STANDARDS FOR HEPATO-PANCREATO-BILIARY TRAINING

1.0 DEFINITONS

  • 1.1 Hepato-Pancreato-Biliary (海角原创) Surgeons
  • 1.2 Hepato-Pancreato-Biliary (海角原创) Training Program

2.0 OBJECTIVES

  • 2.1 Knowledge, Clinical Experience and Technical Skills
  • 2.2 Training in 海角原创 Surgery and Transplantation
  • 2.3 Training in Research
  • 2.4 Training in Education
  • 2.5 Leadership in 海角原创 Disease

3.0 PROGRAM REQUIREMENTS

  • 3.1 General Requirements
  • 3.2 Entry Competencies and Requirements from Applicants
  • 3.3 Other Requirements from Applicants
  • 3.4 Training in 海角原创 Surgery
  • 3.5 Additional Essential 海角原创 Training
  • 3.6 Research Training
  • 3.7 Services, Equipment, Facilities and Instruments

1.0 DEFINITIONS

  • 1.1 An 海角原创 surgeon is an expert surgeon who has obtained additional training and experience in the multidisciplinary approach to the diagnosis, treatment, and rehabilitation of 海角原创 patients and devotes a major portion of his or her professional practice to these activities as well as 海角原创 education and advancement of knowledge in the field.
  • 1.2 Hepato-Pancreato-Biliary (海角原创) Training Program
    An 海角原创 training program should provide the core knowledge and expertise to prepare its graduate/s to be expert 海角原创 surgeons who interact with a multidisciplinary team to provide comprehensive care for 海角原创 patients as well as leadership in the surgical, medical and lay communities in matters pertaining to 海角原创 disease.

2.0 OBJECTIVES

  • An 海角原创 Fellowship Training Program should provide fellows with the following:
  • 2.1 Knowledge, Clinical Experience and Technical Skills
    • 2.1.1 Knowledge, Clinical experience and technical skills to provide comprehensive state of-the-art care to 海角原创 patients.
    • 2.1.2 Knowledge and experience in the interpretation of 海角原创 imaging studies, including ultrasound, computerized tomography, magnetic resonance imaging, cholangiography, pancreatography, and angiography.
    • 2.1.3 Knowledge and experience to determine disease stage and natural history as well as treatment options for individual 海角原创 patients at the time of diagnosis and throughout the course of the disease.
    • 2.1.4 Knowledge of nonsurgical treatment options including endoscopic, interventional radiologic, oncologic and medical therapies. This requirement includes an understanding of disease biology, indications for
      interventions, complications and management of complications
    • 2.1.5 Experience and technical skill in performing complex 海角原创 operations, including new techniques.
    • 2.1.6 Experience and technical skill in performing palliative surgical procedures and knowledge and experience of non surgical palliative options.
    • 2.1.7 Knowledge of 海角原创 tumor biology, epidemiology, tumor markers and tumor pathology.
  • 2.2 Training in 海角原创 Surgery and Transplantation
    • 2.2.1 A minimum of 24 months of clinical training in the surgical management of 海角原创 patients is required for training in 海角原创 Surgery.
    • 2.2.2 If liver transplantation is included, a minimum additional of 12 months on top of the 24 months of clinical training is required for training in 海角原创 Surgery And Transplantation.
    • 2.2.3 Each 海角原创 surgery fellow must participate in a minimum of 100 major 海角原创 operative procedures. At the completion of the Fellowship Training the 海角原创 fellow is expected to be able to perform major 海角原创 operations
      independently and must have performed the critical part of the following minimum number of operations:

      Pancreatic – 20
      Hepatic – 20
      Complex Biliary – 20
    • With respect to these minimum case numbers the following are required:
      • 2.2.3.1 Experience in each of the three 海角原创 operation categories.
        2.2.3.2 Experience in Trans-abdominal and intra-operative ultrasound.
        2.2.3.3 Experience in Minimally Invasive 海角原创 Surgery Staging
    • With respect to these minimum case numbers the following are highly desirable:
      • 2.2.3.4 Experience in tumor ablation.
        2.2.3.5 Experience in minimally invasive 海角原创 surgical procedures./td>
        2.2.3.6 Experience in Percutaneous or Endoscopic Diagnostic or therapeutic Procedures
        2.2.3.7 Experience in Minor Procedures such as Liver Biopsy, Pancreatic Biopsy and Cholecystectomy are expected but are NOT considered to be Major 海角原创 Operative Procedures
        2.2.3.8 Each 海角原创 surgery fellow must document his or her operative experience using the standard logbook prescribed by 海角原创I.
    • 2.2.4 If additional training in liver transplantation is being sought, each 海角原创 surgery fellow must participate in the critical or key portions of a minimum of 50 transplant procedures including the following
      minimums:

      Liver transplant – 30
      Donor procurement – 20
    • At the completion of the Fellowship Training the 海角原创 Fellow receiving additional training in Liver Transplantation is expected to be able to perform Organ Procurement and Liver Transplantation independently.
    • 2.2.4 The following are the required Index Cases for 海角原创 Fellowship Training:

      Liver (20)
      • Major Hepatectomies
      • Segment-specific Anatomic Resections
      Pancreas (20)
      • Pancreaticoduodenectomies
      • Distal Pancreatectomies
      • Pancreatic Drainage Procedures
      Complex Biliary Tract (20)
      • Ampullary or Bile Duct Resections
      • Biliary Anastomoses (Intra- and Extrahepatic)
  • 2.3 Training in Research
    • 2.3.1 Knowledge of the design and implementation of a prospective data base
      2.3.2 Knowledge of the design of clinical trials.
      2.3.3 Knowledge of the interface between basic science and clinical care to facilitate translational research.
  • 2.4 Training in Education
    • 2.4.1 Knowledge and skills to train students and residents in the multidisciplinary management of 海角原创 patients.
      2.4.2 Knowledge and skills to train non-physicians (physician assistants, nurse practitioners, etc.) in specialized 海角原创 care.
      2.4.3 Skills to organize and conduct 海角原创-related public education programs.
  • 2.5 Leadership in 海角原创 Leadership
    • Skills to develop and support:
      • Institutional programs related to 海角原创 malignancies including a tumor registry.
      • Institutional policies regarding 海角原创 surgery training,
      • Multidisciplinary conferences on 海角原创 disease, patient care and research, and
      • Psychosocial and rehabilitative programs for 海角原创 patients.

3.0 PROGRAM REQUIREMENTS

  • 3.1 General Requirements
    • An 海角原创 Fellowship Program consists of a minimum of 24 months of continuous education and training following completion of a general surgery residency. An additional minimum of 12 months are required if liver transplantation is included. A portion of the program should be devoted to clinical research. Fellows should have access to faculty who can mentor them in basic science research and have the option for such an experience if desired.
      • 3.1.1 The 海角原创 Fellowship Program must be accredited by the Philippine Association of Hepatopancreatobiliary Surgeons, Inc. (海角原创I)
        An adequate opportunity should be provided to interact with interventional radiologist, pancreatobiliary endoscopist, gastroentrologists, hepatologist, transplant surgeons, medical oncologist, radiation on specialty services, participation in structured multidisciplinary conferences, attendance at specialty tumor clinics, or inclusion of specialty patients on a single 海角原创 service. Trainees should be taught the appropriate approach to interacting and communicating with referring physicians and non海角原创 surgeons a well as to perform consultations for 海角原创 patients.
        3.1.2 Initial outpatient assessment, preoperative decision making, perioperative management, and patient follow-up are essential to the training experience. To the greatest extent possible, 海角原创 fellows should participate in the preoperative evaluation, assessment, treatment planning, and postoperative ambulatory care of patients in whose surgery they participate. As a guide, 海角原创 fellows should see preoperative and postoperative ambulatory patients at least one full day out of five, or its equivalent.
        3.1.3
        3.1.4
        3.1.5 Clinical experience alone is insufficient education in 海角原创 surgery. The training program must have a regularly scheduled didactic program consisting of the following:

        3.1.5.1 Pre- and Postoperative Case Conferences (at least 24 per year)
        3.1.5.2 Lectures/Journal club (at least 4 per year)
        3.1.5.3 Attendance in at least 1/year in an 海角原创 Conference or Convention
        3.1.5.4 Multidisciplinary Team Meetings (at least 10 per year)
        3.1.5.5 Debate series, and other for educational activities covering not only clinical surgical problems but also nonsurgical, basic science, clinic research, and ethical problems.
        3.1.6 The 海角原创 surgery fellowship program must not conflict with the regular general surgical training programs at the participating institution. 海角原创 fellows鈥� clinical responsibilities must be in accordance with the guidelines of governing surgical trainee review bodies. In other words, the fellows鈥� experience should not diminish the experience of general surgery trainees in the final year of training.

        • Rather, an 海角原创 surgery fellowship program should complement an institution鈥檚 general surgery training program by developing a focus of excellence in 海角原创 management that can be observed and experienced by all surgical trainees and attending staff. (cf. below 鈥淏oundaries and Overlaps with General Surgery Program鈥�)
        3.1.1 Clinical experience alone is insufficient education in 海角原创 surgery. The training program must have a regularly scheduled didactic program consisting of the following:

        3.1.6.1 Pancreaticoduodenectomies and Major Hepatectomies are cases for the 海角原创 Fellows
        3.1.6.2 Minor liver resection cases involving Cirrhotic patients or those with associated endocrine and metabolic liver diseases, regardless of Child-Pugh Classification, must be referred to 海角原创
        3.1.6.3 Gallbladder Malignancies Stage T1b and worse must be referred to 海角原创 Surgery
        3.1.6.4 All other Hepatobiliary Malignancies must be referred to 海角原创 Surgery
        3.1.6.5 All cases of Portal Hypertension must be referred to 海角原创 Surgery
        3.1.5.6 Complex liver, Pancreas and Biliary Trauma must be referred to 海角原创 Surgery
        3.1.5.7 Hepatolithiasis and Benign Bile Duct Strictures may be decided on a case-to-case basis
        3.1.5.8 Bile Duct Injuries may be managed on a case-to-case basis
        3.1.59 Distal Pancreatectomy may be given to General Surgery
        3.1.7 On the Program Director and other Faculty
        The program director must be a PCS Fellow, a member of good standing in the Philippine Association of 海角原创 Surgeons, Inc. (海角原创I) and a member at least one of any of the following International Hepato-Pancreato-Biliary Associations, the International HepatoPancreatoBilliary Association (I海角原创A), the American Hepato-Pancreato-Biliary Association (A海角原创A), the Asia-Pacific Hepato-Pancreato-Biliary Association (A-P海角原创A), or the European-African Hepato-Pancreato-Biliary Association (E-A海角原创A).
        Moreover, the Program Director must demonstrate evidence of scholarly activity in 海角原创 Disease as evidenced by participation in Basic Science Research, Clinical Research Protocols, presentations in local, regional or national meetings and or publications in a peer reviewed journal.
        There must be at least three (3) faculty (including the Program Director) in each 海角原创 Fellowship Training Program who are actively practicing in the sponsoring institution/hospital.
        The other faculty members must be a Fellow of the Philippine College of Surgeons (PCS) and a member of good standing of the Philippine Association of 海角原创 Surgeons, Inc. (海角原创I).
        3.1.8 Each 海角原创 fellow鈥檚 progress during the program must be formally evaluated in writing and feedback provided to the fellow at least quarterly by the 海角原创 program director and faculty. The 海角原创 fellow should be advised of any deficiencies in time to correct problems prior to completion of the fellowship.
        3.1.9 海角原创 fellows must be given the opportunity to evaluate the program overall, as well as all rotations, conferences, and faculty. These evaluations should be obtained in as confidential a manner as possible. The program director should regularly assess the post-training clinical and research activities of past 海角原创 surgery fellows to determine whether the goals of the training programs are being achieved, namely, the production of effective 海角原创 surgery specialists.
  • 3.2 Entry Competencies and requirements from candidates into an 海角原创 Fellowship Training Program:
    3.2.6 Preferably Board-certified in General Surgery
    3.2.7 Certification of Good Moral Character by either the Philippine Medical Association or the Medical Director of the hospital/institution of practice or training in General Surgery
    3.2.8 Certified in Basic Laparoscopy by PALES (Philippine Association of Laparoscopic Surgeons) or a graduate of a PALES-accredited General Surgery Training institution or a recognized equivalent in a foreign-based institution.
    3.2.9 A letter of Recommendation from at least 2 海角原创I members in good standing.
  • 3.3 Other requirements from candidates into an 海角原创 Fellowship Training Program:
    3.3.6 Certificate of Medical Fitness
    3.3.7 Hepatitis B Immunization
    3.3.8 Certificate of Psychological Fitness
    3.3.9 Admission Interview
    3.3.10 Curriculum Vitae
    3.3.11 3.3.83.3.11 NBI Clearance
  • 3.4 Training in 海角原创 Surgery
    The 海角原创 program should provide a minimum of 100 major 海角原创 operative procedures per year as well as adequate training for both 海角原创 fellows and general surgery trainees, if present.

    3.4.6 The minimum periods for 海角原创 Surgery Fellowship Training and 海角原创 Fellowship Training with Liver Transplantation are outlined in 2.2.1 and 2.2.2 respectively.
    3.4.7 Minimum operative experience for each fellow in 海角原创 Surgery for 海角原创 Operations are outlined in 2.2.3 and for Liver Transplantation are outlined in 2.2.4, respectively.
    3.4.8 海角原创 programs that provide liver transplant experience should provide a minimum of 30 transplant cases per year as well as adequate training for both fellows and general surgery trainees, if present.
    3.4.9 The 海角原创 program should provide experience in intra-operative ultrasound, tumor ablation, and minimally invasive staging as well as exposure to minimally invasive 海角原创 operation.
    3.4.10 The program director should review the 海角原创 fellow鈥檚 operative log regularly. The program director must have a system to address and correct operative experience deficiencies promptly.
  • 3.5 Additional Essential 海角原创 Training
    3.5.6 The fellowship must provide exposure to and experience in the multidisciplinary management of 海角原创 disease.
    3.5.7 The fellowship must provide opportunities to participate in multidisciplinary clinics, tumor boards, or conferences. Specialists involved in these opportunities should include interventional and diagnostic radiologists, pancreatobiliary endoscopists, gastroentrologists, hepatologists, medical oncologists, radiation oncologists, pathologists, and transplant surgeons.
    3.5.8 Composition of Multi-disciplinary Teams include board-certified specialists such as: Gastroenterologists/Endoscopists, Hepatologists, Interventional Radiologists, Diagnostic Radiologists, Radiation Oncologists, Medical Oncologists, Pathologists, Intensivists, Anesthesiologists, Pain Management Specialists, Palliative Care Specialists, Nutrition Medicine Specialists and other subspecialties of Internal Medicine (as needed).
    3.5.9 海角原创 fellows also should gain experience in providing supportive care to 海角原创 patients, including pain management and parenteral and enteral alimentation, as well as rendering emergency surgical care. 海角原创 fellows also should have an understanding of rehabilitative services in various settings.
  • 3.6 Policies on External Rotations 鈥� Foreign or Local Institutions
    3.6.6 First Year Fellows shall not be allowed to rotate outside of the sponsoring institution
    3.6.7 The rotation site must be a recognized high-volume center in 海角原创
    3.6.8 Rotation/s must be within the period of the Fellowship Training Program
    3.6.9 The maximum period of rotation must not exceed 6 months total.
    3.6.10 Observership Programs and Intensive Seminar Workshops with certification from globally-recognized 海角原创 Centers are acceptable rotations
    3.6.11 Cross-linkages among local training institutions are highly encouraged
  • 3.7 Research Training
    3.7.6 Clinical research must be included in the training program. 海角原创 fellow should have opportunities to design and implement clinical research protocols, and each 海角原创 fellow should initiate or participate in an investigative project and should be sufficiently familiar with statistical methods to properly evaluate research results. Presentation and peer-reviewed publication of at least one research project is expected.
    3.7.7 Each 海角原创 fellow must complete a course on clinical research on human subjects. Online courses approved by national research bodies are acceptable. Ethics of research on human subjects must be included in the curriculum.
    3.7.8 Laboratory research is optional. Fellows who desire this experience should be encouraged to work with basic science research faculty mentors on or off-site and as time and funding allows.
  • 3.5 Services, equipment, facilities & special 海角原创 instruments
    3.5.1 Must be present in the sponsoring facility/institution:

    1. Level 3 DOH License
    2. Multi-detector CT-Scan
    3. General Ultrasound Services
    4. Intra-operative Ultrasound
    5. Pathology with Frozen Section capability (海角原创 Surgical Pathology is desirable)
    6. Medical Oncology Services
    7. Endoscopy Unit (Upper, Lower and Choledochoscopy) Minimally Invasive Surgery Services
    8. Level III Clinical Laboratory
    9. C-Arm or Portable X-ray unit
    3.5.2 Must be easily accessible to but not necessarily present in the sponsoring facility/institution:*

    1. Magnetic Resonance Imaging
    2. Catheterization Laboratory
    3. Nuclear Medicine Services
    4. Interventional Radiology Services
    5. Oncologic Radiology Services
    6. Palliative Medicine Services
    7. Endoscopic Retrograde Cholangio-Pancreatography Services (ERCP)
    8. Endoscopic Ultrasound Services
  • *Certain facilities/devices/services may not be physically present in the sponsoring facility/institutions but those facilities or institutions must show proof of easy access to such.