currículo , Inquéritos e Questionários , Educação de Pós-Graduação em Medicina , Competência ClínicaRESUMO
Background: Lymph node ratio (LNR; positive/harvested lymph nodes) was identified as overall survival predictor in several cancers, including pancreatic adenocarcinoma. It remains unclear if LNR is predictive of overall survival in pancreatic adenocarcinoma patients staged pN2. This study assessed the prognostic overall survival role of LNR in pancreatic adenocarcinoma patients in relation with lymph node involvement. Methods: A retrospective international study in six different centers (Europe and United States) was performed. Pancreatic adenocarcinoma patients who underwent pancreatoduodenectomy from 2000 to 2017 were included. Patients with neoadjuvant treatment, metastases, R2 resections, or missing data regarding nodal status were excluded. Survival curves were calculated using Kaplan-Meier method and compared using log-rank test. Multivariable Cox regressions were performed to find independent overall survival predictors adjusted for potential confounders. Results: A total of 1,327 patients were included. Lymph node involvement (pN+) was found in 1,026 patients (77%), 561 pN1 (55%) and 465 pN2 (45%). Median LNR in pN+ patients was 0.214 [interquartile range (IQR): 0.105-0.364]. On multivariable analysis, LNR was the strongest overall survival predictor in the entire cohort [hazard ratio (HR) =5.5; 95% confidence interval (CI): 3.1-9.9; P<0.001] and pN+ patients (HR =3.8; 95% CI: 2.2-6.6; P<0.001). Median overall survival was better in patients with LNR <0.225 compared to patients with LNR ≥0.225 in the entire cohort and pN+ patients. Similar results were found in pN2 patients (worse overall survival when LNR ≥0.225). Conclusions: LNR appeared as an important prognostic factor in patients undergoing surgery for pancreatic adenocarcinoma and permitted to stratify overall survival in pN2 patients. LNR should be routinely used in complement to tumor-node-metastasis (TNM) stage to better predict patient prognosis.
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Robotic surgery is being increasingly used for complex benign and malignant hepato-pancreato-biliary (HPB) cases. As use of robotics increases, fellowships to excel in complex robotic procedures will be sought after. With this dedicated training, attending surgeon positions can be obtained that can incorporate and teach this skill set. Unfortunately, there are no evidence-based approaches for constructing a curriculum for an HPB robotic surgery fellowship. This paper describes a technique to develop a structured curriculum to ensure competence and fulfil the learning and practice needs for robotic HPB fellows.
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Procedimentos Cirúrgicos do Sistema Biliar/educação , Currículo , Procedimentos Cirúrgicos do Sistema Digestório/educação , Bolsas de Estudo , Internato e Residência , Procedimentos Cirúrgicos Robóticos/educação , Cirurgiões/educação , Humanos , Robótica , Inquéritos e QuestionáriosRESUMO
Background: Innovative methodologies to redesign care delivery are being applied to increase value in health care, including the creation of enhanced recovery pathways (ERPs) for surgical patients. However, there is a lack of standardized methods to evaluate ERP implementation costs. Objectives: This Recommendations Statement aims to introduce a standardized framework to guide the economic evaluation of ERP care-design initiatives, using the Time-Driven Activity-Based Costing (TDABC) methodology. Methods: We provide recommendations on using the proposed framework to support the decision-making processes that incorporate ERPs. Since ERPs are usually composed of activities distributed throughout the patient care pathway, the framework can demonstrate how the TDABC may be a valuable method to evaluate the incremental costs of protocol implementation. Our recommendations are based on the review of available literature and expert opinions of the members of the TDABC in Healthcare Consortium. Results: The ERP framework, composed of 11 steps, was created describing how the techniques and methods can be applied to evaluate the economic impact of an ERP and guide health-care leaders to optimize the decision-making process of incorporating ERPs into health-care settings. Finally, six recommendations are introduced to demonstrate that using the suggested framework could increase value in ERP care-design initiatives by reducing variability in care delivery, educating multidisciplinary teams about value in health, and increasing transparency when managing surgical pathways. Conclusions: Our proposed standardized framework can guide decisions and support measuring improvements in value achieved by incorporating the perioperative redesign protocols.
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BACKGROUND: The development of technical dexterity is a critical for surgeons in training. This study describes and assesses the feasibility of an objective method for the evaluation of procedure-specific technical dexterity in hepatopancreatobiliary (HPB) surgery using cumulative sum (CUSUM) analysis. METHODS: Dry-lab HPB procedures were divided into procedural steps with binary outcomes (success or failure). Two HPB fellows completed 20 dry lab hepaticojejunostomy (HJ) procedures. Participant progress was tracked over time with CUSUM analytics to establish a learning curve for procedural proficiency. RESULTS: The CUSUM charts for 20 consecutive dry-lab HJ procedures were analysed. A learning curve was created and used to identify areas of weakness to facilitate improvement in technical proficiency. CONCLUSIONS: CUSUM is effective tool for objective evaluation of technical dexterity offering both simplicity and adaptability. We demonstrate its use and feasibility for surgical education and plan to expand its' application to assess residents performing general surgery procedures.
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Procedimentos Cirúrgicos Robóticos , Robótica , Cirurgiões , Anastomose Cirúrgica , Competência Clínica , Humanos , Curva de AprendizadoRESUMO
BACKGROUND: As Enhanced Recovery After Surgery (ERAS®) programs expand across numerous subspecialties, growth and sustainability on a system level becomes increasingly important and may benefit from reporting multidisciplinary and financial data. However, the literature on multidisciplinary outcome analysis in ERAS is sparse. This study aims to demonstrate the impact of multidisciplinary ERAS auditing in a hospital system. Additionally, we describe developing a financial metric for use in gaining support for system-wide ERAS adoption and sustainability. METHODS: Data from HPB, colorectal and urology ERAS programs at a single institution were analyzed from a prospective ERAS Interactive Audit System (EIAS) database from September 2015 to June 2019. Clinical 30-day outcomes for the ERAS cohort (n = 1374) were compared to the EIAS pre-ERAS control (n = 311). Association between improved ERAS compliance and improved outcomes were also assessed for the ERAS cohort. The potential multidisciplinary financial impact was estimated from hospital bed charges. RESULTS: Multidisciplinary auditing demonstrated a significant reduction in postoperative length of stay (LOS) (1.5 days, p < 0.001) for ERAS patients in aggregate and improved ERAS compliance was associated with reduced LOS (coefficient - 0.04, p = 0.004). Improved ERAS compliance in aggregate also significantly associated with improved 30-day survival (odds ratio 1.04, p = 0.001). Multidisciplinary analysis also demonstrated a potential financial impact of 44% savings (p < 0.001) by reducing hospital bed charges across all specialties. CONCLUSIONS: Multidisciplinary auditing of ERAS programs may improve ERAS program support and expansion. Analysis across subspecialties demonstrated associations between improved ERAS compliance and postoperative LOS as well as 30-day survival, and further suggested a substantial combined financial impact.
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Doenças do Sistema Digestório/cirurgia , Recuperação Pós-Cirúrgica Melhorada , Procedimentos Cirúrgicos Operatórios , Doenças Urológicas/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Doenças do Sistema Digestório/mortalidade , Feminino , Fidelidade a Diretrizes , Preços Hospitalares , Humanos , Tempo de Internação/economia , Masculino , Auditoria Médica , Pessoa de Meia-Idade , Estudos Retrospectivos , Procedimentos Cirúrgicos Operatórios/economia , Procedimentos Cirúrgicos Operatórios/mortalidade , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Doenças Urológicas/mortalidade , Adulto JovemRESUMO
BACKGROUND: Cholecystectomy is a common procedure with significantly varied outcomes. We analyzed differences in comorbidities, outcomes, and cost of cholecystectomy by acute care surgery (ACS) versus hepatopancreaticobiliary (HPB) surgery. STUDY DESIGN: Patients were retrospectively identified between 2008 and 2015. Exclusion criteria included the following: (1) part of another procedure; (2) abdominal trauma; (3) ICU admission; vasopressors. RESULTS: One hundred and twenty-six ACS and 122 HPB patients were analyzed. The HPB subset had higher burden of comorbid disease and significantly lower projected 10-year survival (87.4% ACS vs 68.5% HPB, P < .0001). Median lengths of stay were longer in HPB patients (2 vs 5 days, P < .0001) as were readmission rates (30-day 5.6% vs 13.1%, P = .040; 90-day 7.9% vs 20.5%, P = .005). Median cost was higher including operative supply cost ($969.42 vs $1920.66, P < .0001) and total cost of care ($7340.66 vs $19 338.05, P < .0001). A predictive scoring system for difficult gallbladders was constructed and a phone application was created. CONCLUSION: Cholecystectomy in a complicated patient can be difficult with longer hospital stays and higher costs. The utilization of procedure codes to explain disparities is not sufficient. Incorporation of comorbidities needs to be addressed for planning and reimbursement.
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Colecistectomia/estatística & dados numéricos , Doenças da Vesícula Biliar/cirurgia , Adulto , Idoso , Colecistectomia/economia , Comorbidade , Feminino , Doenças da Vesícula Biliar/economia , Custos de Cuidados de Saúde/estatística & dados numéricos , Hospitalização/economia , Humanos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/economia , Estudos Retrospectivos , Fatores de Risco , Adulto JovemRESUMO
BACKGROUND: ERAS protocol compliance is traditionally measured and reported as 'items compliance' which is retrospective longitudinal adherence of all patients to an index element. Reporting in this manner is restrictive and cannot impact care in real-time. In order to modify behavior effectively and instantaneously, we seek to introduce the novel concept of "vertical compliance". METHODS: Vertical compliance is defined as assessment of an individual's compliance along his/her own surgical pathway as ERAS index items are encountered. Prospectively entered data from the ERAS Interactive Audit System (EIAS) database was queried for all patients who underwent pancreatic or hepatic resections. Individual linear regression models were generated using compliance data from 46 ERAS index items against LOS. Significant items with p value < 0.05 were compiled into multivariable linear regression models; each with a unique coefficient that could be used to predict effect on LOS as well as control for the effect of the other items in the model. RESULTS: Compliance data from 483 patients who underwent pancreatic resections and 292 patients who underwent hepatic resections was compiled. Seven ERAS items for pancreatic resections and six ERAS items for hepatic resections were found to significantly impact LOS. Regression models were created for each of the items in an additive fashion. Calculations to determine predicted LOS as a patient progressed through a pathway was able to be determined. CONCLUSION: Vertical compliance is a novel metric, described in this study, that can provide significant and accurate patient-specific risk prediction to impact care in real-time. This can allow for creation of a variable echelon such that pathway items can be ranked by importance on clinical outcome effect and patient progress can be monitored and altered.
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Fidelidade a Diretrizes , Cooperação do Paciente , Feminino , Humanos , Tempo de Internação , Masculino , Complicações Pós-Operatórias , Recuperação de Função Fisiológica , Estudos Retrospectivos , Medição de RiscoRESUMO
BACKGROUND: Since 2012, the AHPBA has hosted an annual HPB Fellows' Course at Carolinas Medical Center. All fellows training in an accredited HPB fellowship are eligible to attend. The aim of this study was to evaluate the impact of this conference and assess possible areas of improvement. METHODS: The Carolinas Fellows' Course (CFC) is a structured educational activity involving didactics, skills labs, and live case presentations. The course emphasizes minimally invasive surgery (MIS) and intraoperative ultrasound (IOUS) technique. This is a retrospective review of a survey emailed to 95 fellows who have attended the course over a 7-year period. RESULTS: Fifty-two attendees completed the survey (54.7% response rate). Sixty-eight percent of respondents now practice primarily HPB surgery. Seventy-six percent agreed that the CFC encouraged them to incorporate IOUS into their practice, while 74% were encouraged to incorporate MIS HPB procedures into their practice. Eighty percent felt that the course laid groundwork for long term communication with peers. CONCLUSION: The study demonstrates that a multisite instructional course can be an effective way to encourage the development of new skills, boost operational confidence, impact real world practices, and foster long term communication and networking among fellows after graduation.
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Comunicação , Bolsas de Estudo , Competência Clínica , Educação de Pós-Graduação em Medicina , Retroalimentação , Humanos , Estudos Retrospectivos , Inquéritos e QuestionáriosRESUMO
Postoperative laboratory testing is an underrecognized but substantial contributor to health-care costs. We aimed to develop and validate a clinically meaningful laboratory (CML) protocol with individual risk stratification using generalizable and institution-specific predictive analytics to reduce laboratory testing and maximize cost savings for low-risk patients. An institutionally based risk model was developed for pancreaticoduodenectomy and hepatectomy, and an ACS-NSQIP®-based model was developed for distal pancreatectomy. Patients were stratified in each model to the CML by individual risk of major complications, readmission, or death. Clinical outcomes and estimated cost savings were compared with those of a historical cohort with standard of care. Over 34 months, 394 patients stratified to the CML for pancreaticoduodenectomy or hepatectomy saved an estimated $803,391 (44.4%). Over 13 months, 52 patients stratified to the CML for distal pancreatectomy saved an estimated $81,259 (30.5%). Clinical outcomes for 30-day major complications, readmission, and mortality were unchanged after implementation of either model. Predictive analytics can target low-risk patients to reduce laboratory testing and improve cost savings, regardless of whether an institutional or a generalized risk model is implemented. Broader application is important in patient-centered health care and should transition from predictive to prescriptive analytics to guide individual care in real time.
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Protocolos Clínicos , Controle de Custos , Testes Diagnósticos de Rotina/economia , Hepatectomia , Preços Hospitalares/estatística & dados numéricos , Pancreatectomia , Pancreaticoduodenectomia , Cuidados Pós-Operatórios/economia , Medição de Risco/métodos , Algoritmos , Feminino , Humanos , Masculino , Estudos Prospectivos , Melhoria de Qualidade , Estados UnidosRESUMO
For over two decades, enhanced recovery pathways have been implemented in many surgical disciplines, most notably in colorectal surgery. Since 2001, the Enhanced Recovery After Surgery (ERAS®) Study Group has developed a main protocol comprising 24 evidence-based core items. While these core items unite similar preoperative, intraoperative, and postoperative principles across surgical subspecialties, variations and modifications exist to these core items based on unique considerations for each surgical subspecialty. This overview will summarize overarching principles for ERAS within hepatopancreaticobiliary (HPB) surgery, first summarizing Pancreaticoduodenectomy and Hepatectomy ERAS Society Guidelines. Specifically, principles and areas of current debate regarding preoperative oral carbohydrate loading/fasting, perioperative fluid management, and analgesia will be discussed. While institutions are beginning to realize both clinical and financial benefits of ERAS within HPB surgery, enhanced recovery remains a relatively recent phenomenon within the field. The complex patient population, high morbidity, and resource-intensive care involved in HPB surgery certainly warrant special consideration. To continue to promote improved clinical outcomes in a cost-effective manner, the ERAS Society will continue to actively address concerns and ensure all recommendations are based on the most up-to-date scientific evidence within the field of HPB surgery.
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Procedimentos Cirúrgicos do Sistema Biliar/métodos , Hepatectomia/métodos , Pancreaticoduodenectomia/métodos , Procedimentos Cirúrgicos do Sistema Biliar/economia , Hepatectomia/economia , Humanos , Assistência Perioperatória/métodos , Guias de Prática Clínica como AssuntoAssuntos
Atenção à Saúde/métodos , Tempo de Internação/estatística & dados numéricos , Assistência Perioperatória/métodos , Complicações Pós-Operatórias/prevenção & controle , Aquisição Baseada em Valor/economia , Atenção à Saúde/economia , Humanos , Tempo de Internação/economia , Assistência Perioperatória/economia , Complicações Pós-Operatórias/economiaRESUMO
BACKGROUND: This study compares clinical and cost outcomes of robot-assisted laparoscopic (RAL) and open longitudinal pancreaticojejunostomy (LPJ) for chronic pancreatitis. METHODS: Clinical and cost data were retrospectively compared between open and RAL LPJ performed at a single center from 2008-2015. RESULTS: Twenty-six patients underwent LPJ: 19 open and 7 RAL. Two robot-assisted cases converted to open were included in the open group for analysis. Patients undergoing RAL LPJ had less intraoperative blood loss, a shorter surgical length of stay, and lower medication costs. Operation supply cost was higher in the RAL group. No difference in hospitalization cost was found. CONCLUSIONS: Versus the open approach, RAL LPJ performed for chronic pancreatitis shortens hospitalization and reduces medication costs; hospitalization costs are equivalent. A higher operative cost for RAL LPJ is mitigated by a shorter hospitalization. Decreased morbidity and healthcare resource economy support use of the robotic approach for LPJ when appropriate.
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Pancreaticojejunostomia/métodos , Pancreatite Crônica/cirurgia , Procedimentos Cirúrgicos Robóticos/métodos , Adulto , Custos e Análise de Custo , Feminino , Custos de Cuidados de Saúde , Humanos , Laparoscopia/economia , Laparoscopia/métodos , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/economia , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Pancreaticojejunostomia/economia , Pancreatite Crônica/economia , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/economia , Resultado do TratamentoRESUMO
Early in their careers, many new surgeons lack the background and experience to understand essential components needed to build a surgical practice. Surgical resident education is often devoid of specific instruction on the business of medicine and practice management. In particular, hepatobiliary and pancreatic (HPB) surgeons require many key components to build a successful practice secondary to significant interdisciplinary coordination and a scope of complex surgery, which spans challenging benign and malignant disease processes. In the following, we describe the required clinical and financial components for developing a successful HPB surgery practice in the nonuniversity tertiary care center. We discuss significant financial considerations for understanding community need and hospital investment, contract establishment, billing, and coding. We summarize the structural elements and key personnel necessary for establishing an effectual HPB surgical team. This article provides useful, essential information for a new HPB surgeon looking to establish a surgical practice. It also provides insight for health-care administrators as to the value an HPB surgeon can bring to a hospital or health-care system.
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Gastroenterologia/organização & administração , Administração da Prática Médica/organização & administração , Especialidades Cirúrgicas/organização & administração , Centros de Atenção Terciária/organização & administração , Codificação Clínica , Delegação Vertical de Responsabilidades Profissionais , Gastroenterologia/economia , Humanos , Hepatopatias/cirurgia , Marketing de Serviços de Saúde/métodos , Marketing de Serviços de Saúde/organização & administração , Salas Cirúrgicas/organização & administração , Pancreatopatias/cirurgia , Densidade Demográfica , Administração da Prática Médica/economia , Área de Atuação Profissional , Encaminhamento e Consulta/organização & administração , Pesquisa , Salários e Benefícios/economia , Especialidades Cirúrgicas/economia , Centros de Atenção Terciária/economia , Estados UnidosRESUMO
BACKGROUND: Hepato-pancreato-biliary (HPB) surgery is a complex subspecialty drawing from varied training pools, and the need for competency is rapidly growing. However, no board certification process or standardized training metrics in HPB surgery exist in the Americas. This study aims to assess the attitudes of current trainees and HPB surgeons regarding the state of training, surgical practice and the HPB surgical job market in the Americas. STUDY DESIGN: A 20-question survey was distributed to members of Americas Hepato-Pancreato-Biliary Association (AHPBA) with a valid e-mail address who attended the 2014 AHPBA. Descriptive statistics were generated for both the aggregate survey responses and by training category. RESULTS: There were 176 responses with evenly distributed training tracks; surgical oncology (44, 28%), transplant (39, 24.8%) and HPB (38, 24.2%). The remaining tracks were HPB/Complex gastrointestinal (GI) and HPB/minimally invasive surgery (MIS) (29, 16% and 7, 4%). 51.2% of respondents thought a dedicated HPB surgery fellowship would be the best way to train HPB surgeons, and 68.1% felt the optimal training period would be a 2-year clinical fellowship with research opportunities. This corresponded to the 67.5% of the practicing HPB surgeons who said they would prefer to attend an HPB fellowship for 2 years as well. Overall, most respondents indicated their ideal job description was clinical practice with the ability to engage in clinical and/or outcomes research (52.3%). CONCLUSIONS: This survey has demonstrated that HPB surgery has many training routes and practice patterns in the Americas. It highlights the need for specialized HPB surgical training and career education. This survey shows that there are many ways to train in HPB. A 2-year HPB fellowship was felt to be the best way to train to prepare for a clinically active HPB practice with clinical and outcomes research focus.