Disparities in hepatopancreatobiliary operative experience among general surgery residents: a 27-year analysis of ACGME case logs

Abstract

Background: The ACGME requires hepatopancreatobiliary (HPB) surgery as a part of general surgery training. In this study, we evaluate the trends in HPB operative experience of general surgery residents. Methods: ACGME national operative log reports from 1990 to 2016 were examined. Trends were analyzed relative to the 2003 duty hour restrictions (DHR): pre-DHR (1990–1999), DHR transition (2000–2008) and post-DHR (2009–2016). Statistical analysis was performed using ANOVA and linear regression analysis. A p-value <0.05 was statistically significant. Results: Operative logs of 27,851 general surgery graduates were examined. Median biliary, liver and pancreatic operative volumes increased by 29.9%, 32.8% and 27.3%, respectively. Operative volume variability, defined as the difference between the most and least prolific residents (90th–10th percentile), increased by 15.5%, 21.2% and 73.0% for these categories (Figure). Trends were then analyzed for specific HPB operations. Increases in operative volume from pre- to post-DHR were seen for laparoscopic cholecystectomy (71.7%), hepatic lobectomy (140.9%), liver transplant (161.9%), distal pancreatectomy (130.8%) and pancreaticoduodenectomy (152.4%, p < 0.05 for each), while decreases were seen for open cholecystectomy (−61.9%), open common bile duct exploration (−76.7%), hepaticojejunostomy (−52.6%) and hepatic wedge resection (−31.4%, p < 0.05 for each). For each specific HPB operation that increased, linear regression analysis revealed an increase in operative volume variability (p < 0.05 for each). Conclusion: While the total HPB operative experience of surgical residents has increased over the past 27-years, an increase in operative volume variability has also occurred, suggesting a dissimilar HPB experience amongst trainees. Educators should be aware of this disparity to ensure equitable training amongst all graduates.