Complex hepato-pancreato-billiary (HPB) caseload during general surgery residency training: Are we adequately training the next generation?

Abstract

Background: Hepato-pancreato-biliary (HPB) procedures are considered among the most technically complex procedures to teach, requiring repetition and procedural volume to obtain proficiency. Accreditation Council for Graduate Medical Education (ACGME) duty hour regulations, increasing emphasis on quality and efficiency, and regionalization of care may impact the HPB experience of general surgery residents. We sought to define overall numbers, as well as recent trends, in HPB surgical volume among general surgery residents. Methods: The ACGME case log database was used to obtain data on graduating resident procedural volumes between 1999 and 2016. Data on liver cases (lobectomy, segmentectomy and wedge resection), pancreas (pancreatoduodenectomy, distal pancreatectomy), and biliary (common bile duct exploration, choledochoenteric anastomosis) procedures were obtained. Trends in average HPB operative volume, as well as changes in operative volume stratified by resident role (surgeon chief, surgeon junior) were examined over time. Results: During the time period analyzed, the number of general surgery residency programs varied between 240 and 253; the average number of graduating chief residents (GCR) at each program increased over time (1999: 3.9 vs. 2016: 4.8). A total of 388,502 HPB cases (36% liver, 42.6% pancreas, 21.4% biliary) were performed by 19,031 graduating chief residents (GCR) over the 18 years examined (mean number of total HPB cases 20.4 per GCR). The average number of HPB cases among GCR was: liver, 7.4 (range: 6.7 to 8.2), pancreas 6.3 (range: 4.5 to 8.1), and biliary 4.5 (range: 2.8 to 6.8). Most HPB cases were performed during the chief years (58%), while a smaller proportion (42%) were done during the junior years. While the mean number of HPB cases logged as a junior resident remained stable over time over time (1999: 7.9 vs. 2016: 8.0), the vast majority of HPB cases were logged as senior resident cases. The total number of cases increased from 18,778 (mean 18.9) in 1999 to 23,978 (mean 19.8) in 2016. The minimum average number of liver and pancreas cases per resident was 3.1 and 4.5, respectively, in 1999; the mean number of liver and pancreas cases among GCR peaked at 8.2 and 8.1, respectively, in 2008 and has subsequently plateaued (Figure). In contrast, the mean number of complex biliary cases among GCR was highest at 6.6 in 1999 with a steady decrease to 2.8 in 2016. Of note, the standard deviation for all three procedures increased over the study period examined suggesting wide variability in the number of HPB operations performed among GCR at different general surgery programs. Conclusion: While the average number of HPB cases logged by GCR has doubled since 1999, more than one-half of GCR still perform fewer than 20 HPB cases at the time of graduation. In addition, most GCR have done fewer than 10 liver, pancreas, or complex biliary operations. The increasing standard deviation for HPB cases among GCR suggests a widening variability in HPB operative experience among residents. These data suggest that most residents are unlikely to have had the experience or training necessary to perform complex HPB at the time of graduation.