HPB Surgery: The Specialty is Here to Stay, but the Training is in Evolution

In our relatively short careers, hepatopancreatobiliary (HPB) surgery has unequivocally become a specialty. A number of trends have colluded to establish the necessity of the HPB surgical specialist. First, major hepatic and pancreatic operations have become safer and more accepted by the general medical community. Historically, hepatic resection was associated with massive blood loss and high mortality. Similarly, pancreatoduodenectomy was associated with extremely high rates of perioperative mortality— to the point where the value of performing the operation at all was questioned openly in medical journals. Now, thanks to individual surgical experience and high-volume hospitals, these operations are performed routinely with acceptable rates of morbidity and mortality. Second, operations on the liver, pancreas, and biliary tract are now well-established parts of the treatment of specific diseases involving these organs. Examples include potentially curative resections of colorectal liver metastases and operations for chronic pancreatitis, which greatly improve the quality of life for patients with this otherwise crippling disease. Last, in recent decades, many individual surgeons, without the benefit of specific HPB training, have successfully established themselves as specialists in this field. These individuals have done so by developing highvolume clinical practices and dedicating themselves to research in the field. Because most HPB operations are not commonly performed or taught beyond an introductory level during general surgery training, it became natural and necessary for hospital systems to develop these practices. Most current practicing HPB specialists have evolved from training in transplantation or surgical oncology, although some were general surgeons who developed an interest and pursued specialization on their own. What is the current argument to support fellowship training in HPB surgery? The most obvious rationale is that HPB surgery requires technical expertise in challenging operations that have significant risk of major complications. Further, an association between volume of operations performed (both by the individual and hospital) and surgical outcome has been well established in relation to operations such as major hepatic and pancreatic resections. It has become evident that HPB operations should not be performed by the occasional HPB surgeon and that this kind of surgery requires experienced surgeons, hospitals, and support personnel. Although many will conclude that these volume–outcome relationships are related primarily to the technical performance of these operations, we maintain that technique is only a component of the specialty. Major HPB operations also require a complete understanding of the underlying diseases, the indications for operative intervention, and a mastery of the management of patients before and after the operation. The clinical judgment pre-, intra-, and postoperatively may be the most important part of being a successful HPB surgeon. Ultimately, the best HPB surgeons are those who combine technical excellence with superb judgment. Unfortunately, most general surgery residents graduate from training with very little exposure to major HPB operations. For example, the median number of pancreatoduodenectomies performed by graduating chief residents in the United States in 2014 was 3.7. It has been suggested that it takes approximately 20 cases to develop baseline proficiency in this operation and 60 to qualify as an expert in the field. The numbers are likely similar for complex hepatic Society of Surgical Oncology 2016