OBJECTIVE To characterize the association between type of fellowship training and patient outcomes following hepatopancreatic (HP) surgery across different surgeon career stages using a national representative cohort of Medicare beneficiaries. BACKGROUND The current state of training in HPB surgery in North America is defined through three main pathways: the Complex General Surgical Oncology (CGSO), the Americas HPB Association fellowship, and the American Society of Transplant surgeons fellowship. Each pathway offers a unique perspective on HPB surgery with different number of training years, yet outcomes of graduates performing HP surgery relative to type of fellowship training have not been defined. METHODS Medicare claims were used to identify patients who underwent HP surgery for cancer between 2016-2021. The association of textbook outcomes (TO), defined as no postoperative complications, no prolonged LOS, no 90-day mortality and no 90-day readmission, relative to different fellowship pathways was examined. RESULTS Overall, 15,411 cancer operations (pancreatectomy: 11,003, 71.4%; hepatectomy: 4,408, 28.6%) were performed by 1,030 HPB surgeons. A total of 9,390 patients (60.9%) were operated on by a CGSO/SONC graduate, 2,315 patients (15.0%) by an HPB fellowship graduate and 3,706 (24.1%) by a transplant fellowship graduate. Patients who were operated on by an HPB fellowship graduate more frequently had a higher Charlson score (>5: 44.8% vs. 38.1%) and more frequently were operated on an urgent basis (7.7% vs. 6.1%) compared with individuals treated by CGSO/SONC graduates. After adjusting for patient, procedural, hospital, and surgeon related factors, the likelihood of TO following an HP operation by an HPB fellowship graduate was 47.7% versus 45.2% among CGSO (% difference 2.7%) and 42.8% among transplant fellowship graduates (% difference 4.9%, P=0.01). While the probability of TO was higher among surgeons having completed a dedicated HPB fellowship during early (1-7th year of independent practice, P=0.032) and middle (8-14th year, P<0.001) career stages, the probability of TO did not differ based on fellowship type among late career surgeons (>15th year, P=0.257). CONCLUSIONS Achievement of TO following an HP procedure was higher among surgeons who had completed a dedicated HPB fellowship, especially during early and middle career stages. Further efforts should be made to enhance HP surgery exposure and training for CGSO fellows interested in a career in HPB surgery.

中文翻译：

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肝胰胆外科：不同奖学金途径毕业生的结果分析。


目的 使用具有全国代表性的 Medicare 受益人队列，描述不同外科医生职业阶段的奖学金培训类型与患者结局之间的关联。背景北美 HPB 手术培训的现状通过三个主要途径定义：复杂普通外科肿瘤学 （CGSO）、美洲 HPB 协会奖学金和美国移植外科医生协会奖学金。每种途径都提供了对 HPB 手术的独特视角，具有不同的培训年限，但毕业生相对于奖学金培训类型进行 HP 手术的结果尚未定义。方法 Medicare 索赔用于确定 2016-2021 年间接受 HP 癌症手术的患者。检查了教科书结局 （TO） 的关联，定义为无术后并发症、无延长 LOS、无 90 天死亡率和无 90 天再入院，相对于不同的奖学金途径。结果 总体而言，15,411 例癌症手术 （胰腺切除术： 11,003， 71.4%;肝切除术： 4,408， 28.6%） 由 1,030 名 HPB 外科医生进行。共有 9,390 名患者 （60.9%） 由 CGSO/SONC 毕业生进行手术，2,315 名患者 （15.0%） 由 HPB 奖学金毕业生进行手术，3,706 名患者 （24.1%） 由移植奖学金毕业生进行手术。与 CGSO/SONC 毕业生治疗的个体相比，更频繁地接受 HPB 奖学金毕业生手术的患者具有更高的 Charlson 评分 （>5： 44.8% vs. 38.1%） 并且更频繁地接受紧急手术 （7.7% vs. 6.1%）。在调整了患者、手术、医院和外科医生相关因素后，HPB 奖学金毕业生在 HP 手术后发生 TO 的可能性为 47.7% 对 45%。CGSO 为 2%（% 差异 2.7%），移植奖学金毕业生为 42.8%（% 差异 4.9%，P=0.01）。虽然在早期 （独立实践的第 1-7 年，P=0.032） 和中期 （8-14 年，P<0.001） 职业生涯阶段完成专门的 HPB 奖学金的外科医生中 TO 的概率较高，但在职业生涯后期的外科医生中，TO 的概率没有根据奖学金类型而有所不同 （>15th， P=0.257）。结论 在完成专门的 HPB 奖学金的外科医生中，HP 手术后 TO 的实现率更高，尤其是在职业生涯的早期和中期。应进一步努力加强对 HPB 手术职业感兴趣的 CGSO 研究员的 HP 手术曝光和培训。