April Issue of HPB - Does your IHPBA membership add value?

The IHPBA world congress has just concluded in Seoul, Korea. This was a major success for the organisation with over 2500 participants from close to 100 countries.

The variety and quality of information presented was outstanding and a credit to both the scientific and local organising committees. The strategic vision of the IHPBA was outlined. It was stated the IHPBA membership will provide “added value”. So is an IHPBA member getting added value and how might that look in the future?

An example of current added value was delivered in the final plenary session by Dr Charles Vollmer. It is not often that one comes away from a conference with a watershed moment with regard to your day to day clinical practice. Yet, Dr Vollmer achieved exactly that for those in the audience of the final plenary session. A meticulous analysis of the effect of Somatostatin analogues on the incidence of post operative pancreatic fistula was presented. Several contradictory randomised controlled trials and multiple systematic reviews on the aforementioned topic have been produced. The most recent systematic review concluded a reduction in post operative complications associated with the use of Somatostatin analogues but Dr Vollmer’s study clearly showed a completely different outcome. This well thought out study used the recently published and validated fistula risk score to analyse the effect of Somatostatin analogues on the incidence of post operative pancreatic fistula following pancreaticoduodenectomy using a large multicentre dataset. It was conclusively and systematically shown that although Somatostatin analogues reduced the incidence of biochemical pancreatic fistula they markedly increased the incidence of clinically significant (grade B/C) pancreatic fistula. The detrimental effect increased as the fistula risk score increased. The meaning of this was that the use of Somatostatin analogues made a high risk pancreatic anastomosis even more likely to breakdown. These findings remained consistent when the components of the fistula risk score were analysed separately. What was even more striking was the fact that a surgeon’s incidence of pancreatic fistula was directly proportional to their use of Somatostatin analogues. This will be a must read paper for all users of Somatostatin analogues when it is published in HPB later this year.

Although several randomised controlled trials were presented throughout the world congress it was disappointing to see so many suffering from poor statistical design. Many of the flaws were relatively simple errors such as lack of power calculations, well defined primary endpoints or failure to control significant confounders or sources of bias. Many of the errors could have been easily remedied prior to the commencement of the trial. Such trials represent large investments of researcher’s time, energy and money as well as patient goodwill. It is important that as much be gained as possible from such endeavours and further thought is required on how the IHPBA can assist its members in improving trial design. Could myHPB act as a platform to provide peer review via a discussion board and mentorship by experienced researchers within IHPBA those with a concept for a proposed trial? Would this be added value?

The surgical mastery demonstrated by the hundreds of members who presented technical surgical video’s was remarkable. The continuing drive to perform ever increasing complex HPB procedures via a minimally invasive approach was clearly evident. However the high cost of the hardware, prolonged operating times and the labour intensive nature of the surgery did not sit well with the lack of hard endpoints clearly demonstrating an overall benefit to society, and left many questions unanswered for this author. Yet, there will be no going back, surgeons love technology too much. As a surgeon with a medium volume practice in a small isolated country that does not have a high volume national centre or availability of robotic technology a further issue requires exploration. As several ‘over the coffee cups’ conversations recounted harrowing technical disasters associated with surgeon learning curves and minimally invasive HPB surgery, a recurring thought persisted. How does one embark on a move to a minimally invasive approach for complex HPB surgery without compromising patient care? Although having previously attended “one-off” courses the long gap between patients with suitable pathology and lack of a nearby experienced mentor has held back the routine incorporation of these new skills into routine clinical practice. Listening to others’ experiences, it was clear that this phenomenon is not uncommon and a different approach is required. Collaboration, access to experienced mentorship, video capture with critical review, and reflective audit are a given but are there other options? Perhaps the most exciting and potentially promising was the development of simulation via the robot, and for laparoscopic or robotic training the development of anatomically and tactilely correct 3-D printed organs. If combined with an online learning programme with component videos and links to experienced mentors delivered via myHPB, there would be added value indeed!

To view the table of contents of the current issue, click here

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