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Journal of Gastrointestinal Surgery

, Volume 16, Issue 8, pp 1597–1604 | Cite as

A Modern Approach to Teaching Pancreatic Surgery

Stepwise Pancreatoduodenectomy for Trainees
  • Gabriele Marangoni
  • Gareth Morris-Stiff
  • Sunita Deshmukh
  • Abdul Hakeem
  • Andrew M. SmithEmail author
How I do it

Abstract

Introduction

Pancreatoduodenectomy (PD) has always been regarded as one of the most technically demanding abdominal procedures, even when carried out in high-volume centers by experienced surgeons. The reduction in higher surgical trainees working hours has led to reduced exposure, and consequently less experience in operative procedures. Furthermore, trainees have also become victims as health care systems striving for operating room efficiency, have attempted to reduce procedure duration by encouraging consultant led procedures at the expense of training. A strategy therefore needs to be developed to match the ability of the trainee with the complexity of the surgical procedure. As a PD can be deconstructed into a number of different steps, it may indeed be an ideal training operation for varying levels of ability.

Methods

We describe our technique for PD and break it down to nine steps of varying technical ability making it suitable for many different stages of surgical training.

Results

The complexity and variety of steps required to perform a PD makes it an ideal training operation from the junior surgical trainee to the most senior fellow, allowing the development of a wide range of skill sets.

Discussion

Since the introduction of reduced working hours (48 h per week in Europe and 80 h per week in the USA) the “apprenticeship” model of surgical training has shifted towards a time-limited program with greater emphasis on supervision. Due to the complexity of surgery, and the perception of diminished levels of trainees’ competency, a PD is often viewed as a consultant level operation. We believe that PD is an excellent model as it provides opportunities for trainees with varying levels of operative experience so that a PD could be considered the ideal “teaching case”. Breaking down PD into a number of different steps may help building up surgical expertise more quickly while maintaining patients’ safety and allowing the surgery to be expedited in a timely manner.

Keywords

Pancreatoduodenectomy Surgical training EWTD ACGME 

References

  1. 1.
    Yeo CJ, Cameron JL, Sohn TA, Lillemoe KD, Pitt HA, Talamini MA, Hruban RH, Ord SE, Sauter PK, Coleman J, Zahurak ML, Grochow LB, Abrams RA. Six hundred fifty consecutive pancreaticoduodenectomies in the 1990s: pathology, complications, and outcomes. Ann Surg 1997; 226(3):248–257PubMedCrossRefGoogle Scholar
  2. 2.
    Halloran CM, Ghaneh P, Bosonnet L, Hartley MN, Sutton R, Neoptolemos JP. Complications of pancreatic cancer resection. Dig Surg 2002; 19(2):138–146PubMedCrossRefGoogle Scholar
  3. 3.
    Schmidt CM, Turrini O, Parikh P, House MG, Zyromski NJ, Nakeeb A, Howard TJ, Pitt HA, Lillemoe KD. Effect of hospital volume, surgeon experience, and surgeon volume on patient outcomes after pancreaticoduodenectomy: a single-institution experience. Arch Surg 2010; 145(7):634–640PubMedCrossRefGoogle Scholar
  4. 4.
    Sosa JA, Bowman HM, Gordon TA, Bass EB, Yeo CJ, Lillemoe KD, Pitt HA, Tielsch JM, Cameron JL. Importance of hospital volume in the overall management of pancreatic cancer. Ann Surg. 1998; 228(3):429–438.PubMedCrossRefGoogle Scholar
  5. 5.
    Fong Y, Gonen M, Rubin D, Radzyner M, Brennan MF. Long-term survival is superior after resection for cancer in high-volume centers. Ann Surg. 2005; 242(4):540–547PubMedGoogle Scholar
  6. 6.
    Birkmeyer JD, Finlayson SR, Tosteson AN, Sharp SM, Warshaw AL, Fisher ES. Effect of hospital volume on in-hospital mortality with pancreaticoduodenectomy. Surgery 1999;125(3):250–256PubMedCrossRefGoogle Scholar
  7. 7.
    Eppsteiner RW, Csikesz NG, McPhee JT, Tseng JF, Shah SA. Surgeon volume impacts hospital mortality for pancreatic resection. Ann Surg. 2009;249(4): 635–640PubMedCrossRefGoogle Scholar
  8. 8.
    Tseng JF, Pisters PW, Lee JE, Wang H, Gomez HF, Sun CC, Evans DB. The learning curve in pancreatic surgery. Surgery 2007;141(4):456–463PubMedCrossRefGoogle Scholar
  9. 9.
    Hardacre JM. Is there a learning curve for pancreaticoduodenectomy after fellowship training? HPB Surg. 2010;2010:230287. Epub 2011 Jan 24Google Scholar
  10. 10.
    Council of the European Union. Council Directive 93/104/EC 1993Google Scholar
  11. 11.
    NHS Management Executive. Junior Doctors, the New Deal. Working Arrangements for Hospital Doctors and Dentists in Training. London: DH; June 1991.Google Scholar
  12. 12.
    Donaldson L. Unfinished Business: Proposals for Reform of the Senior House Officer Grade. London: DH; August 2002Google Scholar
  13. 13.
    Phillips H, Fleet Z, Bowman K. The European Working Time Directive – interim report and guidance from the Royal College of Surgeons of England Working Party chaired by Mr Hugh Phillips. London: Royal College of Surgeons; January 2003Google Scholar
  14. 14.
    Damadi A, Davis AT, Saxe A, Apelgren K. ACGME duty-hour restrictions decrease resident operative volume: a 5-year comparison at an ACGME-accredited university general surgery residency. J Surg Educ. 2007 Sep–Oct;64(5):256–259 PubMedCrossRefGoogle Scholar
  15. 15.
    Ferguson CM, Kellogg KC, Hutter MM, Warshaw AL. Effect of work-hour reforms on operative case volume of surgical residents. Curr Surg. 2005 Sep–Oct;62(5):535–538PubMedCrossRefGoogle Scholar
  16. 16.
    Rohatgi A, Sutcliffe R, Forshaw MJ, Strauss D, Mason RC. Training in oesophageal surgery—the gold standard: a prospective study. Int J Surg. 2008 Jun;6(3):230–233.PubMedCrossRefGoogle Scholar
  17. 17.
    Borowski DW, Ratcliffe AA, Bharathan B, Gunn A, Bradburn DM, Mills SJ, Wilson RG, Kelly SB; Northern Region Colorectal Cancer Audit Group (NORCCAG). Involvement of surgical trainees in surgery for colorectal cancer and their effect on outcome. Colorectal Dis. 2008 Oct;10(8):837–845.PubMedCrossRefGoogle Scholar
  18. 18.
    Chaudhuri N, Grayson AD, Grainger R, Mediratta NK, Carr MH, Soorae AS, Page RD. Effect of training on patient outcomes following lobectomy. Thorax 2006 Apr;61(4):327–30PubMedCrossRefGoogle Scholar
  19. 19.
    Praseedom RK, Paisley A, Madhavan KK, Garden OJ, Carter DC, Paterson-Brown S. Supervised surgical trainees can perform pancreatic resections safely. R Coll Surg Edinb 1999 Feb;44:16–18Google Scholar
  20. 20.
    Paisley AM, Madhavan KK, Paterson-Brown S, Praseedom RK, Garden OJ. Role of the surgical trainee in upper gastrointestinal resectional surgery. Ann R Coll Surg Engl 1999 Jan;81(1):40–45PubMedGoogle Scholar
  21. 21.
    Talamonti M. Borderline resectable pancreatic cancer: a new classification for an old challenge. Ann Surg Oncol. 2006 Aug;13(8):1019–1020PubMedCrossRefGoogle Scholar
  22. 22.
    Chalmers CR, Joshi S, Bentley PG, Boyle NH. The lost generation: impact of the 56-hour EWTD on current surgical training. Ann R Coll Surg Engl (Suppl) 2010; 92:102–106Google Scholar
  23. 23.
    Morris-Stiff GJ, Sarasin S, Edwards P, Lewis WG, Lewis MH. The European working time directive: one for all and all for one? Surgery 2005; 137: 293–297PubMedCrossRefGoogle Scholar
  24. 24.
    Horrocks M, Ahmed-Little Y, Johnston M. Working Time Directive 2009: Meeting the challenge in surgery. London: Royal College of Surgeons; June 2008Google Scholar
  25. 25.
    Morris-Stiff G., Ball E., Torkington J., Foster M.E., Lewis M.H., Havard T.J. Registrar operating experience over a 15-year period: more, less or more or less the same. The Surgeon 2004;2:161–164PubMedCrossRefGoogle Scholar
  26. 26.
    Crofts TJ, Griffiths JM, Sharma S et al. Surgical training: an objective assessment of recent changes for a single health board. BMJ 1997 Mar 22;314:891–95PubMedCrossRefGoogle Scholar
  27. 27.
    Dixon H, Siciliani L. Waiting-time targets in the healthcare sector: how long are we waiting? J Health Econ. 2009 Dec; 28(6):1081–1098PubMedCrossRefGoogle Scholar
  28. 28.
    Clark W, Hernandez J, McKeon BA, Kahn A, Morton C, Toomey P, Mullinax J, Ross S, Rosemurgy A. Surgery residency training programmes have greater impact on outcomes after pancreaticoduodenectomy than hospital volume or surgeon frequency. HPB (Oxford). 2010 Feb; 12(1):68–72CrossRefGoogle Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2012

Authors and Affiliations

  • Gabriele Marangoni
    • 1
  • Gareth Morris-Stiff
    • 1
  • Sunita Deshmukh
    • 1
  • Abdul Hakeem
    • 1
  • Andrew M. Smith
    • 1
    Email author
  1. 1.HPB and Transplant Unit, St. James’ HospitalLeedsUK

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