What to expect when you're expecting a hepatopancreatobiliary surgeon: self‐reported experiences of HPB surgeons from different training pathways

BackgroundHepatopancreatobiliary (HPB) surgery fellowship training has multiple paths. Prospective trainees and employers must understand the differences between training pathways. This study examines self‐reported fellowship experiences and current scope of practice across three pathways.MethodsAn online survey was disseminated to 654 surgeons. These included active Americas Hepato‐Pancreato‐Biliary Association (AHPBA) members and recent graduates of HPB, transplant–HPB and HPB–heavy surgical oncology fellowships.ResultsA total of 416 (64%) surgeons responded. Most respondents were male (89%) and most were practising in an academic setting (83%). 290 (70%) respondents underwent formal fellowship training. Although fellowship experiences varied, current practice was largely similar. Minimally invasive surgery (MIS) and ultrasound were the most commonly identified areas of training deficiencies and were, respectively, cited as such by 47% and 34% of HPB‐, 49% and 50% of transplant‐, and 52% and 25% of surgical oncology‐trained respondents. Non‐HPB cases performed in current practice included gastrointestinal (GI) and general surgery cases (56% and 49%, respectively) for HPB‐trained respondents, transplant and general surgery cases (87% and 21%, respectively) for transplant‐trained respondents, and GI surgery and non‐HPB surgical oncology cases (70% and 28%, respectively) for surgical oncology‐trained respondents.ConclusionsFellowship training in HPB surgery varies by training pathway. Training in MIS and ultrasound is deficient in each pathway. The ultimate scope of non‐transplant HPB practice appears similar across training pathways. Thus, training pathway choice is best guided by the training experience desired and non‐HPB components of anticipated practice.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/113167/1/hpb12430.pd

The adequacy of Hepato‐Pancreato‐Biliary training: how closely do perceptions of fellows and programme directors align?

BackgroundHepatopancreatobiliary fellowship programmes have recently undergone significant changes with regards to training standards, case‐volume thresholds and multimodality educational platforms. The goals of this study were to compare the perspectives of fellows and programme directors (PDs) on perceptions of readiness to enter practice and identify core Hepato‐Pancreato‐Biliary (HPB) procedures that require increased emphasis during training.MethodsThis survey targeted PDs and trainees participating in the Fellowship Council/AHPBA pathway. Data related to demographics, education and career plans were collected. Analysis of PD and fellow opinions regarding their confidence to perform core HPB procedures was completed.ResultsThe response rate was 88% for both fellows (21/24) and PDs (23/26). There was good agreement between PDs and fellows in the perception of case volumes. Select differences where PDs ranked higher perceptions included major hepatectomies (PDs: 87% versus fellows: 57%, P = 0.04), pancreaticoduodenectomies (100% versus 81%, P = 0.04) and laparoscopic distal pancreatectomies (78% versus 43%, P = 0.03). ‘Good or excellent’ case volumes translated into increased fellow readiness, except for some pancreatitis procedures, laparoscopic distal pancreatectomies and potentially major hepatectomies.ConclusionsThis study provides insight into content domains that may require additional attention to achieve an appropriate level of proficiency and confidence upon completion of training.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/113116/1/hpb12457.pd

An unusual case of autoimmune pancreatitis presenting as pancreatic mass and obstructive jaundice: a case report and review of the literature

<p>Abstract</p> <p>Background</p> <p>Autoimmune pancreatitis is a rare chronic inflammatory pancreatic disease that is increasingly being diagnosed worldwide. As a result of overlap in clinical and radiological features, it is often misdiagnosed as pancreatic cancer. We report the case of a patient with autoimmune pancreatitis that was initially misdiagnosed as pancreatic cancer.</p> <p>Case presentation</p> <p>A 31-year-old Caucasian man presented to our hospital with epigastric pain, jaundice and weight loss. His CA 19-9 level was elevated, and computed tomography and endoscopic ultrasound revealed a pancreatic head mass abutting the portal vein. Endoscopic retrograde cholangiopancreaticography showed narrowing of the biliary duct and poor visualization of the pancreatic duct. Fine-needle aspiration biopsy revealed atypical ductal epithelial cells, which raised clinical suspicion of adenocarcinoma. Because of the patient's unusual age for the onset of pancreatic cancer and the acuity of his symptoms, he was referred to a tertiary care center for further evaluation. His immunoglobulin G4 antibody level was 365 mg/dL, and repeat computed tomography showed features typical of autoimmune pancreatitis. The patient's symptoms resolved with corticosteroid therapy.</p> <p>Conclusion</p> <p>Autoimmune pancreatitis is a rare disease with an excellent response to corticosteroid therapy. Its unique histological appearance and response to corticosteroid therapy can reduce unnecessary surgical procedures. A thorough evaluation by a multidisciplinary team is important in rendering the diagnosis of autoimmune pancreatitis.</p

Phenotypic screening reveals TNFR2 as a promising target for cancer immunotherapy.

Antibodies that target cell-surface molecules on T cells can enhance anti-tumor immune responses, resulting in sustained immune-mediated control of cancer. We set out to find new cancer immunotherapy targets by phenotypic screening on human regulatory T (Treg) cells and report the discovery of novel activators of tumor necrosis factor receptor 2 (TNFR2) and a potential role for this target in immunotherapy. A diverse phage display library was screened to find antibody mimetics with preferential binding to Treg cells, the most Treg-selective of which were all, without exception, found to bind specifically to TNFR2. A subset of these TNFR2 binders were found to agonise the receptor, inducing iκ-B degradation and NF-κB pathway signalling in vitro. TNFR2 was found to be expressed by tumor-infiltrating Treg cells, and to a lesser extent Teff cells, from three lung cancer patients, and a similar pattern was also observed in mice implanted with CT26 syngeneic tumors. In such animals, TNFR2-specific agonists inhibited tumor growth, enhanced tumor infiltration by CD8+ T cells and increased CD8+ T cell IFN-γ synthesis. Together, these data indicate a novel mechanism for TNF-α-independent TNFR2 agonism in cancer immunotherapy, and demonstrate the utility of target-agnostic screening in highlighting important targets during drug discovery.GW, BM, SG, JC-U, AS, AG-M, CB, JJ, RL, AJL, SR, RS, LJ, VV-A, RM and RWW were funded by MedImmune; JP and VB were funded by AstraZeneca PLC; JW, RSA-L and JB were funded by NIHR Cambridge Biomedical Research Centre and Kidney Research UK; JS and JF were funded by Retrogenix Ltd

Development of an international online learning platform for hepatopancreatobiliary surgical training: a needs assessment

Background The A mericas Hepato‐Pancreato‐Biliary Association ( AHPBA ) and the Australian and New Zealand Hepatic, Pancreatic and Biliary Association ( ANZHPBA ) are developing an online distance learning curriculum to facilitate an interactive didactic experience for hepatopancreatobiliary ( HPB ) fellows in the operationalization of existing HPB fellow curricula. Two needs assessment surveys were carried out to identify the optimal structure and process for deployment in fellow education. Methods A 22‐question survey querying fellows' learning styles and current and anticipated use of learning tools was disseminated electronically to 38 N orth A merican and A ustralasian HPB fellows. A follow‐up 20‐question survey was administered to assess fellows' feelings regarding online content. Results Response rates were 55% ( n = 21) for the first survey and 42% for the second ( n = 16). In the first survey, 67% of respondents claimed familiarity with the required HPB curriculum, and 43% indicated dissatisfaction with current personal study strategies. A total of 62% ( n = 13) reported studying with focused clinical relevance versus using a prescribed curriculum ( n = 1, 5%). Fellows anticipated participating using online tools once ( n = 10, 48%) or two or three times ( n = 5, 24%) per week. Most respondents ( n = 18, 86%) would meaningfully follow one or two discussions per month. The second survey identified themes for improvement such as discussion topics of interest, avoidance of holiday timing and mandatory participation. Conclusions An international online distance learning format is an appealing mechanism for improved dissemination and operationalization of the established HPB fellow curricula. Fellows will engage in interactive discussions monthly. Controversial topics or those requiring complex decision making are best suited to this learning format.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/109609/1/hpb12289-sup-0001-si.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/109609/2/hpb12289.pd

Non-canonical Notch signaling drives activation and differentiation of peripheral CD4+ T cells

Cleavage of the Notch receptor via a γ-secretase, results in the release of the active intra-cellular domain of Notch that migrates to the nucleus and interacts with RBP-JΚ, resulting in the activation of downstream target genes. This canonical Notch signaling pathway has been documented to influence T-cell development and function. However, the mechanistic details underlying this process remain obscure. In addition to RBP-JΚ, the intra-cellular domain of Notch also interacts with other proteins in the cytoplasm and nucleus, giving rise to the possibility of a alternate, RBP-JΚ independent Notch pathways. However, the contribution of such RBP-JΚ independent, non-canonical Notch signaling in regulating peripheral T-cell responses is unknown. In this report we specifically demonstrate the requirement of Notch1 for regulating signal strength and signaling events distal to the T-cell receptor in peripheral CD4+ T cells. By using mice with a conditional deletion in Notch1 or RBP-JΚ, we show that Notch1 regulates activation and proliferation of CD4+ T cells independently of RBP-JΚ. Furthermore, differentiation to TH1 and iTreg lineages although Notch dependent, is RBP-JΚ independent. Our striking observations demonstrate that many of the cell intrinsic functions of Notch occur independently of RBP-JΚ.. Such non-canonical regulation of these processes likely occurs through NF-ΚB. This reveals a previously unknown, novel role of non-canonical Notch signaling in regulating peripheral T-cell responses. <br/