Presence of a fellowship improves perioperative outcomes following hepato-pancreato-biliary procedures

Maria Altieri, MD, MS, Jie Yang, PhD, Andrew Bates, MD, Dana Telem, MD, Yaqi Xue, Mark Talamini, MD, Aurora Pryor, MD. Stony Brook University Hospital

Introduction: There is an increase in surgical subspecialization and therefore an increase in surgeons seeking fellowship training in the United States.   Data regarding the effect of Surgical Oncology/hepato-pancreato-biliary (HPB) fellowship programs on perioperative outcomes is scarce.  This study aims to compare perioperative outcomes and the presence of an HPB fellowship across all institutions following complex surgeries involving the pancreas, liver, and gallbladder, in the State of New York. 

Methods: Following IRB approval, the New York Statewide Planning and Research Cooperative System (SPARCS) administrative database was used to identify several complex surgeries involving the pancreas, liver, and gallbladder by using ICD-9 codes for inpatient procedures between 2012-2013.  Hospitals with fellowships were identified from the Fellowship Council website.  Patients under 18 years old, with missing identifier, or with multiple surgery records for the same surgery were excluded from analysis. Procedures were compared in terms of 30-day readmission, hospital length of stay (HLOS), and major complications between institutions with and without fellowship.   Facilities and the operating physicians were considered as two random effects to take into account of clustering nature of patients from the same facilities or the same physician.  Generalized linear mixed models were used to compare the differences.  P<0.05 was considered significant.

Results: There were 1,867 procedures identified during 2012-2013 in the state of New York.  Among these, 819 (43.9)% were pancreatic surgeries, 590 (31.6) were liver surgeries, and 458 (24.5%) were gallbladder surgeries. Elderly patients (p<0.001) and patients with more co-morbidities (p<0.001) tended to go to the hospitals with fellowship.  Univariate analysis showed that institutions with fellowship were associated with less severe complications (p=0.0072).  Following multiple logistic regression and controlling for other factors, hospitals with fellowship remained significantly associated with less severe complications (OR=0.4, 95% CI: 0.2-0.8, p=0.01).  No differences were seen between hospitals with and without fellowship in terms of 30-day readmissions (p=0.3) and hospital length of stay (p=0.3)

Conclusion: Fellowship status of an institution is associated with significantly improved perioperative outcomes, although there were no significant differences in terms of 30-day readmission rate or hospital length of stay.  This data highlights that fellowships in complex hepatico-pancreato-biliary procedures may actually improve patient outcomes even during the training period.