Fellowship in Hepato-pancreatico-biliary surgery

Fellowship in Hepato-pancreatico-biliary surgery

 

Fellowship in Hepato-pancreato-biliary Surgery is a three years Fellowship Programme of Chitwan Medical College (CMC), Bharatpur in Hepatobiliary and Pancreatic Science. The curriculum is based on the current competency-based model followed in the world in any specialist training of the medical professionals. The training will be conducted in CMC, Bharatpur. CMC Teaching Hospital is a 750-bedded hospital with state of the art facility. There is 20 beded Hepato-pancreato-biliary Surgery ward, 22 beded surgical intensive care,  with 12 ventilators, 8 bedded recovery ward, 22 bedded postoperative ward and state of art operation theatres with endoscopic surgery facility. Also facility for endoscopy, colonoscopy, ERCP, Endoscopic Ultrasound (EUS), Double ballon Enterscopy, CT Scan, MRI is available at hospital.   

PURPOSE

The purpose of Fellowship education of HPB Surgery is to provide a structured educational and training experience necessary to achieve expertise in the understanding, diagnosis, and management (including the necessary surgical skills) in the treatment of diseases of the liver, pancreas, and biliary tract.

This curriculum provides HPB Surgery Program Directors with a basis for instruction and evaluation of Fellows and provides Fellows with a guide to the study of HPB Surgery and defines the essential areas of knowledge and technical skills that need to be mastered.

At the conclusion of the fellowship in HPB Surgery, the fellow will be able to provide comprehensive, state-of-the-art medical and surgical care to patients with surgical diseases/disorders of the liver, pancreas, biliary tract, duodenum ,spleen and diaphragm. This expertise will include the ability to investigate, diagnose, recommend appropriate treatment options, perform operative procedures, and provide the pre- peri- and late postoperative care.

OBJECTIVES

The objectives of this training is to provide specialized training in Hepato-pancreato-biliary surgery  to produce competent specialists who will be capable to:

  1. provide surgical care of the highest order to the patients with Hepato –Pancreato- biliary (HPB)  disease in the tertiary care centers.
  2. perform all types of diagnostic and therapeutic  endoscopy in  HPB disease.
  3. serve as teachers, trainers, researchers and leaders in the field of HPB science.
  4. deliver preventive and rehabilitative care for HPB disease

 

ADMISSION CRITERIA:

Eligibility:

  1. Minimum Qualifications:
    1. MS in General Surgery or equivalent
  2. The MS degree must be a three-year fulltime residency degree and recognised by Tribhuvan University
  • Candidates should be registered in Nepal Medical Council as Specialist

Entrance Examination:

  1. The entrance examination will consist of theory and practical. Those candidates who obtain pass marks (50%) in theory will only be eligible for clinical examination. Candidates should achieve minimum 50% marks both in the written MCQs type entrance examination as well as in clinical assessment.
  2. The MCQs and clinical examination will be related to the basic applied sciences, critical care and related subjects
  3. Final results include theory 60% and Clinical (40%).

Selection Criteria:

  1. Candidates with higher combined marks of written and clinical assessment will be selected as per the available seats.
  2. In case if the achieved marks are equal, marks obtained in clinical assessment will be considered to select candidates.
  3. The candidate once selected must sign a contract to attend the entire duration of the course on full time basis.
  4. The candidate will not be allowed to do any private practice during the entire residency period.
  5. The candidate registered for the course, should agree not to enter other academic university programs until the completion of the course.
  6. The candidate should agree to abide by the rules and regulations or else may face expulsion from the program on disciplinary ground.

 

STRUCTURE OF THE TRAINING PROGRAMME:

The training program shall be of three years, full time, residential and structured training in the field of HPB surgery. The training will take place in Chitwan Medical College (CMC).

The candidate can arrange 12 months elective posting in any institution in the country or outside under a professor or an associate professor. The financial burden of the elective posting will be borne by the candidate himself/herself.

 

 

LEARNING STRATERGY:

Rotation:

Year

Placement

Activity

First Year

CMC

·         Three months in Surgical  ICU and SICU for the  management of  complex HPB cases.

·         Nine months rotation in different Unit

Second Year

Elective

·         Posting at other national/regional/international institute/s for related exposure/other related department for completion of their study

Third Year

CMC

·         Three months of rotation in interventional radiology

Nine months rotation in different Units of Surgery

 

Clinical Training Schedule

Activity

Frequency

Bedside rounds (presentation of cases to the faculty with discussion)

 Daily

Mortality meeting                                            

 once a month

Seminar                                                          

 once a month

Grand rounds                                                                

 once a week

Journal club                                                     

 once a week

Clinical case discussion                                 

 once a week

HPB – radiology conference                                                        

 once a week

HPB – pathology conference                                                     

 once a month

Surgical – medical HPB meeting                                               

 once a month

*Workshops related to teaching/learning and research will be conducted during First Year of training.

*Teaching of  other fellow Surgery residents, interns and students if available is part of the training.

 

Academic abd Clinical Training Requirements:

Minimum number of procedures (To be recorded in Log Book)                                                                                           

HPB Surgeries:

  • Overall HPB Cases: 100

(No variance will be allowed in the minimum number of overall cases required.)

Liver : Minimum 25 cases

(Out of 25, at least 20 major hepatectomies (required), detail as under:)

  • Hemi-hepatectomy
  • Trisectionectomy
  • Central hepatectomy
  • Right posterior sectionectomy
  • in situ donor hemi-hepatectomy

Additional minor liver procedures may include:

  • Resection of 1 or 2 or segments
  • Partial, or non-anatomic resections
  • Unroofing of large or multiple hepatic cysts

Pancreas : Minimum 25 cases

Out of 25, at least 20 pancreaticoduodenectomies (required)

  • Pancreatic resection
  • Pancreatic tumor enucleation
  • Pancreatic anastomosis (e.g. pancreaticojejunostomy)
  • Pancreatic drainage procedures (e.g. pseuodocyst procedure)
  • Pancreatic debridement or necrosectomy

Biliary Tract :  Minimum 15 cases

  • Ampullary or bile duct resection
  • Transduodenal sphincteroplasty
  • Biliary anastomosis (intra-hepatic or extra-hepatic)
  • Radical cholecystectomy
  • CBDE
  • (May include pancreaticoduodenectomies if excess in pancreas)
  • (Major biliary procedures do not include cholecystectomies)

Note: A deficit of up to 15%  cases will be allowed in any one category [liver, pancreas, biliary tract],provided the minimum number of major HPB cases (100) is met and the minimum number of cases in all other categories is met.)

 

Fellow’s Role

The fellow will act as primary surgeon or teaching surgeon for at least 70% of the 100 major HPB cases

Multiple Procedures as a part of other procedures

Multiple procedures may be recorded per case under the following circumstances only:

  • Intraoperative US, diagnostic laparoscopy, or simultaneous tumor ablation performed in conjunction with another major HPB case
  • Separate unrelated operation is performed at the time of a major HPB case (e.g. colectomy performed at time of hepatic metastectomy).
  • Concomitant major pancreas and liver procedures performed during same case (e.g. Whipple and liver resection).
  • Intrahepatic biliary reconstruction performed at time of major liver resection may be recorded as a separate biliary procedure

 

SYLLABUS SPECIFIC PROGRAMME CONTENT:

The Curriculum consists of Eight  Major Units, some with Subunits:

Unit 1 – The Liver

  • Anatomy, Embryology, Physiology, Testing (diagnostic and therapeutic evaluation)
  • Congenital and Acquired Non-neoplastic Liver Disease
  • Neoplastic Liver Disease
  • Liver Surgery

Unit 2 – The Biliary Tract including Gallbladder

  • Anatomy, Embryology, Physiology, Testing (diagnostic and therapeutic evaluation)
  • Congenital and Acquired Non-neoplastic Biliary Disease
  • Neoplastic Biliary Disease

Unit 3 – The Pancreas and Duodenum

  • Anatomy, Embryology, Physiology, Testing (diagnostic and therapeutic evaluation)
  • Congenital and Acquired Non-neoplastic Pancreatic Disease
  • Neoplastic Pancreatic Disease
  • Diseases of the Duodenum

Unit 4 - Disease of the spleen and Diaphragm

  • Anatomy, Embryology, Physiology, Testing (diagnostic and therapeutic evaluation)
  • Congenital, Non-neoplastic and neoplastic Disease of the spleen
  • Diseases of the Diaphragm

Unit 5 – Imaging

Unit 6 – Oncology

Unit 7 – Trauma

Unit 8 – Transplantation (liver, pancreas, spleen)

Unit 9 - others

Each Unit or Subunit is organized into 3 Sections:

  1. Objectives: description of the topics the Fellow must understand and the specific knowledge to be acquired
  2. Content: description of the specific areas of study necessary to achieve the unit objectives
  3. Clinical Skills: description of the clinical activities and technical skills that are to be mastered

 

Unit 1 – The Liver

  1. Anatomy, Embryology, Physiology, Testing
  2. Objectives: Upon completion of this unit the fellow will understand:
  3. Intrahepatic and extrahepatic anatomy of the liver and the relationship with the adjacent and surrounding structures
  4. The embryology of the liver and biliary tract and the potential anomalies
  5. The physiology of the liver
  6. Clinical hematologic and biochemical tests relevant to the liver and their indications and interpretation:

(1) Tests of hepatocellular injury

(2) Tests of liver function

  1. Hepatic imaging techniques and their indications and interpretation
  2. Implications of investigations and surgical procedures on the liver
  3. Neoplastic and non neoplastic liver disease and their management
  4. Content:
  5. Embryology of the liver

(1) Relationship to other foregut structures

  1. Extrahepatic anatomy of the liver

(1) Lobes, sectors, segments

(2) Nomenclature systems

(3) Ligaments, fissures and incisures

(4) Anomalies

  1. Anatomy of the porta

(1) Portal vein, hepatic artery

(2) Bile duct, gall bladder

(3) Variants of normal and anomalies

(4) Lymphatic drainage and nodal anatomy

(5) Nerves

  1. Anatomy of the retrohepatic space

(1) IVC and its branches

(2) Adrenal, kidney, diaphragm

  1. Intrahepatic anatomy:

(1) Hepatic veins and variants of normal

(2) Portal triad structures and segmental anatomy

(3) Histology of the normal liver

  1. Physiology of the liver

(1) Bilirubin metabolism

(2) Coagulation

(3) Other clinically relevant metabolic pathways

(4) hepatic blood flow, liver regrowth and regeneration

  1. Hematologic, biochemical, and histologic testing (assessment) of the liver

(1) Transaminases and markers of cholestasis

(2) Measures of liver function

(a) Static – including INR (PT), Factors V and VII, bilirubin, albumin

(b) Dynamic – including clearance tests , e.g. ICG, galactose, aminopyrine, lidocaine  (MEGX), other lab. test used in the assessment of liver function

(3) Indicators of portal hypertension

(4) Indications for liver biopsy

  1. Imaging of the liver

(1) Ultrasound (U/S) and Doppler, Computerized Tomography (CT) Scans, Magnetic Resonance Imaging (MRI) Scans

(2) Nuclear tests: Proton Emission Tomographic (PET) Scans, Liver/Spleen scans, Biliary excretion (e.g. HIDA) Scans, RBC Scans

  1. Application of investigations to hepatic surgery

j.Perioperative assessment in the patients with liver surgery

  1. Recent advances in the diagnosis and therapeutic techniques
  2. Clinical Skills:
  3. Identify, recognize, and describe anatomic structures in and around the liver

(1) By reading and interpreting images of the liver

(2) Intraoperatively

  1. Perform and interpret intraoperative U/S of the liver and porta
  2. Perform liver biopsy – percutaneously, laparoscopic or open
  3. Identify anatomic anomalies and explain their embryologic origin
  4. Understand the indications for and be able to interpret the hematologic and biochemical tests and explain the underlying physiology
  5. Interpret the dynamic tests of liver function
  6. Apply the relative advantages and disadvantages to the application of the different modalities of hepatic imaging
  7. Determine the appropriate abdominal wall incisions for open procedures on the liver
  8. Determine the appropriate port site placements and patient positions for laparoscopic procedures on the liver, and the relative indications for each and the need for a hand-port
  9. Evaluate liver function and portal hypertension (including Child’s score and its variations)
  10. Assess the overall risk and the hepatic risk of surgery by recognizing the implications of abnormalities of liver hematologic and biochemical testing on both hepatic and non-hepatic procedures.
  11. Develop a detailed operative strategy for liver resections based on preoperative assessment and imaging

 

  1. Congenital and Acquired Non-neoplastic Liver Disease
  2. Objectives: Upon completion of this unit the fellow will understand:
  3. The pathophysiology, presentation and natural history of the congenital and acquired non-neoplastic diseases of the liver.
  4. The investigative procedures available to efficiently diagnose the disease/disorder.
  5. The treatment options available for the condition and the results, including the risks and benefits of the operative and non-operative procedures.
  6. The pre, intra- and postoperative management, including the management of complications of therapy.
  7. Content:
  8. Pediatric liver diseases

(1) Biliary atresia and Allegille’s syndrome and other liver disease

(a) Presentation, evaluation and natural history

(b) Treatment options and indications for intervention

  1. Liver cysts and abscesses

(1) Solitary liver cysts/ simple liver cyst

(a) Presentation, evaluation and natural history

(b) Distinguish from cystic neoplasm

(c) Treatment options and indications for intervention

(2) Polycystic liver disease

(a) Classification ,Associated abnormalities

(b) Presentation, evaluation and natural history

(c) Treatment options and indications for intervention

(3) Pyogenic and fungal liver abscess

(a) Potential bacterial and fungal pathogens and sources

(b) Presentation, evaluation

(c) Treatment and indications for surgical drainage

(4) Other liver abscess including amoebic abscess, TB

(a) Presentation,Types, evaluation and natural history

(b) Treatment options and indications for intervention

(5) Echinococcal liver cyst and other parasitic infection

(a) Life cycle, epidemiology, target organs, classifications

(b) Presentation, evaluation and natural history

(c) Treatment options and indications for intervention

            (6). Alveolar hydatid cyst

  1. Liver failure

(1) Hepatitis (acute and chronic) and acute liver failure

(a) Causes of acute liver failure

(b) Investigation and prognosis

  1. Classification systems including King’s College criteria

(c) Treatment strategies

  1. Role of liver support systems
  2. Role of liver transplantation

(2) Cirrhosis and portal hypertension

(a) Causes of cirrhosis, diagnosis and natural history, staging and  treatment options (including indications for liver transplantation) for each

  1. Viral hepatitis B, C, D
  2. Alcoholic liver disease

iii. Non-alcoholic fatty liver disease, hepatic steatosis and steatohepatitis

  1. Autoimmune liver disease
  2. Autoimmune chronic active hepatitis
  3. Primary biliary cirrhosis
  4. Primary sclerosing cholangitis
  5. Hemochromatosis, Wilson’s disease, alpha-1 antitrypsin deficiency
  6. Budd Chiari syndrome and veno occlusive disease

Vii. Chemotherapy induced liver injury

(b) Portal hypertension:

  1. Pathophysiology, causes, classification, clinical features
  2. Interpretation of hematologic and biochemical tests and imaging

iii. Non-operative treatment options and strategies:

Indications, Technique,complications and management of complications

  1. Portosystemic decompression
  2. Indications and sequellae
  3. Risks and benefits of TIPS and surgical shunts
  4. Types of surgical shunts
  5. i) Relative indications, contraindications and complications
  6. Sugiura procedure and other operations
  7. Indications for liver transplantation
  8. Hepatopulmonary syndrome and portopulmonary hypertension

vii. Recent advances in the diagnosis and therapeutic techniques

 

  1. Clinical Skills:
  2. Diagnose and treat patients with cystic diseases of the liver
  3. Diagnose and manage patients with liver abscess(es)
  4. Perform laparoscopic and open drainage of liver cyst or abscess (unroofing,

resection)

  1. Diagnose and classify acute and chronic liver failure.
  2. Diagnose, investigate and manage patient with portal hypertension

(1) Perform portosystemic shunt – portocaval, mesocaval, splenorenal and their variants.

(2) Perform the Sugiura procedure

(3) Able to perform banding, glue injection and sclerotherapy

  1. Neoplastic Liver Disease
  2. Objectives: Upon completion of this unit the fellow will understand:
  3. The pathophysiology, presentation and natural history of benign, primary and secondary malignant neoplasms of the liver.
  4. The investigative procedures available to efficiently diagnose the disease/disorder.
  5. The staging of malignancies of the liver including histologic assessment
  6. The treatment options available for the neoplasm, and the results, including the risks and benefits of the operative and non-operative procedures.
  7. The pre, intra- and postoperative management, including the management of complications of therapy.
  8. The role of neoadjuvant and adjuvant therapy of malignant liver neoplasms.
  9. Content:
  10. Benign neoplasms of the liver

(1) Presentation, investigation, diagnosis, and natural history of hemangioma, hamartoma, adenoma, focal nodular hyperplasia

(2) Histology and indications for biopsy

(3) Treatment options and indication for ablation or resection

  1. Primary malignancies of the liver

(1) Hepatocellular carcinoma (HCC)

(a) Etiology, presentation, investigation, diagnosis,different staging system and natural history of HCC

(b) Role of screening and staging systems for HCC

Treatment options and the risk: benefit ratio for each: resection, transplantation, ablation, chemotherapy +/- embolization, radiation

(2) Cholangiocarcinoma (intrahepatic or peripheral)

(a) Diagnosis, investigation and staging

(b) Treatment options including palliative procedures

(3) Epithelioid hemangioendothelioma, lymphoma, sarcoma and others

neoplasms

(a) Diagnosis, investigation and staging

(b) Treatment options

  1. Secondary malignancies of the liver

(1) Colorectal primary

(a) Pathogenesis, staging of colorectal cancer

(b) Investigation and staging

(c) Treatment options

  1. Indications, and risk: benefit ratio of ablation /resection
  2. Neo-adjuvant, downstaging, and adjuvant

chemotherapy

(2) Neuroendocrine, non neuroendocrine and other primary

(a) Investigation and staging

(b) Treatment options

  1. Indications, and risk: benefit ratio ablation / resection and other options

(c) Neoadjuvant and adjuvant therapy

  1. Cystic neoplasm of liver
  2. Drug induced liver disease
  3. Fulminant liver failure and liver support system
  4. Hepatic Cancer in childhood
  5. Vascular disease of the liver
  6. Recent advances in the diagnosis and therapeutic techniques
  7. Clinical Skills:
  8. Evaluate patients with benign neoplasms of the liver, including interpretation

of imaging and indications for biopsy

  1. Manage patients with benign hepatic neoplasms
  2. Evaluate patients with HCC, including screening for potential HCC and staging
  3. Evaluate patients with primary and secondary adenocarcinoma and other metastatic lesions of the liver including staging
  4. Manage patents with primary and secondary hepatic malignancies
  5. Participate in multidisciplinary tumor review conferences
  6. Perform liver resections
  7. Provide pre- and postoperative therapy following liver resection including the

diagnosis and management of complications

  1. Recommend appropriate therapy for unresectable hepatic malignancies
  2. Recommend appropriate adjuvant radiation and/or chemotherapy following

resection for hepatic malignancies

  1. Interact with Medical and Radiation Oncologists
  2. Liver Surgery
  3. Objectives: Upon completion of this unit the fellow will understand:
  4. The types of and techniques for liver resections
  5. Preoperative patient assessment and the cumulative risks of the proposed

procedure

  1. Preoperative management
  2. Intraoperative management during a liver resection
  3. Postoperative management including complications.
  4. Content:
  5. Types of liver resection

(1) Nomenclature of liver resections (Brisbane system),couinaud, Goldsmith and Woodburne

(2) Laparoscopic, laparoscopic-assisted, open laparotomy

(3) Nonanatomic, segmental, lobectomy, extended lobectomy

(4) Vascular control: none, Pringle maneuver, total vascular isolation

(5) Vascular resection and reconstruction

(6) Staged resections

(7) Combination with ablation

  1. Preoperative assessment and the cumulative risks to the proposed procedure

(1) Patient comorbidities (cardiopulmonary and other)

(2) Hepatic risk

(a) Assessment of liver function, portal hypertension

(b) Volumetric assessment of liver remnant

(c) Portal vein embolization:Rationale , indications, techniques, result

  1. Preoperative management

(1) Prophylaxis against common complications

(a) DVT, infection

                        (2) Neuroendocrine hormonal blockade

 (3) Detailed operative plan based on preoperative imaging

  1. Liver resection

(1) Anesthetic considerations

(a) Agents, coagulation, CVP

(2) Blood loss conservation including cell saver and blood product

administration

(3) Laparoscopic techniques

(a) Patient and port placement

(b) Hand port

(4) Parenchymal transection techniques

(a) Relative advantages and disadvantages

(b) Normal, fatty, fibrotic and cirrhotic parenchyma

(c) Laparoscopic or open use

(5) Concomitant resection and reconstruction of the

(a) Diaphragm

(b) IVC

(c) Portal vein

(d) Bile duct

  1. Postoperative management

(1) Complications and management, including liver failure

  1. Recent advances in the diagnosis and therapeutic techniques
  2. Clinical Skills:
  3. Evaluate patients for liver surgery including the comorbidities and any

underlying liver disease to determine risk

  1. Determine the need for portal vein embolization, staged resection or

concomitant ablation

  1. Perform intraoperative staging of tumors including intraoperative U/S
  2. Perform liver resections using a variety of approaches and transection

techniques

  1. Perform complex liver resections including bile duct, portal vein, IVC,

diaphragm

  1. Manage the liver resection patient during the immediate, early and late postoperative

periods and diagnose and treat complications of the resection

 

Unit 2 – The Biliary Tract including Gallbladder

  1. Anatomy, Embryology, Physiology, Testing( Diagnostic evaluation)
  2. 1. Objectives: Upon completion of this unit the fellow will understand:
  3. The anatomy of the biliary tract including the intra- and extrahepatic, hepatic

duct, the gallbladder and cystic duct, the common bile duct, the ampulla of

Vater, and their relationships with the adjacent and surrounding structures

  1. The embryology of the liver and biliary tract and the potential anomalies
  2. The physiology of bile metabolism and biliary tract epithelium
  3. Clinical biochemical tests relevant to the biliary tract and their interpretation
  4. Biliary imaging techniques and their indications and interpretation
  5. Implications of investigations on surgical procedures on the bile duct
  6. Content:
  7. Embryology of the biliary tract

(1) Relationship to liver, pancreas and other portal and foregut structures

  1. Anatomy of the hepatic duct and biliary plate

(1) Segmental anatomy and variants of normal

(2) Blood supply and lymphatic drainage

(3) Relationship with other portal structures

  1. Anatomy of the gallbladder and cystic duct

(1) Blood supply and lymphatic drainage

(2) Variants of normal and anomalies

  1. Anatomy of the bile duct

(1) Blood supply, lymphatic drainage and regional lymph nodes

(2) Variants of normal and anomalies

(3) Relationship with other portal structures and the pancreatic duct

(4) Sphincter of Oddi and ampulla of Vater

  1. Bile metabolism and biliary physiology

(1) Bile-salt dependent and independent bile production

(2) Hormonal influences

(3) Biliary epithelium and gallbladder function

(4) Sphincter of Oddi motility

  1. Biochemical investigation

(1) interpretation

  1. Enterohepatic circulation, Bile flow , Composition and Gallbladder function
  2. Imaging

(1) Axial and body imaging techniques:

(a) U/S, CT scan and MRI scan, including MRCP

(2) Endoscopic U/S

(3) Direct contrast imaging

(a) Percutaneous transhepatic cholangiogram (PTC) and

cholecystography and endoscopic retrograde cholangiopancreatography

(ERCP)

(4) Endoscopic assessment of Ampulla of Vater

(5) Nuclear biliary excretion imaging (HIDA scan) – qualitative and

quantitative (HIDA scan), nuclear imaging

(6) others NBI, Magnification endoscopy, EUS

  1. Recent advances in the diagnosis and therapeutic techniques
  2. Clinical Skills:
  3. Identify and describe biliary tract structures (normal and abnormal)

(1) By reading and interpreting images of the biliary tract

(2) Intraoperatively

  1. Perform and interpret intraoperative U/S of the liver and biliary tract
  2. Identify anatomic anomalies and explain their embryologic origin
  3. Understand the indications for and be able to interpret the biochemical tests

and explain the underlying physiology

  1. Apply understanding of the relative advantages and disadvantages of the

different modalities of biliary tract imaging to determine optimal investigation

  1. Determine the abdominal wall incisions that are appropriate for open

procedures on the biliary tract and the relative indications for each

  1. Determine the appropriate port site placements and patient positions that are

useful for laparoscopic procedures on the biliary tract and the relative

indications for each

  1. Develop a detailed operative strategy for biliary surgery based on

preoperative assessment and imaging

 

  1. Congenital and Non-neoplastic Biliary Disease
  2. Objectives: Upon completion of this unit the fellow will understand:
  3. The pathophysiology, presentation and natural history of the congenital and

acquired non-neoplastic diseases of the biliary tract including the gallbladder

  1. The investigative procedures available to efficiently diagnose of the

disease/disorder

  1. The treatment options available for the condition, and the outcomes,

including the risks and benefits of the operative and non-operative

treatments

  1. The pre-, intra- and postoperative management, including the management

of complications of therapy

  1. Content:
  2. Congenital and pediatric

(1) Choledochal cyst, Caroli’s disease, congenital hepatic fibrosis, biliary

atresia and Allegille’s syndrome and others

(a) Presentation, classification, evaluation and natural history

(b) Treatment options and indications for intervention

  1. Gallstones

(1) Pathogenesis, complications and its management

(2) Presentation and investigation of

(a) Biliary colic, cholecystitis, cholangitis, Mirrizzi’s syndrome,

gallstone ileus

(3) Treatment: Percutaneous, laparoscopic, open, NOTES, Robotic

(4) Cholecystectomy-related biliary injuries

(a) Mechanism of injury & classification

(b) Associated injuries

(c) Management

c.Post cholecystectomy problems

d.Bile duct stones

(1)classification , types predisposing factors, investigation modalities, management options and complications

  1. Benign strictures

(1) Primary sclerosing cholangitis (PSC)

(a) Etiology, pathophysiology, natural history and non-operative

management

(b) Complications and management

  1. Screening for cholangiocarcinoma
  2. PTC with biliary drainage (PTBD), ERCP with

endobiliary stent

iii. Resection

  1. Transplantation

(2) Posttraumatic and idiopathic

(a) Mechanism of injury and classification

(b) Management options and complications

  1. Intrahepatic stones

(1) Pathophysiology, presentation and investigation

(2) Common infectious bacteria and classification

(3) Surgical options including liver resection and biliary access (Hutson)

choledochojejunostomy, hepaticojejunostomy with transhepatic stents

  1. ERCP in the evaluation and the management of HPB disease
  2. Pyogenic Cholangitis

i.Biliary parasitic disease

  1. Biliary dyskinesia and sphincter of oddi dysfunction

k.Recent advances in the diagnosis and therapeutic techniques

 

  1. Clinical Skills:
  2. Investigate the jaundiced patient by determining the most efficient

modalities, and interpret the results of biochemical testing and imaging

  1. Apply understanding of the relative merits and disadvantages of nonoperative

biliary manipulation (PTBD and endoscopic stenting) to treat biliary

tract obstruction.

  1. Manage the patient with complex gallstone disease
  2. Manage biliary injuries resulting from cholecystectomy and other trauma
  3. Perform resection and reconstruction for choledochal cysts, intrahepatic

stones, and benign strictures

  1. Evaluate and manage the patient with the complications of PSC

 


  1. Neoplastic Biliary Disease
  2. 1. Objectives: Upon completion of this unit the fellow will understand:
  3. The presentation and natural history of benign and malignant neoplasms of

the bile duct and gallbladder

  1. The investigative procedures available to efficiently diagnosis the neoplasm.
  2. The staging of adenocarcinoma of the bile duct and gallbladder including

histologic assessment

  1. The treatment options available for the neoplasm, and the indications and

outcomes, including the risks and benefits of the operative and non-operative

treatments

  1. The pre-, intra- and postoperative management, including the management

of complications of surgery.

  1. The role of neoadjuvant and adjuvant chemo- and radiation therapy of

malignant biliary neoplasms

  1. Content:
  2. Gallbladder

(1) Polyps and other benign disorders

(a) Presentation, natural history

(b) Indications for resection

(c) Principles of resection

(2) Adenocarcinoma

(a) Presentation, staging (including histology) and natural history

(b) Investigation

(c) Surgical options

  1. Extent and timing of resection

(d) Chemo and radiotherapy

  1. Neo- and/or adjuvant therapy

iii. Definitive management

                        (e) Palliative care options

  1. Bile duct

(1) Adenoma of Ampulla of Vater

(a) Presentation, natural history, investigation

(b) Resection options

  1. Endoscopic, transduodenal resection and reconstruction

(2) Adenocarcinoma

(a) Location: Hilar (Klatskin), intrapancreatic, ampulla

(b) Type – papillary, sclerosing

(c) Presentation, investigation and staging, including laparoscopic

staging

(d) Resection and reconstruction–indications and contraindication

(e) Palliative options

  1. PTBD or endoscopic stent
  2. Surgical bypass

            (3). Recent advances in the diagnosis and therapeutic techniques

  1. Clinical Skills:
  2. Investigate and manage patients with gallbladder polyps and benign

neoplasms of the ampulla of Vater

(1) Perform extended cholecystectomy for potential oncologic

indication

(2) Perform transduodenal resection of the Ampulla of Vater with

reconstruction of the bile and pancreatic ducts

  1. Investigate and manage patients with hilar cholangiocarcinoma

(1) Perform extended resection of the biliary bifurcation with the

caudate and ipsilateral lobes of the liver, portal lymphadenectomy,

and biliary reconstruction

  1. Investigate and manage patients with distal bile duct tumors

(1) Perform pancreatoduodenectomy

  1. Participate in multidisciplinary tumor review conferences
  2. Provide postoperative management including the diagnosis and treatment

of complications of biliary resection and/or bypass

  1. Recommend appropriate adjuvant radiation and/or chemotherapy

following resection and interacts with Medical and Radiation Oncologists

  1. Recommend appropriate therapy for unresectable carcinoma of the gallbladder

or bile duct

 


Unit 3 – The Pancreas & Duodenum

  1. Anatomy, Embryology, Physiology, Testing
  2. Objectives: Upon completion of this unit the fellow will understand:
  3. Anatomy of pancreas and its relationship with portal structures,

retroperitoneal structures and the adjacent organs

  1. Anatomy of the pancreatic duct and its relationship with the bile duct,

sphincter of Oddi and the ampulla of Vater

  1. Anatomy of duodenum and its relationship with portal structures,

retroperitoneal structures and the adjacent organs

  1. The embryology of the pancreas, pancreatic duct and duodenum and

potential anomalies

  1. The physiology of pancreatic exocrine and exocrine functions and duodenal

physiology

  1. Clinical biochemical tests of pancreatic function and injury and their

interpretation

  1. Pancreatic and duodenal imaging techniques and their indications and

interpretation

  1. Implications of investigations on surgical procedures on the pancreas and

duodenum

  1. Content:
  2. Embryology of the pancreas and duodenum

(1) Relationship to liver, bile duct and other foregut structures

(2) Etiology of anomalies including pancreas divisum and annular pancreas

  1. Anatomy of the pancreas

(1) Spectrum of normal anatomy and variants

(2) Arterial supply , venous drainage and nerve supply

(3) Lymphatic drainage and regional lymph nodes.

(4) Relationship with:

(a) Portal structures: duodenum, bile duct, hepatic artery, portal vein,

splenic and superior mesenteric veins and their branches

(b) Retroperitoneum: IVC and its branches, aorta and SMA and their

branches, adrenal gland, kidneys

(c) Adjacent organs: stomach, spleen, colon, small intestine

  1. Anatomy of the pancreatic duct

(1) Variants of normal and anomalies

(2)Anomaly of pancreato-biliary junction,variation(komi lassification)

(3)sphincter of Boyden/Oddi

  1. Anatomy of the duodenum

(1) Spectrum of normal anatomy and variants

(2) Arterial supply and venous drainage

(3) Lymphatic drainage and regional lymph nodes.

(4) Relationship with:

(a) Portal structures: bile duct, hepatic artery, portal vein, splenic and

superior mesenteric veins and their branches

(b) Retroperitoneum: IVC and its branches, aorta and SMA and their

branches, adrenal gland, kidneys

(c) Adjacent organs: pancreas, stomach, spleen, colon, small intestine

  1. Pancreatic metabolism and physiology

(1) Exocrine enzyme physiology

(a) Synthesis, excretion, activation and digestion

(b) Neural and hormonal influences

(2) Endocrine metabolism

(a) Islet cell function, neuroendocrine hormones

  1. Duodenal physiology

(1) Motility, digestion and absorption

(2) Neuroendocrine (“gut”) hormone physiology

(3) Biochemical investigation and interpretation

  1. Biochemical Testing

(1) Markers of pancreatic injury

(2) Measures of pancreatic exocrine function/ pancreatic function test (PFT)

(3) Urinary and serum neuroendocrine hormones

  1. Imaging

(1) Axial and body imaging techniques:

(a) U/S, CT scan and MRI scan, including MRCP

(2) Endoscopy, endoscopic U/S,and other endoscopic technique

(3) Direct contrast imaging

(a) Endoscopic retrograde cholangio-pancraetography (ERCP)

(4) Nuclear studies:

(a) PET scan

(b) Neuroendocrine imaging (Octreotide scan)

  1. Application of testing and imaging to pancreatic and duodenal surgery
  2. Recent advances in the diagnosis and therapeutic techniques
  3. Clinical Skills:
  4. Identify, recognize, and describe anatomic structures in and around the

pancreas & duodenum

(1) By reading and interpreting images of the duodenum, pancreas and

its duct

(2) Intraoperatively

  1. Perform and interpret intraoperative U/S of the pancreas and surrounding

structures

  1. Identify anatomic anomalies and explains their embryologic origin
  2. Understand the indications for and interpret the biochemical tests and explain

the underlying physiology including the tests of pancreatic function

  1. Apply the relative advantages and disadvantages of the different modalities

of pancreatic imaging to efficiently investigate diseases and disorders of the

pancreas and duodenum

  1. Determine the appropriate abdominal wall incision for open procedures on

the pancreas and/or duodenum

  1. Determine the appropriate port site placements and patient positions for

laparoscopic procedures on the pancreas and/or duodenum and the relative

indications for each and the need for a hand-port

  1. Develop a detailed operative strategy for pancreatic and duodenal surgery

based on preoperative assessment and imaging

  1. Congenital and Acquired Non-neoplastic Pancreatic Disease
  2. Objectives: Upon completion of this unit the fellow will understand:
  3. The pathophysiology, presentation and natural history of the congenital and

acquired non-neoplastic diseases of the pancreas

  1. The investigative procedures available to efficiently diagnose the

disease/disorder

  1. The treatment options available for the condition, and results, including the

risks and benefits of the operative and nonoperative procedures

  1. The pre-, intra- and postoperative management, including the management

of complications of therapy

  1. Content:
  2. Pancreatitis

(1) Acute

(a) Etiology ,Pathogenesis,classifications, staging, diagnostic assessment of biliary, alcoholic and other etiology and prognosis

(b)Pseudocyst and other complications of acute pancreatitis, Management of complications, including surgical options (time and types of interventions)

(c) Indications for surgical intervention

(2) Chronic

(a) Definitions, classifications Pathogenesis, complications and nonoperative management

(b) Pancreatic stents and endoscopic/percutaneous drainage procedures

(c) Surgical options and indications

(d) Pain control

  1. Pancreas Divisum

 (1) Pathogenesis, staging and prognosis

 (2) Management, including surgical options and complications

 (3) Indications for surgical intervention

  1. Annular pancreas and other anomalies

 (1) Pathogenesis, staging and prognosis

 (2) Management, including surgical options and complications

 (3) Indications for surgical intervention

  1. Endoscopic and minimally invasive therapy for complications of acute and chronic pancreatitis
  2. Recent advances in the diagnosis and therapeutic techniques
  3. Clinical Skills:
  4. Manage patients with acute pancreatitis, including complications

(1) Determine the need for surgical intervention

(2) Perform open and/or laparoscopic procedures for acute pancreatitis

  1. Investigate and manage the patient with chronic pancreatitis

(1) Determine the need for operative intervention

(2) Perform: pseudocyst-enterostomy, lateral pancreaticojejunosomy

with/without limited resection of the head of the pancreas (Frey procedure), pancreatic resection

  1. Neoplastic Diseases of the Pancreas
  2. Objectives: Upon completion of this unit the fellow will understand:
  3. The Pathophysiology, presentation and natural history of benign, primary and

secondary malignant neoplasms of the pancreas

  1. The investigative procedures available to efficiently diagnose the

disease/disorder

  1. The staging of malignancies of the pancreas including histologic assessment
  2. The treatment options available for the neoplasm, and the outcomes,

including the risks and benefits of the operative and nonoperative procedures

  1. The pre-, intra- and postoperative management, including the management

of complications of therapy

  1. The role of neoadjuvant and adjuvant therapy of malignant pancreatic lesions
  2. Content:
  3. Benign cysts and neoplasms of the pancreas

(1)  Serous cystic neoplasm

(a) Presentation,classification, investigation, diagnosis, and natural history

(b) Histology and indications for biopsy

(c) Treatment options and indication for resection

(2) Mucinous cystic neoplasm

(a) Presentation,classification, investigation, diagnosis, and natural history

 (b) Histology and indications for aspiration/biopsy

                        (c) Treatment options and indication for resection

(3) Intraductal papillary mucinous neoplasm (IPMN)

(a) Presentation,classification, investigation, diagnosis, and natural history

(b) Histology and indications for aspiration / biopsy

(c) Treatment options and indication for resection

 (4) Solid Pseudopapillary Neoplasms

                        (a) Presentation, investigation, diagnosis, and natural history

(b) Histology and indications for aspiration / biopsy

(c) Treatment options and indication for resection

 (5) Cystic Neuroendocrine Tumors and other cystic lesion of pancreas

 (a) Presentation, investigation, diagnosis, and natural history

(b) Histology and indications for aspiration / biopsy

(c) Treatment options and indication for resection

(6) Von Hippel Lindau syndrome

(a) Pathology, associated lesions, investigation

(b) Management

(7) pancreatic problems in infants and children

(8) prevention and management of complications in pancreatic surgery

  1. Malignancies of the pancreas

(1) Primary

(a) Adenocarcinoma

  1. Presentation, investigation and staging
  2. Assessment of resectability
  3. Pre-, peri- and postoperative management
  4. Palliative procedures

 (b) Neuroendocrine tumors

  1. Presentation, investigation and staging
  2. Assessment of resectability
  3. Pre-, peri- and postoperative management

 (c) Lymphoma

  1. Presentation, staging
  2. Role of surgery

(2) Secondary

(a) Renal cell carcinoma

  1. Presentation and management

            (b) Melanoma

  1. Presentation and management

C.Vascular malformation of pancreas and peripancreatic issue

  1. Hemobilia, Bilehemia,Hemosuccus pancreaticus
  2. Recent advances in the diagnosis and therapeutic techniques
  3. Clinical Skills:
  4. Investigate and manage patients with benign cysts and neoplasms of the

pancreas

(1) Determine need for biopsy/aspiration and resection

(2) Perform resections including enucleation of NE tumors and spleen

preserving distal pancreatectomy

  1. Investigate and manage patients with adenocarcinoma of the pancreas

(1) Stage the tumor pre- and intraoperatively and determine resectability

(2) Perform pancreatoduodenectomy +/- portal vein resection and

reconstruction

(3) Perform distal pancreatectomy and regional lymphadenectomy

(4) Perform palliative procedures for unresectable tumors

  1. Participate in multidisciplinary tumor review conferences
  2. Provide postoperative management including the diagnosis and treatment of

complications of pancreatic resection and/or bypass

  1. Recommend appropriate therapy for unresectable pancreatic carcinoma
  2. Recommend appropriate neo- and adjuvant radiation and/or chemotherapy

and interact with Medical and Radiation Oncologists

 

  1. Diseases of the Duodenum
  2. Objectives: Upon completion of this unit the fellow will understand:
  3. The pathophysiology, presentation and natural history of the diseases of the

pancreas

  1. The investigative procedures available to efficiently diagnose the

disease/disorder

  1. The treatment options available for the condition, and the results, including

the risks and benefits of the operative and non-operative procedures

  1. The pre-, intra- and postoperative management, including the management

of complications of therapy

  1. Content:
  2. Congenital disorders of the duodenum

(1) Duodenal atresia and duplication

(2) Duodenal diverticulae

  1. Duodenal ulcer disease

(1) Pathogenesis, investigation and diagnosis

(2) Nonoperative treatment

(3) Operative management

(4)Complications of duodenal ulcer and its management

  1. Crohn’s disease

(1) Presentation, investigation, diagnosis

(2) Management

  1. Benign neoplasms

(1) Adenoma

(2) Hereditary Familial Polyposis

(a) Genetics, presentation, investigation

(b) Management

  1. Malignant neoplasms of the duodenum

(1) Adenocarcinoma

(a) Presentation, investigation, staging

(b) Management

(2) Gastrointestinal stromal tumor (GIST) and sarcomas

(a) Presentation, investigation, staging

(b) Management options

  1. Chemotherapy
  2. Resection

(3) Neuroendocrine tumor

(a) Presentation (syndromes) investigation, staging

(b) Management

(4) “Secondary” to direct invasion of adjacent malignancy

(a) Carcinoma of the stomach or colon

(b) Renal cell carcinoma

(c) Investigation, staging

(d) Operative management

(4) vascular malformation of duodenum

  1. Recent advances in the diagnosis and therapeutic techniques

 

  1. Clinical Skills:
  2. Investigate and manage patients with benign lesions of the of the duodenum

(1) Determine need for operative intervention

(2) Perform acid-reduction procedures, limited resection and duodenal

bypass procedures

  1. Investigate and manage patients with malignant neoplasms of the duodenum

(1) Stage the tumor pre- and intraoperatively and determine resectability

(2) Perform appropriate resection (including pancreatoduodenectomy +/-

portal vein resection and reconstruction when necessary) with regional lymphadenectomy

(3) Perform palliative procedures for unresectable tumors

(4) Participate in multidisciplinary tumor review conferences

(5) Recommend appropriate therapy for unresectable duodenal

malignancies

(6) Recommend appropriate neo- and adjuvant radiation and/ chemotherapy

and interact with Medical and Radiation Oncologists

  1. Provide postoperative management including the diagnosis and treatment of

complications of duodenal resection and/or bypass

 

Unit 4 –Spleen and Diaphrag

Anatomy, Embryology, Physiology, Testing

  1. Objectives: Upon completion of this unit the fellow will understand:
  2. Gross and microscopic anatomy of the spleen and diaphragm and the relationship with the adjacent and surrounding structures
  3. The embryology of the spleen an diaphragm liver and the potential anomalies
  4. The physiology of the spleen and diaphragm
  5. Clinical hematologic and biochemical tests relevant to the disease of the spleen and diaphragm and their indications and interpretation:
  6. Spleen imaging techniques and their indications and interpretation
  7. Implications of investigations and surgical procedures on the spleen and diaphragm
  8. Content
  9. Embryology of the spleen and diaphragm

            (1) Spectrum of normal anatomy and relationship to adjacent structures

(2) Developmental anomalies including site of possible splenunculi

(3) Normal and anomalous anatomy of splenic venous and arterial blood

supply including patterns of segmental branching

(4) Embryology and composition of the diaphragm

(5) Attachments of the diaphragm and traversing structures

(6) Relationships of adjacent organs

  1. Physiology of the spleen

(1) Immune and haematological function of the spleen

(2) Interpretation of tests of immune spleen function

  1. Diseases of the spleen

(1) Etiology and pathogenesis of hypersplenism

(2) Etiology, pathophysiology and prognosis of hyposplenism including OPSI

(3) Splenic Infarct and abscesses

(4) Parasitic Infections of the spleen including Hydatid disease

(5) Splenic Tumours: Etiology, pathology and natural history

i- Benign: splenic cysts,solid and cystic lesions

  1. Malignant: lymphoproliferative disorders, sarcoma, hemangiothelioma

(6) Vascular: Etiology, pathophysiology and complications

i- splenic vein thrombosis

ii- splenic artery aneurysm

(7)Splenectomy

  1. Indications (absolute and relative), contraindications, techniques,minimally invasive techniques and complications

(8) Causes of splenomegaly, splenorraphy and splenic auto transplantation

(9) Recent advances in the diagnosis and management of splenic disorder

 

3.Clinical skills:

  1. Identify, recognize, and describe anatomic structures around the spleen and diaphragm

(1) By reading and interpreting images of the spleen

(2) Intraoperatively

  1. Identify anatomic anomalies and explain their embryologic origin
  2. Understand the indications for and be able to interpret the hematologic and

biochemical tests and explain the underlying physiology

  1. Interpret the tests of spleen disorder
  2. Apply the relative advantages and disadvantages to the application of the

different modalities of spleen imaging

  1. Determine the appropriate abdominal wall incisions for open procedures on

the spleen

  1. Determine the appropriate port site placements and patient positions for

laparoscopic procedures on the spleen, and the relative indications for each and

the need for a hand-port

  1. Assess the overall risk of surgery by recognizing the implications of abnormalities by hematologic and biochemical testing.

 

Unit 5– Imaging

  1. Objectives: Upon completion of this unit the fellow will:
  2. Understand the physics and technology of Ultrasound and Doppler, CT Scan,

MRI Scan, PET Scan and the other nuclear medicine imaging procedures

including biliary excretion scan (HIDA), RBC scan, Octreotide scan, and L/S

scan

  1. Understand the relative advantages, disadvantages and indications of each
  2. Read and interpret the detailed information provided by the imaging of the

liver biliary tract, pancreas and duodenum

  1. Perform and interpret intraoperative ultrasound
  2. Content:
  3. The applied physics and technology of Ultrasound and Doppler, CT Scan, MRI

Scan, PET Scan and the other nuclear medicine imaging procedures

  1. The clinical protocols available for each technology

(1) The information provided by each protocol

(2) The interpretation of images

(3) The application to clinical investigation

  1. Imaging algorithm for the investigation of hepatobiliary and pancreatic

lesions including

(1) Liver cyst or tumor

(2) Jaundice

(3) Periampullary tumor

(4) Cyst or mass in the pancreas

d.Recent advances in the imaging techniques in HPB diseases

 

  1. Clinical Skills:
  2. Apply understanding of the relative merits of each imaging modality to

efficiently investigate (including staging of) lesions of the liver, biliary tract,

and pancreas

  1. Interpret images to correctly identify normal structures, anomalies and

pathologic abnormalities

  1. Correlate and integrate the findings of the various imaging studies during the

investigation of a patient

  1. Perform and interpret intraoperative ultrasound
  2. Interact with Diagnostic Radiologists with expertise in HPB diseases and body

imaging

Unit 6 – Oncology

  1. Objectives: Upon completion of this unit the fellow will:
  2. Understand the basic pathophysiology of neoplasia and the currently

understood mechanisms of carcinogenesis

  1. Understand the mechanisms of action of the classes of chemotherapeutic

agents currently available for HBP malignancies

  1. Understand the physics, mechanism of action and technology of radiation

therapy

  1. Apply this understanding to the multidisciplinary management of HBP

malignancies

  1. Content:
  2. Basic pathophysiology of neoplasia

(1) Mechanisms of carcinogenesis

(2) Genetic alterations, oncogene , proto-oncogene and tumor suppressor gene

(3) Viral carcinogenesis

(4) Chronic inflammation

(5) Tumor biology including the potential for metastases

(6)Tumor markers in HPB disease

  1. Chemotherapy

(1) Principle of chemotherapy ,Classes of drugs

(2) Mechanisms of action

(3) Toxicities

(4) Combination therapy and available protocols

  1. Radiation therapy

(1) Principle of radiotherapy ,Applied physics and technology

(2) Mechanism of action

(3) Toxicity

(4) Combination protocols with chemotherapy

d.Tumour immunology and immunotherapy

  1. Multidisciplinary management

(1) Relative roles of surgery, ablation, chemotherapy and radiation

therapy as:

(a) Definitive management

(b) Neo- and adjuvant therapy

(c) Therapy for recurrent disease

(d) Palliative therapy

  1. Recent advances and updates in the chemotherapy , radiotherapy and immunotherapy in the management of HPB disease

 

  1. Clinical Skills
  2. Apply knowledge of tumor biology, chemotherapy and radiation therapy to

recommend an appropriate treatment strategy for the management of

individual HBP malignancies

  1. Participate regularly in multidisciplinary tumor review conferences
  2. Interact with Interventional Radiologists, Medical Oncologists, Radiation

Oncologists, Oncology Nurses and Allied Health Professionals, Palliative Care

Physicians and Nurses

 

Unit 7 – Trauma

  1. Objectives: Upon completion of this unit the fellow will understand:
  2. The pathophysiology of blunt and penetrating trauma to the liver, biliary tract

and portal structures, pancreas, duodenum and adjacent structures

  1. The methods of assessment and diagnosis
  2. The principles and techniques available to manage traumatic injuries
  3. The management of complications of trauma to the liver, biliary tract,

pancreas and duodenum

  1. Content:
  2. Liver trauma

(1) Mechanisms of injury, presentation and grading

(2) Diagnosis and classification of liver lacerations

(3) Management

(a) Angiography and embolization

(b) Liver parenchyma hemostasis techniques

(c) Total vascular exclusion +/- IVC shunt or veno-venous bypass

for retrohepatic IVC and/or hepatic vein injuries

(d) Resection

(4) Complications: diagnosis and management

  1. Biliary tract and portal structures

(1) Mechanisms of injury, presentation and grading

(a) “External” trauma

(b) Operative injury during cholecystectomy

(2) Investigation, diagnosis and classification of bile duct injuries

(a) Identification of associated injuries

(3) Management

(a) Timing and role of ERCP + stent and PTBD

(b) Principles and techniques of biliary reconstruction

(4) Complications: diagnosis and management

  1. Pancreatic and duodenal trauma

(1) Mechanisms of injury , presentation and grading

(2) Investigation, diagnosis

(a) Identification of pancreatic duct disruption

(b) Identification of duodenal injury

(3) Management

(a) Indications for pancreatic resection

(b) Techniques for repair of duodenal injuries

(4) Complications: diagnosis and management

 

 

d.Spleen and Diaphragm injury

(1) Mechanisms of injury, presentation and grading

(2) Diagnosis and classification of Speen lacerations

(3) Identification of associated injuries

(4) Management

     Techniques of Splenorraphy, partial Splenectomy

(5) Identification and management of diaphragm and associated injury

e.Recent advances and updates in the management of HPB trauma

  1. Clinical Skills
  2. Consult and manage patients with blunt and penetrating trauma to the upper

abdomen

  1. Evaluate injuries to the liver, biliary tract, porta, pancreas and duodenum
  2. Evaluate post-cholecystectomy injuries to the bile duct and determine a

management strategy

  1. Perform emergency and elective operative procedures to resole and/or repair

injuries to the liver, bile duct, portal structures, pancreas, and duodenum

  1. Manage complications of operative intervention

 

Unit 8 – Transplantation

  1. Objectives: Upon completion of this unit the fellow will have a working

knowledge of:

  1. Organ procurement and preservation
  2. Indications and contraindications for liver and pancreas transplantation
  3. Outcomes including complications of transplantation
  4. Immunosuppression and its toxicities
  5. Content:
  6. Organ procurement

(1) Brain death and donor management

(a) Deceased donor hepatectomy and pancreatectomy

(2) Living donor assessment

(a) Living donor left or right hepatectomy

  1. Organ preservation

(1) Principles and application

  1. Transplantation

(1) Indications for liver transplantation

(a) Acute and chronic liver failure

(b) Hepatocellular carcinoma and other liver tumors

(c) Childs’ and MELD scores and organ allocation

(2) Liver

(a) Transplant hepatectomy

(b) Liver transplant techniques

(3) Pancreas

(a) Back bench reconstruction

(b) Pancreas transplant

(4) Immunosuppression

(a) Drugs, mechanisms of action, toxicities and combination

therapy

(5) Complications of transplantation

(a) Surgical

(b) Infectious

(c) Immunologic

(d) Updates in liver and pancreas transplantation

  1. Clinical Skills: a. Apply understanding of liver transplantation to recommend a liver

transplant to the appropriate patient at the appropriate time

  1. Recognize the oncologic impact of immunosuppression on recurrence of

hepatocellular carcinoma following liver transplantation and the increased

risk of de-novo malignancies

LOG BOOK

The fellows shall maintain a Record Book (Log Book) of the work carried out by them & training program undergone including details of procedures carried out independently or assisted by the candidate. The logbook will be checked by the faculty members imparting the training and has to be certified by the head of the Department. The logbook will also be evaluated and discussed during the viva voce of the Final Examination. The minimum number of procedures as outlined has to be completed to be eligible for the final examination.   

  • A logbook will be provided to the fellows, which has to be filled by the fellows and signed by the immediate supervisor and the head of department after individual postings.
  • All the details of individual postings with dates and number of night calls will be recorded in the logbook.
  • All the case management details will be recorded in the logbook.
  • All presentations, conferences, CMEs, Meetings will also be recorded in the logbook.
  • Record of leave, absence, and disciplinary action if any will also be recorded in the logbook.
  • Logbook will be analysed by the Preceptor in a regular bi-annual basis and be used to identify and remediate any gaps in acquired skills.
  • Retrospective entry into logbook will not be permitted and may entail inadequate performance or attendance thus leading to extension of the training period.
  • Logbook will have to be submitted to the Coordinator, at the end of training.

 

 

 

SUBJECT COMMITTEE

The unit chief of Hepatopancreatobiliary surgery will be the coordinator of the subject committee. Head of the department of surgery, the faculties of the concerned and related specialties and head of medical education may be appointed as the members of the subject committee. Visiting faculty in inside or outside the country may be appointed to help in the formative and summative assessment as necessary by email. The responsibilities of the subject committee will include:

  • Appointment of a senior consultant faculty of the level of Professor or Associate professor managing the Department of Hepatopancreatobiliary Surgery as the supervisor of the candidate
  • Rotation and posting of the candidates to acquire the required competency
  • Arrangement of applied basic science, research and ethics and medical education classes,
  • Arrangement of optional training abroad,
  • Logbook review,
  • Formative and summative assessment,
  • Question collection & discussion,
  • Helping to decide eligibility for examination as per the criteria
  • Helping to conduct examination,
  • Monitoring of the institutions and training program,
  • Supervision of students and teachers,
  • Other required activities for the program.

The subject committee should also develop the system of monitoring the responsibility of faculty and units and the assessment of students and evaluation of the programme

 

LEAVE

Fellows will be entitled to a leave of 15 days per year which will have to be preapproved from the coordinator and cannot be taken more than 7 days at a span.

 

ASSESSMENT METHODS:

Thesis/Dissertation:

  • Trainee has to submit synopsis/proposal for thesis/dissertation within six months of enrolment.
  • Trainee has to write a thesis/dissertation and submit 6 months ahead of qualifying examination.
  • The thesis/dissertation will be sent to evaluation at least to one external reviewer.    

Publications:

  • Trainee has to publish two research articles (Review/Original) in indexed national/regional/international journals before appearing into final examination.
  • Manuscript accepted for publication may be considered (Proof required).

 

Assessment consist of two components:

  • Formative
  • Summative (Qualifying/Certifying Examination)

 

Formative Assessment

Formative assessment will be carried out over following activities of the Candidate:

1)         Ward work. This will be done at regular intervals by the consultants in the concerned unit.

2)         Case presentation

3)         Seminar

4)         Journal club

5)         Internal Assessemnts: Theory paper (SAQs, MCQs, PBQs) once in a year

6)         Clinical assessment: at the end of each Clinical Posting “End Posting Examination’

7)         General assessment of funstional attitude be medical and paramedical sttaff

Feedbacks will be given after each formative evaluation. If the performance is found to be unsatisfactory, the candidate will be given opportunity to improve his / her performance and would be helped in the process. Specified number of formative assessment should be completed satisfactorily before appearing in the final examination. (Details are annexed)

 

Summative Assessment (Qualifying/Certifying/Exit Examination)

This will be conducted by the institute and would be the final certifying examination.

  1. Eligibility:
  • The eligibility to appear in the Summative Assessment (Qualifying/Certifying/Exit Examination) includes (All the criteria must be fulfilled):
  1. Successful completion of three years of fellowship
  2. Satisfactory formative assessment
  3. Successful completion of Thesis / Dissertation and approval of Thesis from the Examination committee.
  4. Completed log book and duly signed by the specified facilitators and signature must not be done in retrospect.
  5. Successful publication of two original articles or submission of two publishable articles
  6. Passed internal assessments.
  1. Summative assessment:

Summative assessment consists of two parts:

  1. Evaluation of thesis/dissertation prepared by the candidate
  2. Final examination consisting of three theory papers and one clinical examination.

                                 

Thesis/dissertation

The dissertation shall be defended before internal and external examiners and will be assessed as:

  1. Approved
  2. Not approved

 

Final examination will consist of:

  • Written Examination- Theory Papers
  • Practical Examination- Clinical Examination

WRITTEN EXAMINATION (Theory Papers)

Total marks 300

20% (total 60 marks) formative assessment & 80% (240) final examination

  • There will be 3 papers; all carry 80 marks. Each paper consists of Short Answer Questions (SAQs), Multiple Choice Questions (MCQs) and Problem Based Questions (PBQs)

Paper I:            Basic applied sciences 

Paper II:          Principles, practice and recent advances in general surgery

Paper III:         Principles practice and recent advances in Hepatopancreatibiliary surgery

PRACTICAL EXAMINATION (Clinical Examination):

Total marks 300        20% (60 marks) formative assessment & 80% (240) final assessment

Format of final assessment:

Long/Semi-long/short cases/MiniCEX:

Chart round/Case based discussion:

Case discussion:

OSCE/investigations/pictures/viva:

  • The coordinator and one of the faculty members of the concerned or related subject will be the internal examiners. There will be total four examiners, out of which at least two external examiners of the concerned subject will be invited for final examination. The external examiners will also review the portfolio consisting of the fulfillment of eligibility criteria of the candidate and may make any suggestions to improve the training programme.
  • The candidate has to pass separately in both theory and clinical practical, achieving at least overall 60% each in theory examination and in clinical practical examination.

 

DEGREE:     

Candidate who has completed all the criteria of eligibility for final examination and has passed both the written and clinical practical examinations  would be awarded: Fellowship of Chitwan Medical College in hepato-pancreato-biliary Surgery (FCMC HPBS)

SUGGESTED READING MATERIAL

  1. TEXTBOOKS
  2. Sabiston Textbook of Surgery.
  3. Shackelford's Surgery of the Alimentary Tract: 2-Volume set
  4. Maingot's Abdominal Operations
  5. Mastery of Surgery(two volumes)
  6. Skandalakis' Surgical Anatomy
  7. Blumgarts Surgery of the Liver, Biliary Tract and Pancreas: 2-Volume Set
  8. A Companion to Specialist Surgical Practice: Hepatobiliary and Pancreatic Surgery
  9. Master Techniques in Hepatobiliary and Pancreatic surgery
  10. Handbook of Hepato-Pancreato-Biliary surgery
  11. Liver transplantation by Dilip Chakravarty K
  12. Recent Advances in Surgery by Irving Taylor and Colin Johnson
  13. Recent Advances in Surgery by Roshan Lall Gupta
  14. ERCP: Recent edition
  15. JOURNALS & ANNUAL REVIEWS
  1. Journal of Pancreas
  2. Annals of Surgery
  3. Journals of hepatp-pancreato-biliary Sciences
  4. GI surgery annual: AIIMS publication
  1. DISEASE SPECIFIC NATIONAL, REGIONAL AND INTERNATIONAL GUIDELINES
  1. WHO guidelines
  2. NCCN guidelines
  3. European guidelines
  4. American guidelines
  5. Austarilian guidelines 

ANNEXURES

ANNEXURE I

PROFORMA FOR Formative Assessment

Assessment form for “Clinical Work”

(To be completed once in 6 months by respective Unit Heads)

Name:                                                                                                 Date:

Points to be considered:

  1. Punctuality
  2. Regularity of attendance
  3. Quality of Ward Work
  4. Ethical Practice
  5. Maintenance of case records
  6. Presentation of cases during rounds
  7. Investigations work-up
  8. Bedside manners
  9. Rapport with patients
  10. Undergraduate teaching (if applicable)
  11. Others:

Guidance for Scoring:

1                                  2                                  3                      4                                  5

Poor,                Below Average,          Average,          Above average,           Very Good

 

Total Score:

 

 

Signature (With date):


ANNEXURE II

EVALUATION FORM FOR “SEMINAR”

 

Name:                                                                                                             Date:

 

Points to be considered:

 

  1. Presentation
  2. Completeness of preparation
  3. Cogency of presentation
  4. Use of audiovisual aids
  5. Understanding of subject
  6. Ability to answer questions
  7. Time scheduling
  8. Consulted all relevant literature
  9. Overall performance

10        Others:

Guidance for Scoring:

1                                  2                        3                                4                                  5

Poor,                Below Average,          Average,          Above average,           Very Good

Total Score:

 

 

 

Signature (With date):


ANNEXURE III

EVALUATION FORM FOR “CLINICAL MEETING”

Name:                                                                                                             Date:

Points to be considered:

  1. Completeness of history
  2. Whether all relevant points elicited
  3. Cogency of presentation
  4. Logical order
  5. Mentioned all positive and negative points of importance
  6. Accuracy of general physical examination
  7. Whether all relevant physical signs elicited
  8. Whether any major signs missed or misinterpreted
  9. Diagnosis: whether it follows logically from history and findings.
  10. Investigations required –

- Complete list

- Relevant order

- Interpretation of investigations

  1. Overall:

Ability to react to questions – Whether answers relevant and complete

Ability to defend diagnosis

Ability to justify differential diagnosis

Confidence

Others

Guidance for Scoring:

1                                  2                        3                                4                                  5

Poor,                Below Average,          Average,          Above average,           Very Good

 

Total Score:

Signature (With date):

 


 ANNEXURE IV

The candidate on admission will be allotted one of the subject faculties who have fulfilled the requirement to be guides for purposes of guiding Dissertation / thesis. The topic for dissertation shall be finalized and discussed in the subject faculty meeting and allotted to the individual candidate before the completion of 6 months after admission. The candidate should present three proposals and choose one to do the research with the guide. The thesis work should be submitted before six months of the final exams. The thesis should be defended and accepted before being allowed to sit for the final exams.

The purpose of dissertation is to develop in the candidate the ability to perform an independent study keeping the research methodology in mind. The candidate will therefore work on the prospective problem either within the department or in collaboration with other departments. There will be continuous monitoring of the dissertation work by the guides and co-guides and by the other staff throughout the course. The candidate will present the progress of the dissertation to the faculty on the completion of 1½ years for monitoring and feedback. The completed dissertation should be submitted no later than 6 month before final examination.

The dissertation shall be evaluated independently by the internal and external examiners Candidate will have to defend his / her thesis work to get it approved. Presentation and defending of the thesis will have to be made by the candidate to the external and internal examiners who will critically and objectively analyze the thesis.

In all cases the approval shall be given at least before 3 months of the date of appearing for the examination and this will be essential before the candidate is allowed to appear for the written examination.

 

FORM FOR CONTINUOUS EVALUATION OF “DISSERTATION WORK”

Name:                                                             Date:

Points to be considered:

  1. Interest shown in selecting a topic
  2. Appropriate review
  3. Discussion with guide and other faculty
  4. Quality of protocol
  5. Preparation of proforma
  6. Regular collection of case material
  7. Depth of analysis/discussion
  8. Departmental presentation of findings
  9. Quality of final output
  10. Defence in Viva
  11. Others:

Guidance for Scoring:

1                                  2                        3                                4                                  5

Poor,                Below Average,          Average,          Above average,           Very Good

 

Total Score:

 

 

 

Signature (With date):


ANNEXURE V

EVALUATION FORM FOR “JOURNAL CLUB”

Name:                                                             Date:

Points to be considered:

  1. Choice of articles
  2. Cogency of presentation
  3. Whether he has understood the purpose of the article
  4. How well did he defend the article
  5. Whether cross references have been consulted
  6. Whether other relevant publications have been consulted
  7. His Overall impression of articles

If good – reasons:

If poor - reasons:

  1. Audiovisual aids
  2. Response to questioning
  3. Overall presentation
  4. Others:

Guidance for Scoring:

1                                  2                        3                                4                                  5

Poor,                Below Average,          Average,          Above average,           Very Good

Total Score:

 

 

 

Signature (With date):


ANNEXURE VI

 

LOG BOOK (PERFORMANCE RECORD BOOK)

Maintenance of performance record Lob book is mandatory. Certified and assessed copy should be made available at the time of practical examination for review by examiners. The cases should be assisted, done under supervision or done independently by the candidate.

 

Log Book should contain:

 

1)         Certificate duly signed by Facilitator, Head of Department, Head of Institute  stating – Dr………has worked in department from ---- to ---- for a period of 3 years.

This performance record book contains authentic record of work done and being assessed over last 3 years.

 

2) Record of training

Name of the candidate

Hospital

Training period

Name of facilitator

           

3)Record of Posting in different  sub specialties       

  • Liver surgery  
  • Pancreatic surgery
  • Biliary surgery
  • National or International level hospital         
  • others

                       

4) Journal club

Date

Title of Article

Name of journal, Year, volume, Number (If any), Page number

Name of Assessor / faculty:

Score / grading: (1-5)

Facilitator’s Signature:

 

 

 

5) Seminars

Date

Topic / Subject

Name of Assessor / faculty:

Score / grading: (1-5)

Facilitator’s Signature:

 

6) Case presentations:

Date

Case (Working diagnosis)

Name of Assessor / faculty:

Score / grading: (1-5)

Facilitator’s Signature:

 

7) Death Audit / C P C

Date

Case discussed

Name of Assessor / faculty:

Score / grading: (1-5)

Facilitator’s Signature:          

 

8) Teaching activity

Date

Topic / Class

 

9)Participation in Research Activity

Name of project

Duration

 

10) Conferences / Workshop

Title of the Conferences / Workshop attended

Title of the paper presentation / Publications

 

 

 

 

 

 

 


ANNEXURE VII

 

LOG BOOK DOCUMENTATION FOR HPB FELLOWSHIP

 

Procedure

 

 

 

Surgen mentor scrubbed

 

Surgeon mentor in theatre

 

Surgeon mentor available

 

Assisting surgeon mentor

 

Total

Gallbladder Surgery

 

 

 

 

 

Open cholecystectomy

 

 

 

 

 

Cholecystectomy + op cholangiogram (open)

 

 

 

 

 

Laparoscopic cholecystectomy

 

 

 

 

 

Cholecystectomy + op cholangiogram(laparoscopic)

 

 

 

 

 

Cholecystectomy + Common bile duct exploration (open)

 

 

 

 

 

Cholecystectomy + CBDE (laparoscopic)

 

 

 

 

 

choledochoscopy

 

 

 

 

 

CBDE without cholecystectomy Insertion tube /stent

 

 

 

 

 

Transduodenal sphincteroplasty

 

 

 

 

 

Other -specify

 

 

 

 

 

Bile Duct Surgery

 

 

 

 

 

choledochoenterostomy

 

 

 

 

 

Gastroenterostomy and choledochoenterostomy

 

 

 

 

 

Hepaticojejunostomy – to confluence

 

 

 

 

 

Left hepaticojejunostomy

 

 

 

 

 

Right hepaticojejunostomy

 

 

 

 

 

 

Laparoscopic biliary bypass

 

 

 

 

 

 

Bile duct reconstruction for injury or benign stricture

 

Bile duct reconstruction for tumour

 

 

 

 

 

 

Resection for hilar cholangiocarcinoma

 

 

 

 

 

 

Radical node dissection

 

 

 

 

 

 

Choledochal cyst excision

 

 

 

 

 

 

Other -specify

 

 

 

 

 

Liver Surgery

 

 

 

 

 

Radical cholecystectomy and liver resection

 

 

 

 

 

Insertion of infusaport

 

 

 

 

 

Right hepatectomy

 

 

 

 

 

Right trisectionectomy

 

 

 

 

 

Left hepatectomy 234

 

 

 

 

 

Left hepatectomy 23

 

 

 

 

 

Liver segmental resection

 

 

 

 

 

Non anatomical resection

 

 

 

 

 

Laparoscopic liver resection specify

 

 

 

 

 

Intra operative ultrasound

 

 

 

 

 

Hepatic trauma resection

 

 

 

 

 

Operative management of hepatic trauma(specify)

 

 

 

 

 

Ablation procedure for liver tumour

 

 

 

 

 

Other -specify

 

 

 

 

 

Liver transplantation

 

 

 

 

 

donor organ retrieval

 

 

 

 

 

backbench

 

 

 

 

 

Recipient hepatectomy

 

 

 

 

 

venous anastomosis

 

 

 

 

 

Arterial anastomosis or reconstruction vascular graft

 

 

 

 

 

Biliary anastomosis

 

 

 

 

 

Other - specify

 

 

 

 

 

Other Liver Surgery

 

 

 

 

 

Shunt surgery for portal hypertension

 

 

 

 

 

Devascularisation procedures for portal

hypertension

 

 

 

 

 

Fenestration of liver cysts (open)

 

 

 

 

 

Fenestration liver cysts (laparoscopic)

 

 

 

 

 

Hydatid Surgery (specify)

 

 

 

 

 

Liver abscess surgery

 

 

 

 

 

Insertion infusion device

 

 

 

 

 

Other - specify

 

 

 

 

 

Pancreas and Duodenum

 

 

 

 

 

Pancreaticoduodenectomy (open-laparoscopic)

 

 

 

 

 

Pancreaticoduodenectomy (pylorus preserving)

- Vascular reconstruction

 

 

 

 

 

Retroperitoneal node dissection

 

 

 

 

 

Distal pancreatectomy (open laparoscopic)

 

 

 

 

 

Spleen preserving distal pancreatectomy

 

 

 

 

 

Central pancreatectomy

 

 

 

 

 

Enucleation of pancreatic endocrine tumour

 

 

 

 

 

Other (specify)

 

 

 

 

 

Total pancreatectomy

 

 

 

 

 

Duodenal preserving pancreatectomy (Begers)

 

 

 

 

 

Pancreas sparing duodenectomy

 

 

 

 

 

Freys procedure

 

 

 

 

 

Pancreaticojejunostomy

 

 

 

 

 

Pseudocyst gastrostomy

 

 

 

 

 

Pseudocyst enterostomy

 

 

 

 

 

External drainage pseudocyst

 

 

 

 

 

Pancreatic necrosectomy - open

- laparoscopic

- percutaneous

 

 

 

 

 

Local excision duodenal tumour

 

 

 

 

 

Duodenal exclusion procedures

 

 

 

 

 

Pancreatic Duct sphincteroplasty

 

 

 

 

 

Operations for visceral aneurisms

 

 

 

 

 

Operations for nerve ablation procedures

 

 

 

 

 

Pancreas transplantation

 

 

 

 

 

Other (specify)

 

 

 

 

 

Spleen operations

 

 

 

 

 

Splenectomy (laparoscopic)

 

 

 

 

 

Splenectomy (open)

 

 

 

 

 

Splenectomy for massive spleen

 

 

 

 

 

Splenorrhaphy

 

 

 

 

 

Other spleen operations (specify)

 

 

 

 

 

Other Operations

 

 

 

 

 

Staging laparoscopy and/or biopsy

 

 

 

 

 

Laparoscopy US

 

 

 

 

 

Laparoscopy RFA/Microwave

 

 

 

 

 

Feeding jejunostomy

 

 

 

 

 

Feeding gastrostomy

 

 

 

 

 

Laparotomy for abdominal sepsis/peritonitis

Lavage

 

 

 

 

 

Laparotomy for post op bleeding

 

 

 

 

 

Small bowel resection with anastomosis

 

 

 

 

 

 

Large bowel resection with anastomosis

 

 

 

 

 

 

Bowel Resection with

 

 

 

 

 

ileostomy/colostomy

 

 

 

 

 

Non shunt surgery in cirrhosis

 

 

 

 

 

Abdominal wall hernias

 

 

 

 

 

Others (specify)

 

 

 

 

 

Non HPB surgery in OLT patients

(specify)

 

 

 

 

 

Conservative

 

 

 

 

 

Liver primary malignancy -

 

 

 

 

 

conservative

- RFA

 

 

 

 

 

- TACE

 

 

 

 

 

Liver secondary malignancy

 

 

 

 

 

conservative

- RFA

 

 

 

 

 

- TACE

 

 

 

 

 

- SIRT

 

 

 

 

 

Malignant obstructive jaundice - conservative

- stenting

(Specify site):

 

 

 

 

 

Duodenal /gastric obstruction - stenting

 

 

 

 

 

Malignancy - conservative

 

 

 

 

 

Specify site

 

 

 

 

 

MDT meetings

 

 

 

 

 

Non malignant jaundice - conservative

 

 

 

 

 

ERCP/sphincterotomy

 

 

 

 

 

Lithotripsy

Stenting

 

 

 

 

 

Acute pancreatitis - conservative

ERCP

 

 

 

 

 

Percutaneous drainage

 

 

 

 

 

GI haemorrhage (non PHT) -

 

 

 

 

 

conservative

- angiography

 

 

 

 

 

Variceal bleeding - conservative

 

 

 

 

 

- banding/schlerotherapy

 

 

 

 

 

- angiography

 

 

 

 

 

TIPS

 

 

 

 

 

Liver cysts

 

 

 

 

 

Adenoma, FNH incidentaloma

 

 

 

 

 

Ascites - conservative aspiration

 

 

 

 

 

- TIPS

 

 

 

 

 

- Peritoneovenous shunt

 

 

 

 

 

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