HPB Surgery

[Medstart108]

I've been looking around but cannot seem to find any list of surgeries that different surgical specialties perform on a regular basis.

If anyone has any information I would love to know!

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[Winged Scapula]

Are you asking specifically about HPB or all surgical specialties?

 

[vhawk]

If you have specific questions about HPB surgery or HPB fellowship I am happy to answer

 

[dienekes88]

I've been looking around but cannot seem to find any list of surgeries that different surgical specialties perform on a regular basis.

If anyone has any information I would love to know!

Look at the Table of Contents of Mastery of Surgery, and you'll get a sense of the range of operations.

Given that you're years away from graduating from medical school, most of that isn't going to make sense. With the help of youtube, netter, and some patience, you can probably get through a few chapters.

A surgeon is more than just a technician who performs the operations, though, so just reading about this stuff won't give you a sense of the field. Better to ask guys like vhawk, or residents at your institution... maybe even faculty.

 

[vhawk]

How do you feel about entering a field that in ~10 years will have more practitioners than the annual incidence of resectable pancreatic cancer?

oh dont worry we can take out pancreases for all KINDS of reasons. On an unrelated topic, have you still got all of your pancreas?

 

[thedrjojo]

How do you feel about entering a field that in ~10 years will have more practitioners than the annual incidence of resectable pancreatic cancer?

That's why it's best to go via transplant if you want to be an hpb surgeon so you can remove pancreatic cancer and liver masses and transplant them like a boss

 

[vhawk]

The obvious drawback being, you know, transplant

 

[thedrjojo]

The obvious drawback being, you know, transplant

you mean the ultimate hepatobiliary surgeries? totally a drawback

 

[dynx]

you mean the ultimate hepatobiliary surgeries? totally a drawback

Are you still a resident as indicated? If so, take my advise: that transplant garbage gets old real, real, real quick. Some folks that I imagine have some sort of emotional trauma in their past seem to like it and god bless them for it, someone has to do it but be careful, whats cool when your late 20s early 30s becomes painful later in life. Sleep starts to matter. Kids come along etc. Plan carefully.

 

[thedrjojo]

Are you still a resident as indicated? If so, take my advise: that transplant garbage gets old real, real, real quick. Some folks that I imagine have some sort of emotional trauma in their past seem to like it and god bless them for it, someone has to do it but be careful, whats cool when your late 20s early 30s becomes painful later in life. Sleep starts to matter. Kids come along etc. Plan carefully.

yeah, applying for fellowship now. thanks for the advice. If you are still a fellow as indicated, I'm not sure to what extent you know that the transplant "garbage" gets old real, real, real quick since you clearly have your opinions and your thoughts on transplant, and you are more than entitled to them and entitled to share them, but I'm not going to put too much stock into them. My mentor is in his 60's still going strong, another of the transplant guys here is also in his 60's and going even stronger and our program director is a transplant trained guy who has decided to "settle down" after his 35 years of transplant into a general surgery gig with primarily administrative/program director duties.

 

[dynx]

attending. Like I said, some people do love it. I've met them as well (my experience is cardiac/lung transplant but the operation isnt the issue, its the logistics). But I've met more that were just looking for a way out. Be sure you know as a resident what it is, and its hard to say because it's institution dependent. But if you get stuck in a situation where you're not at an istitution with a LOT of support it can be a killer. If you base your expectations off of how the big guys at the mayo clinic roll you'll be unpleasantly supprised when you're hired to help the 1 other tranplant guy at no-name U. I dont want to discourage you but to give you an alternative view. People told me not to do cardiac surgery, they were wrong. I might be giving you wrong advice for your personal situation but I went through training with 2 folks that ended up doing transplant (1 HB 1 cardiac/lung) and both are at a "what was I thinking" point in their lives.

Just as clarification: the real, real quick happens in fellowship. Tranplant was kinda cool in residency I admit.

 

[vhawk]

I would agree that fellowship has been a very eye opening experience. Far more so than residency was.

 

[Rifampicin]

If you have specific questions about HPB surgery or HPB fellowship I am happy to answer

I'm not the OP but I have a couple of questions regarding HPB surgery. Been interested in HPB for a while.. I imagine HPB surgery as one of the more academically-oriented general surgery subspecialties. So what cases do academic HPB surgeons usually do? Do they further become superspecialized for a specific organ (i.e., are there ones who do liver only, pancreas only)? Also, in the US, is it common for HPB surgeons to perform their own vascular reconstruction for borderline Whipple?

 

[vhawk]

I think there are sort of 3 main tracks for HPB surgeons out in practice (of course there are probably as many tracks as surgeons but just speaking generally). At very specialized, high-volume, academic centers, like MSK or MD Anderson or a few other places, HPB surgeons are academic surgeons who do only HPB and yeah they do tend to specialize even further, such as just doing livers or just doing pancreas. I think this is a very small % of people who do fellowship training in HPB or who consider themselves HPB surgeons. The middle group is academic surgeons who do maybe 50/50 HPB/general surgery, or some other mix between 25-75% HPB and the other 75-25% in something else, usually gen surg or surg onc or transplant, depending on their pathway. These are academic surgeons, but they tend to do all HPB cases that they can, mostly because the volume just isnt there to be picky. This is the pathway I'm planning on btw.

The other pathway is more private practice HPB surgeon, which again is gonna be mostly a mix of gen surg and HPB, usually starting out as mostly gen surg and building into HPB practice with time and getting your name out there. This also includes going somewhere and starting your own HPB program, whether thats a smaller academic place or a private group. This represents probably half of those completing HPB fellowship training.

I do not think it is common for HPB surgeons to do their own reconstruction aside from straightforward things like primary repair of PV/SMV or patches. I think for anything more complex than that, either you have vascular help or you refer them out if you cant get vascular help. I'm sure there are some badasses who do it all (Doug Evans comes to mind) but thats the exception.

 

[Rifampicin]

I think there are sort of 3 main tracks for HPB surgeons out in practice (of course there are probably as many tracks as surgeons but just speaking generally). At very specialized, high-volume, academic centers, like MSK or MD Anderson or a few other places, HPB surgeons are academic surgeons who do only HPB and yeah they do tend to specialize even further, such as just doing livers or just doing pancreas. I think this is a very small % of people who do fellowship training in HPB or who consider themselves HPB surgeons. The middle group is academic surgeons who do maybe 50/50 HPB/general surgery, or some other mix between 25-75% HPB and the other 75-25% in something else, usually gen surg or surg onc or transplant, depending on their pathway. These are academic surgeons, but they tend to do all HPB cases that they can, mostly because the volume just isnt there to be picky. This is the pathway I'm planning on btw.

The other pathway is more private practice HPB surgeon, which again is gonna be mostly a mix of gen surg and HPB, usually starting out as mostly gen surg and building into HPB practice with time and getting your name out there. This also includes going somewhere and starting your own HPB program, whether thats a smaller academic place or a private group. This represents probably half of those completing HPB fellowship training.

I do not think it is common for HPB surgeons to do their own reconstruction aside from straightforward things like primary repair of PV/SMV or patches. I think for anything more complex than that, either you have vascular help or you refer them out if you cant get vascular help. I'm sure there are some badasses who do it all (Doug Evans comes to mind) but thats the exception.

Hey, thank you for your answer! Last question, so I guess it's safe to say that 60% or maybe even 90% general surgeons who wants to do non-transplant HPB fellowship are interested in doing the Whipples (can't blame them though, I also think it's the coolest gen surg procedure). With that being said, are surgeons in the "middle group" you're describing going to get high enough Whipple volume? I'm talking about >10 or >12 Whipples per year.

I know it's still very long way for me to think or even ask about fellowship training. Currently, I'm still in my clinical phase of my medical education and about 2-3 years away from residency (not US med school, so that's actually a fairly short time), but I'm pretty dead-set on general surgery. I'm really interested in practically everything GS-related: breast, endocrine and thyroid, stomach, colorectal, appendix and ofc HPB and biliary tree.

 

[vhawk]

It's a good question and one of the big questions in hpb right now. The answer is at this point probably not. The guys at big programs are working hard publishing data trying to show that the guys in the middle shouldn't be doing 10 whipples a year. They are also working on lap and robot whipple skills in order to snag a bigger part of a small market. Other groups are working on expanding indications. You'll notice very little of this has anything to do with actually helping patients. I think you have to be pragmatic about it and realize that no job is perfect and you will have to work to shape your practice. But the cases are out there.

 

[thedrjojo]

I think there are sort of 3 main tracks for HPB surgeons out in practice (of course there are probably as many tracks as surgeons but just speaking generally). At very specialized, high-volume, academic centers, like MSK or MD Anderson or a few other places, HPB surgeons are academic surgeons who do only HPB and yeah they do tend to specialize even further, such as just doing livers or just doing pancreas. I think this is a very small % of people who do fellowship training in HPB or who consider themselves HPB surgeons. The middle group is academic surgeons who do maybe 50/50 HPB/general surgery, or some other mix between 25-75% HPB and the other 75-25% in something else, usually gen surg or surg onc or transplant, depending on their pathway. These are academic surgeons, but they tend to do all HPB cases that they can, mostly because the volume just isnt there to be picky. This is the pathway I'm planning on btw.

The other pathway is more private practice HPB surgeon, which again is gonna be mostly a mix of gen surg and HPB, usually starting out as mostly gen surg and building into HPB practice with time and getting your name out there. This also includes going somewhere and starting your own HPB program, whether thats a smaller academic place or a private group. This represents probably half of those completing HPB fellowship training.

I do not think it is common for HPB surgeons to do their own reconstruction aside from straightforward things like primary repair of PV/SMV or patches. I think for anything more complex than that, either you have vascular help or you refer them out if you cant get vascular help. I'm sure there are some badasses who do it all (Doug Evans comes to mind) but thats the exception.

This bolded part is also why I prefer the Transplant over HPB pathway in training. Transplant surgeons are reconstructing hepatic arteries, portal veins, etc all the time, so when we transected a replaced hepatic artery on our whipple, we just repaired it ourselves. But clearly, those fellowships you aren't going to be doing 100 pancreas cases, so you trade the volume of pure HPB cases, and deal with transplant logistics

 

[thedrjojo]

attending. Like I said, some people do love it. I've met them as well (my experience is cardiac/lung transplant but the operation isnt the issue, its the logistics). But I've met more that were just looking for a way out. Be sure you know as a resident what it is, and its hard to say because it's institution dependent. But if you get stuck in a situation where you're not at an istitution with a LOT of support it can be a killer. If you base your expectations off of how the big guys at the mayo clinic roll you'll be unpleasantly supprised when you're hired to help the 1 other tranplant guy at no-name U. I dont want to discourage you but to give you an alternative view. People told me not to do cardiac surgery, they were wrong. I might be giving you wrong advice for your personal situation but I went through training with 2 folks that ended up doing transplant (1 HB 1 cardiac/lung) and both are at a "what was I thinking" point in their lives.

Just as clarification: the real, real quick happens in fellowship. Tranplant was kinda cool in residency I admit.

Yeah, my exposure is at a medium busy (40-50 transplants a year) program with 4 attendings, no fellows, and god awful logistics. I can't believe the attendings who started this program in the late 80's are still here and going strong, and another who joined them in the mid 90's as well, especially given the structure of our system. I think the people in the system do admirably for what we have, but we just have no resources, not great institutional support, and are just understaffed.