Hepato-pancreato-biliary Surgery: Analysis of Outcomes Among Graduates of Different Fellowship Pathways

To characterize the association between the type of fellowship training and patient outcomes after hepatopancreatic (HP) cancer surgery across different surgeon career stages using a nationally representative cohort of Medicare beneficiaries.

The current state of training in hepato-pancreato-biliary (HPB) surgery in North America is defined through 3 main pathways: the Complex General Surgical Oncology (CGSO), the Americas HPB Association fellowship, and the American Society of Transplant Surgeons fellowship. Each pathway offers a unique perspective on HPB surgery with a different number of training years, yet outcomes of graduates performing HP surgery relative to the type of fellowship training have not been defined.

Medicare claims were used to identify patients who underwent HP surgery for cancer between 2016 and 2021. The association of textbook outcomes (TOs), defined as no postoperative complications, no prolonged length of stay, no 90-day mortality, and no 90-day readmission, relative to different fellowship pathways was examined.

Overall, 15,411 cancer operations (pancreatectomy: 11,003, 71.4%; hepatectomy: 4408, 28.6%) were performed by 1030 HPB surgeons. A total of 9390 patients (60.9%) were operated on by a CGSO/surgical oncology graduate, 2315 patients (15.0%) by a HPB fellowship graduate, and 3706 (24.1%) by a transplant fellowship graduate. Patients who were operated on by a HPB fellowship graduate more frequently had a higher Charlson score (>5: 44.8% vs 38.1%) and more frequently were operated on an urgent basis (7.7% vs 6.1%) compared with individuals treated by CGSO/surgical oncology graduates (both P <0.001). After adjusting for patient, procedure, hospital, and surgeon-related factors, the likelihood of TO after a HP operation by a HPB fellowship graduate was 47.7% versus 45.2% among CGSO (% difference: 2.5%) and 42.8% among transplant fellowship graduates (% difference: 4.9%, P = 0.001). Differences in TO were mostly attributable to differences in outcomes after pancreatectomy ( P <0.001) rather than hepatectomy ( P = 0.758). While the probability of TO was higher among surgeons having completed a dedicated HPB fellowship during the early (1st-7th year of independent practice, P = 0.032) and middle (8th-14th year, P < 0.001) career stages, the probability of TO did not differ based on fellowship type among late-career surgeons (≥15th year, P = 0.257).

Achievement of TO following a HP cancer procedure was higher among surgeons who had completed a dedicated HPB fellowship, especially during early and middle career stages. Further efforts should be made to enhance HP surgery exposure and training for CGSO fellows interested in a career in HPB surgery.