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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
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
• Kevin Nguyen
– 404 596 1157
The end
