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

“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

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

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

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

How should we train the HBP surgeon? and What Is the Current Status of Postgraduate Training in HBP Surgery?

….” By definition, HBP surgeons had to have one full year of training in HPB surgery with or without training in liver transplantation”

EBSQ Examinations in HPB Surgery

……at least 50 major HBP procedures

The Hepatobiliary Institute’s objective : henri.bismuth@pbr.aphp.fr .ihb2.org www The Hepatobiliary Institute’s 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.

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

Romanian Model of the Hepato-Bilio-Pancreatic Surgery Training

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

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 VIOREL SCRIPCARIU

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

983 HBP SURGICAL PROCEDURES Fundeni Clinical Institute High volume center 983 HBP SURGICAL PROCEDURES

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

Who Should Attend? Letter of intention Letters of recommendations The applicant- Board Certified General Surgeon - Board Certified Pediatric Surgeon CANDIDATE SELECTION by: Letter of intention Letters of recommendations Oral interview

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

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

TOPICS Liver Resections Biliary Tract Surgery Liver Vascular Reconstruction Pancreatic Surgery Multidisciplinary Oncological Approach of HBP Pathology Organ Transplantation - LT 24

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

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

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

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;

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