pancreas surgery at piedmont
TRANSCRIPT
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Pancreas Surgery at PiedmontAtlanta Pancreas Cancer Conference - 2019
Andrew Page, M.D., FACS
Kevin Tri Nguyen, M.D. Ph.D., FACS
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MCW, DPC, and PAH
• Heidi
• Mike
• Dolores
Recognition
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None
Disclosures
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Overview – Pancreas Surgery at Piedmont
• Past– Roots
– General Surgery
• Present (2014 – current)*– Growth
– System
– Outpatient Clinic
– Patient Care
• Future– Opportunities
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William E. Mitchell, Jr. MD
• Father of Pancreas Surgery at Piedmont
• Atlanta native
• Father was general surgeon at Piedmont
• “Never graduated from anything.”
• University of Chicago, Johns Hopkins
• Drafted to Cubs
• Piedmont Surgeon, years 1969 – 2010.
Roots
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Roots – Hopkins 1968
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Edward Bradley, MD
• Integrated Emory and Piedmont
– 1974 – 1993
– Piedmont, 1984-1994
• Specific interest in pancreas
surgery and patient advocacy
• International Symposium on Acute
Pancreatitis – 1992.
– Foundation for many other
classifications and scores
• Especially radiology
Roots
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Piedmont Roots – More Recently
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Overview – Pancreas Surgery at Piedmont
• Past– Roots
– General Surgery
• Present – Growth
– System
– Outpatient Clinic
– Patient Care
• Future– Opportunities
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Liver, Pancreas, and Cancer Surgery (LPC)
• This is not a new problem
• Patient-centered, straightforward – HPB?
• Inclusive of all fields
– Surgical oncology
– Transplant
– HPB
• PLC? LPC it is
Starts With a Name
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Mission statement
To deliver the highest level of patient-centered and evidence-
based cancer care in Georgia.
Goals:
1. Our surgical and clinic volumes will be driven by our superior care,
outcomes, and service.
2. Develop and maintain a unique and strong camaraderie within our
team of transplant surgeons, hepatobiliary surgeons, and surgical
oncologists; this same cooperative relationship will be extended to
our referring physicians.
3. Transition from being a surgeon-specific practice, to a program-
based practice.
What is our Mission?
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Growth
0
10
20
30
40
50
60
70
80
90
2014 2015 2016 2017 2018 2019
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Volumes Correlate with Outcomes
Birkmeyer et al, Hospital Volume and Surgical Mortality, NEJM, 2002
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Volumes Correlate with Outcomes
Meguid et al, JACS 2008
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Pancreas Cancer Clinics
• Atlanta: Wednesday and Friday
• Athens and Fayette: Alternating
every other Tuesday
• New patients seen within 7 days
Where is the Growth Coming From?
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Overview – Pancreas Surgery at Piedmont
• Past– Roots
– General Surgery
• Present– Growth
– System
– Clinic
– Patient Care
• Future– Opportunities
– Robotic Surgery
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Formation of Piedmont Clinical Governance Councils (CGC):
A new structure for physician led clinical governance at the specialty level
The Burning Platform for a new Clinical Governance Structure
Exponential growth of Piedmont Healthcare & Clinic:• 400% growth in Clinic network since 2010
• Additional of 7 hospitals since 2010
Limited organization and engagement of physicians at specialty-level across system
Need for maturation of clinical governance structure to meet changing clinical integration requirements
Integration and structure needed
Engagement tool required
Update of governance model
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Oncology CGC – Clinical Governance Council
• Goal – improve and potentially standardize care across the system
• Monthly meetings, with representatives across spectrum, including
administration and quality improvement
• Oncology CGC:
– Breast Cancer– Jonathan Bender (Fayette, oncology)
– Survivorship – Andrew Pippas (Columbus, oncology)
– Pancreas Cancer – Andrew Page (Atlanta, surgery)
System – 11 hospitals, 650 locations
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• CT pancreas protocol
– Scan
– Read/interpretation
• Offer neoadjuvant chemo +/- XRT for all resectable and borderline
resectable
• All pancreas cancer patients presented at MDTB*
– Available for calling in, and to provide others opportunity to call in
• Lesson in implementation
– Governing bodies/EPIC
– Ask for feedback
– Implement and ask for forgiveness
• Metrics of adherence are followed with active dashboard through the
Quality Improvement Office
Pancreas Cancer CGC – 3 Initiatives
* MDTB – Multidisciplinary Tumor Board
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Pancreas Mass – Concern for Adenocarcinoma
CT pancreas protocol (no oral contrast, EPIC order “Pancreas Staging” and present at MDTB
Head/Uncinate lesion Body/Tail lesion
EUSSend Tumor Markers
EUS and Biliary Decompression with Metal StentSend Tumor Markers when Bilirubin Normal
ResectableBorderline resectable
Locally advanced, unresectable Metastatic,
unresectable
FOLFIRINOX vs Gem-abraxane,+/- chemoXRT
FOLFIRINOX vs Gem-abraxane,with chemoXRT
Re-present at MDTBClassify case/resectabilityConsider surgery versus rebiopsy
If (+) for adenocarcinoma
Palliative chemoNot curable
V4
Neoadjuvant Chemo Decision: Step 2
Piedmont Pancreas Cancer Decision Tree
Re-Present at MDTBCT Chest (for staging)Classify case/resectability
Re-present at MDTBClassify case/resectabilityConsider surgery versus rebiopsy
If (+) for adenocarcinoma
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• Great exercise in communication/networking
• The system is large and there are many opportunities across the
system to do this type of project
• Not all wins – e.g. breast
• Anecdotally, progress with pancreas
• But will be interested to see data after implementation
CGC Conclusions
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Overview – Pancreas Surgery at Piedmont
• Past– Roots
– General Surgery
• Present – Growth
– System
– Outpatient Clinic
– Patient Care
• Future– Opportunities
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• Long course
• Fear
• Overwhelmed
• Physicians/APPs cannot meet the expectations
– Patient education
– Surgical care
• Prehab
• Nutrition
– NCCN guidelines (genetics)
Clinic – Optimizing patient experience
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• Long course
• Fear
• Overwhelmed
• Physicians/APPs cannot meet the expectations
– Patient education
– Surgical care
• Prehab
• Nutrition
– NCCN guidelines (genetics)
Clinic – Optimizing patient experience
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Growing the Team
• Surgical Education: Navigator – Sharmeen Jones
– Former floor nurse that took care of our patients
– The primary contact for all pancreas cancer patients
considering surgery
• Surgical care
– Prehab: Joel Hardwick – Exercise physiologist
– Pre/post surgical nutrition – Sara/Lindsey/Sam
• Genetics
– Amanda Eppolito
• Already involved at tumor board
• But hoping to directly involve in our clinic
Patient Experience– Physicians/APPs cannot meet the
expectations
• Patient education
• Surgical care
– Prehab
– Nutrition
• NCCN guidelines (genetics)
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Solution – The Piedmont
Pancreas Passport
What is in the passport?Sections:• Navigator – education • Prehab – activity • Nutrition – bulk up• Genetics
• Simple check boxes• Brief blurbs• Area to take notes• Contacts
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Overview – Pancreas Surgery at Piedmont
• Past– Roots
– General Surgery
• Present – Growth
– System
– Outpatient Clinic
– Patient Care
• Future– Opportunities
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Presentation/Workup
• Tumor board is our foundation
– Every patient is presented at some point (CGC)
• If there is suspicion of adenocarcinoma, we get tissue
– EUS, occasionally multiple times
– CT guided biopsies rarely
– Tumor markers
• Metal stents are our friends
• Offer neoadjuvant as our standard of care – chip shot distal versus
Whipple with vascular reconstruction, no difference ***
Patient Care
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Perioperative – ERAS based care
• Avoiding preoperative fasting – Gatorade en route
• Surgical apprenticeship (AMC) or with APP
• Maximizing regional blocks (TAP/QL blocks)
– Minimizing opioids when possible
– Epidurals were not sustainable
– Lidocaine gtt
• Two drain team
Patient Care
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Perioperative – ERAS based care
• Skin vacs – we agree to disagree
• GJ tubes on older patients that have undergone
neoadjuvant tx
– Nutrition team guidance
– Dobhoff tubes
• Cohort patients together
– Camaraderie amongst the nurses, patients, and
surgical teams
• Early ambulation
– Use their education from prehab teaching
Patient Care
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Dec 2018: Recognition of providing exemplary care
Prism Award and AHPBA
March 2019: AHPBA – Moderator – Community HPB
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NPF – Center of Excellence
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Overview – Pancreas Surgery at Piedmont
• Past– Roots
– General Surgery
• Present – Growth
– System
– Outpatient Clinic
– Patient Care
• Future– Opportunities
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Many opportunities – Research and Patient-Centeredness
• Retrospective data review
• Specimens
• NPF and PanCAN
• HPB fellowship
• Trials and Collaboration
– TGEN/DPC
– PCI
– UCBC
– MCW
• Additional Surgeon starting in July
Future
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• DPC and MCW
• Transplant, Cancer, Foundation
• Non surgeons across the state
• The Glue
– Brooke Latterell
– Morgan Edwards
– Melissa Morgan
– Jackie Weiting
– Inpatient Army and Residents
Acknowledgements
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slide 36
Questions
• Andrew Page
– 404 372 1968
• Kevin Nguyen
– 404 596 1157
The end