Fellowship Overview

Description

The HPB Surgical Oncology Fellowship at the University of Toronto is a 2-year clinical training program in HPB Surgery and Oncology offered by the Division of General Surgery and Department of Surgical Oncology at the University Health Network (Toronto General Hospital and Princess Margaret Cancer Centre) in the Department of Surgery at the University of Toronto.

It consists of a first clinical “core” year in HPB Surgery & transplantation followed by a second year in HPB Surgical Oncology and related research. The HPB Fellowship is offered to one individual every year.

This Fellowship operates within the Department of Surgery, University of Toronto and within the guidelines outlined in the Task Force on Clinical Fellows document.

The aim of the HPB Fellowship is to provide the trainee with the basic and clinical education and experience necessary to develop expertise in the understanding, diagnosis, and management (including the necessary surgical skills) in the treatment of diseases of the liver, biliary tract and pancreas. The emphasis on Surgical Oncology derives directly from the spectrum of clinical activity in the program, and our multidisciplinary approach to oncologic management. Clinical and/or translational research productivity is a vital component of the Fellowship.

The HPB Oncology program at the University Health Network (Toronto General Hospital and the Princess Margaret Cancer Centre) is the largest HPB Centre in Canada. As designated by Cancer Care Ontario, it is one of only 9 HPB centres in Ontario, a province of approximately 13.6 million people. With institutional annual surgical volumes of over 150 major liver resections and 100 major pancreatic resections, our HPB and Transplant Fellows are actively involved in this very high-volume HPB activity. The distinguishing features of our HPB center include the application of living-donor transplant techniques to complex HPB oncology with arterial and venous resections (following neoadjuvant protocols) for pancreatic and hepatic malignancies, laparoscopic major liver resections, and multidisciplinary cancer care for all malignancies, including transplantation for hepatocellular carcinoma and cholangiocarcinoma. Through integration with the Transplant Program, the HPB Fellow is also cross-trained in transplantation. At any one time there are 6 to 8 Fellows in HPB and Transplant Surgery making Toronto a large Fellowship program.

Transplant and HPB Fellows 2002

Transplant & HPB Fellows, 2002

Front Row: Chuck Vollmer, Ian McGilvary, Elijah Dixon
Back Row: Bernie Langer, Bryce Taylor, Steve Gallinger, David Grant, Mark Cattral, Paul Greig

The Fellows work with 10 HPB and Transplant staff surgeons. The HPB Surgical Oncology Program has 6 staff surgeons: Drs. Gallinger, Greig, McGilvray, Moulton, Sapisochin and Wei.The Transplant program has 4 staff surgeons: Drs. Cattral, Ghanekar, Grant,  & Selzner. Drs. Greig, McGilvray & Sapisochin are also transplant surgeons.

Fellows are expected to transition to independent operating during their Fellowship. It is anticipated that each Fellow should be capable of independent deceased donor procurement (liver, pancreas and kidney) by the 3rd or 4th month of the first year. Independence in performing major HPB procedures is expected by mid-second year.

The Role of the University of Toronto

Clinical fellows play a significant role in our healthcare system, and the University of Toronto is a leading institution in the training of clinical fellows. According to the most recent data of the Canadian Post MD Education Registry (CAPER), 68% of all the clinical fellows in Ontario and 47% of all the clinical fellows in Canada are registered at the University of Toronto. This share of the total provincial and national clinical fellowship enrolment has belonged to the University of Toronto since 2007.

Clinical fellowship education involves the participation of numerous, and varied, stakeholders. To ensure the widest possible understanding of the University of Toronto’s role in the advanced postgraduate medical training of these doctors, the University has prepared concise documentation outlining the role of the University in Fellowship Training. This item is directly accessible via the following web link: http://pg.postmd.utoronto.ca/?ddownload=4004

Rotations

First Year

During the first year, the Transplant and HPB Fellowships are integrated and each Fellow does deceased donor and transplant procedures, elective HPB surgery and in-patient management, HPB & transplant clinics, and all transplant & HPB rounds, seminars and educational activities.

HPB Elective Surgery and Call
  • Three month rotations with one or two HPB staff for their clinics and elective surgery
  • Three month rotations on HPB in-patient service (Blue team), without donor or recipient call, responsible for HPB emergencies (CBD injuries, ruptured adenomas etc.)
Transplant Surgery and Call
  • Donor call: 1 in 5-6 throughout the year
  • Liver recipient and MOT ward call: 1 in 5-6 throughout the year
  • Pancreas/kidney call: 1 in 5-6 throughout the year

Throughout the first year the Fellow is responsible for the clinics and elective HPB surgery of her/his staff surgeons. Also note that Fellows’ transplant call for donor, recipient, and MOT ward occurs throughout the year (usually 1 week for each, every month). This is in contra-distinction to a schedule of blocks (often 2-3 months) of pure donor call, liver call, pancreas call, and kidney call. This is to ensure optimal exposure to donors and recipients throughout the year and avoid the inequity of a first year Fellow being assigned to liver transplant during the first three months, vs the last three months of the year.

Transplant and HPB Fellows 2006

Transplant & HPB Fellows, 2006

Zoltan Mathe, Sean Cleary, Shimul Shah, Markus Selzner

Second Year

The second year provides in-depth training in HPB Surgical Oncology during which the second year Fellow focuses on more complex HPB procedures, and multidisciplinary oncologic care:

  • Transduodenal resection of the ampulla of Vater, with reconstruction
  • Klatskin-type resections
  • Arterial & venous resections and reconstructions
  • In-situ liver cooling resections with re-implantation
  • Laparoscopic HPB Procedures
  • Biliary injuries (post laparoscopic cholecystectomy
  • Medical & Radiation Oncology Clinics (3 months each)
  • The Fellow actively pursues one or more HPB oncologic-related research projects which are individualized to the Fellow’s academic goals. They may be in the fields of translational research, or outcomes-based clinical epidemiology. The focus and staff supervisor for the second year projects will be determined during the first Fellowship year.

Curriculum & Didactic Teaching

Our HPB curriculum follows the Fellowship Council’s Advanced GI Curriculum for Hepato-Pancreato-Biliary Surgery Fellowship. Fellows are required to contribute to the online myHPB cases discussions as proscribed by the AHPBA, and participate in the Monthy “HPB Grand Rounds video-conferences. The Toronto Video Atlas of Liver, Pancreas & Transplant Surgery has been developed specifically for Fellowship training. An extensive series of HPB and transplant cases has been developed for the Fellows integrating 3D reconstructions of anatomy, intraoperative videos and graphic overlays using a case-based teaching methodology. The Educational Objectives for the HPB Fellowship (in CanMeds format), as required by the Division of Postgraduate Medical Education of the Faculty of medicine, University of Toronto are provided in the letter of offer of HPB Fellowship to the successful applicant. The following regularly scheduled rounds, and conferences are held:

Date Frequency Name Mandatory
Monday 7-9am weekly Surgical Oncology Seminar Series
Monday 4:30-5:30pm weekly General Surgery Quality Rounds  mandatory
Monday 6-8pm monthly HPB/Hepatology Faculty Club Series
Tuesday 8-9am weekly Live Liver Donor Review
Tuesday 4-5pm weekly Hepatoma Review Board
Tuesday 5-6pm weekly GI Tumour Review Board
Tuesday 6-9pm quarterly HPB Journal Club mandatory
Wednesday 8-9am weekly Multi-Organ Transplant Rounds
Wednesday 5-6pm monthly HPB Video Conference Grand Rounds mandatory
Thursday 4-5pm monthly Transplant Quality Review mandatory
Thursday 4:30-5:30pm monthly Teach Residents at HPB Seminars mandatory
Thursday 6-9pm quarterly Transplant Journal Club mandatory
Friday 7:30-8:30am weekly University or Hospital – Wide Rounds
Friday 9-10am weekly Liver Transplant Listing Conference
Friday 10-11am weekly HPB Clinical Research Rounds mandatory
Friday 11-12pm weekly Professor Round: Case Review mandatory
Friday 12-1pm weekly HPB Tumor Board/Multidisciplinary Cancer Conference mandatory

The Toronto Video Atlas of Liver, Pancreas & Transplant Surgery (TVASurg)

Toronto Video Atlas banner The Toronto Video Atlas is an important component of our transplant curriculum. The website is designed to instruct surgeons in the care of patients with complex problems in liver, pancreas and transplant surgery, and highlight the advanced surgical techniques required for the management of these diseases. The curriculum and cases have been targeted to surgeons who have completed their training in General Surgery and are enrolled in Fellowship training in liver, pancreas and transplant surgery. In each case the discussion regarding the pre-operative planning is enhanced by 3D reconstructions of the patient’s anatomy taken directly from the patient’s imaging, and the intraoperative video images are augmented with graphic overlays and 3D reconstructions to re-orient the viewer appropriately. The Atlas continues to grow with one new case added to the website each month. The Transplant Section contains donor and recipient procedures for both adult and pediatric recipients. Click here for an example of a live donor liver transplant using a right lobe graft. The website is publicly available.

Invited Professors

The following Invited Professorships have been made possible through generous donations to the Transplant & HPB Fellowship programs at the University of Toronto.

The Feeney Invited Professor

Dr. William Jarnagin (2014)

Professor of Surgery, Memorial Sloan Kettering Cancer Center; New York, New York
“The Enigma of Gall Bladder Cancer”

Dr. Elijah Dixon (2015)

Associate Professor, University of Calgary; Calgary, Alberta

“Clinical Trials & Tribulations”

Dr. Jen Jen Yeh (2017)

Associate Professor, University of North Carolina; Chapel Hill, North Carolina

“Deconstructing Pancreatic Cancer to Understand Tumour-Specific Signals”

The Charbonneau Invited Professor

Dr. Jean Nicolas Vauthey (2013)

Professor of Surgery, M D Anderson Cancer Center; Houston, Texas
“Colorectal Liver Metastases”

Dr. Rebecca Minter (2015)

Associate Professor, University of Michigan; Ann Arbor, Michigan
“Can I trust you to do my whipple?”

Dr. Alan Hemming (2017)

Professor of Surgery, University of California; San Diego, California
“Extending the Limits of Liver Surgery: Can this high-risk surgery be justified?”

The Rogan Invited Professor

Dr. Robert Padbury (2013)

Professor of Surgery, University of Adelaide; Adelaide, Australia
“Quality in HPB Surgery”

Dr. Nicolas O’Rourke (2012)

Professor of Surgery, University of Queensland; Brisbane, Australia
“Laparoscopic HPB Surgery”

 

The Mummenhoff Invited Professor in Transplantation

Dr. Jean Emond (2009)

Professor of Surgery, Columbia University; New York, New York
“Organ Allocation”

Dr. John Roberts (2012)

Professor of Surgery, University of California; San Francisco, California
“Live Donor Liver Transplantation”

Dr. William Chapman (2016)

Professor of Surgery, Washington University; St. Louis, Missouri

“Development of an Organ Donor Recovery Center”

Dr. Lucas McCormack (2017)

Professor of Surgery, Universidad de Buenos Aires; Argentina

“Liver Transplantation for HCC in Argentina: How can we make it better?”

 

The John Palmer Lecture (University of Toronto)

Dr. Mike Choti (2012)

Professor of Surgery, Johns Hopkins School of Medicine; Baltimore, Maryland
“Image-Guided Liver Surgery: Current Status and Future Directions”

Dr. Tim Pawlik (2015)

Professor of Surgery, Johns Hopkins School of Medicine; Baltimore, Maryland

Dr. David Kooby (2016)

Professor of Surgery, Emory University School of Medicine; Atlanta, Georgia

“Minimally Invasive Pancreatic Resection: Where We Are and Where We Need to Go”

 

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