Pancreas Surgery at Piedmont

Pancreas Surgery at PiedmontAtlanta Pancreas Cancer Conference - 2019

Andrew Page, M.D., FACS

Kevin Tri Nguyen, M.D. Ph.D., FACS

MCW, DPC, and PAH

• Heidi

• Mike

• Dolores

Recognition

None

Disclosures

Overview – Pancreas Surgery at Piedmont

• Past– Roots

– General Surgery

• Present (2014 – current)*– Growth

– System

– Outpatient Clinic

– Patient Care

• Future– Opportunities

slide 5

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

slide 6

Roots – Hopkins 1968

slide 7

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

slide 8

Piedmont Roots – More Recently

slide 9

Overview – Pancreas Surgery at Piedmont

• Past– Roots

– General Surgery

• Present – Growth

– System

– Outpatient Clinic

– Patient Care

• Future– Opportunities

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

slide 11

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?

slide 12

Growth

0

10

20

30

40

50

60

70

80

90

2014 2015 2016 2017 2018 2019

Volumes Correlate with Outcomes

Birkmeyer et al, Hospital Volume and Surgical Mortality, NEJM, 2002

Volumes Correlate with Outcomes

Meguid et al, JACS 2008

slide 15

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?

slide 16

Overview – Pancreas Surgery at Piedmont

• Past– Roots

– General Surgery

• Present– Growth

– System

– Clinic

– Patient Care

• Future– Opportunities

– Robotic Surgery

slide 17

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

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

• 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

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

• 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

Overview – Pancreas Surgery at Piedmont

• Past– Roots

– General Surgery

• Present – Growth

– System

– Outpatient Clinic

– Patient Care

• Future– Opportunities

slide 23

• Long course

• Fear

• Overwhelmed

• Physicians/APPs cannot meet the expectations

– Patient education

– Surgical care

• Prehab

• Nutrition

– NCCN guidelines (genetics)

Clinic – Optimizing patient experience

slide 24

• Long course

• Fear

• Overwhelmed

• Physicians/APPs cannot meet the expectations

– Patient education

– Surgical care

• Prehab

• Nutrition

– NCCN guidelines (genetics)

Clinic – Optimizing patient experience

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)

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

Overview – Pancreas Surgery at Piedmont

• Past– Roots

– General Surgery

• Present – Growth

– System

– Outpatient Clinic

– Patient Care

• Future– Opportunities

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

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

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

Dec 2018: Recognition of providing exemplary care

Prism Award and AHPBA

March 2019: AHPBA – Moderator – Community HPB

NPF – Center of Excellence

Overview – Pancreas Surgery at Piedmont

• Past– Roots

– General Surgery

• Present – Growth

– System

– Outpatient Clinic

– Patient Care

• Future– Opportunities

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

• 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

slide 36

Questions

• Andrew Page

– 404 372 1968

– Andrew.Page@piedmont.org

• Kevin Nguyen

– 404 596 1157

– Kevin.Nguyen@piedmont.org

The end