E42 Henry Pitt on Quality in Hepatobiliary Surgery

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Chad Ball  00:15

Welcome to Cold Steel, the Canadian Journal of Surgery podcast with your hosts Ameer Farooq and Chad Ball. The goal of the CJS podcast is threefold. The first is to highlight the best research currently being completed by Canadian surgeons. Second is to offer educational topics for both surgeons and trainees alike. And most importantly, the third goal is to inspire discussion, thoughts, creativity and career development in all Canadian surgeons. We hope you enjoy it.

Ameer Farooq  00:50

This week, we were joined by one of the pioneers of Pancreato-Biliary surgery in the US, Dr. Henry Pitt. Dr. Pitt is the chief of oncologic quality at Rutgers Cancer Institute in New Jersey. And we really delve deep with him on this episode on his initiatives to improve the quality of HPB surgery in the US, North America and around the world.

Chad Ball  01:10

So Dr. Pitt, first of all, thank you very much for joining us on call to do It’s a real honor to have you on. You know that there’s no question that, that most of us across the country know who you are and know, your decades of work, and certainly within the US, and probably globally, hey, you’re you’re really an icon of particularly HPB surgery. For those of us that don’t know you as well, as we do, I just was wondering if you could tell us a bit about where you grew up and what your training pathway was like and, and how that sort of took you to Hopkins and then beyond?

Henry Pitt  01:43

Sure, and thanks for the opportunity to have this conversation today. So both my wife Betty and I grew up in North Jersey, about 25 miles from Manhattan. We actually met as teenagers, but didn’t get married until halfway through medical school. I went to college in upstate New York at Cornell actually played baseball, but perhaps more importantly, for your audience, we’ve had a really good ice hockey team when I was there. There was this goalie by the name of Ken Dryden who was fabulous. We won the NCAA championship. You know, he went on to play in the Olympics, and I think win win the most valuable player in the Stanley Cup but shortly thereafter, so that was great having him as the goalie. I then came closer to where our home was for medical school, also at Cornell, but now in New York City. And for one reason or another, I got interested in the biliary system and infections and worked with one of the infectious disease professors. And the very first paper on my CV is something about gentamicin levels in the biliary tract. That was a brand new antibiotic then, this was unknown. We had patients with T tubes and we wrote a paper so that was where I got started down that pathway. I matched in surgery at Johns Hopkins. So we went to Baltimore for a couple of years. At that point in time, there were pyramids. So there were 18 of us interns and I think 16 wanted to go into general surgery, but there were only four spots. Most of us had a military commitment. I had a commitment to be in the Navy. And although I wanted to wind up at the National Naval Medical Center in Bethesda, I think nationally, probably three or 400 other people did as well. And we wound up being stationed in Buford, South Carolina, for two years taking care of marine recruits. It turns out that that was a great experience for our family. I had been smart enough to write a paper with my chairman George Zuidema on liver abscess while I was away and got a slot back in Baltimore. Another part of the training there was actually an experience in Ireland. So we lived in Dublin for six months, as a fourth year resident on a vascular service, which actually was great training for what I eventually wound up doing. And then when I finished my training, we had sort of three options. There was a private practice job, a very good job back in New Jersey, where we had grown up. I could have stayed the faculty at Johns Hopkins. But we’re talking about the 70s and there really wasn’t a lot of liver or pancreato surgery going on. But there was a fellow by the name of Will Longmire who was trained in Hopkins and was prior Chairman at UCLA and had been the president of the American Surgical and the American College of Surgeons and internationally known. And I felt that if I went there to UCLA, I would really learn even more. So that’s what we did. We were on the faculty there for six years, and had great opportunities to learn from them. We can talk a little bit more about that later. And then John Cameron became the chair of Hopkins. John had been junior faculty when I had been a residence in the 70s. And he asked me to come back. So we came back to Hopkins in 85. At the time, there were a couple of super two presidents by the name of Keith Romo and Charlie Yau, both of whom were kept on the faculty. Keith and I became very close in terms of mentor mentee. And Mike Zehner, was also brought back to the faculty and Charlie and Mike worked very closely for a couple of years. And we had a great time all together for the next 12 years, doing a number of randomised trials. John, of course, was the senior of the four of us, nine years older than me and then I was nine years older than Chief Keith and Charlie, so and sort of no question that John was the boss. And I was sort of like, the big brother, and Keith and Charlie were the younger brothers. But we really work very well together as a team and had a fantastic time.

Ameer Farooq  06:47

Dr. Pitt, you’re often credited, rightly so is one of the pioneers of American biliary surgery. Can you tell us about what it was like to be doing those surgery in really what was a newly developing field and what some of the sentinel jump forwards were in, in developing biliary surgery as its own discipline?

Henry Pitt  07:10

Sure. You know, again, back when I was a medical student and a resident, there was not a lot of complex biliary surgery as we think of it now. But there was a lot of gallbladder surgery and common bile duct surgery. So we were very facile at doing open common bile duct explorations, doing interoperative choledoscopies, completion cholangiograms and that was really the state of the art back in the 60s and 70s. I think the audience won’t really understand this, but we had no ultrasounds we had no CAT scans. We had no MRI scans. ERCP hadn’t quite been invented in the early 70s. So all of the stone disease was cervical disease back then. As residents we did see an occasional bile duct injury, an occasional  cholangiocarcinoma. Those were the kinds of things that we now think of as complex biliary surgery. And we all know want to scrub on those cases, but they were few and far between. But that was part of the reason that I wanted to go work with Dr. Longmire, because he was near the end of his career at that time, and had some of the largest experience in the world with repair bile duct injuries, pilot  cholangiocarcinoma, liver surgery, pancreato surgery. He built reverse as I just described the pylorus preserving pancreaticoduodenectomy in 78. And I got to UCLA in 79. So I really had the opportunity to look up those series series and faces in surgical center of Boston, another operation that’s rarely done anymore. And Dr. Longmire, asked me to write a chapter on cholangitis, which got me even more interested in the biliary infections. And he also was doing surgery on patients with sclerosing cholangitis. Couldn’t remember the sequence for liver transplants, but there were cases with an early extra product disease that we would do and why clinical judgment often moves on. I remember distinctly telling John Cameron about that at a DDW meeting in 1980. And then he began doing them in Baltimore, and we did a lot more subsequently. The other person who was key for me at UCLA was JV Sitzmann , another faculty person, and was doing research and gallstone pathogenesis and I started working with biliary. And that got me to be even more knowledgeable about biliary physiology and bile acids and all those sorts of things which played a role in my subsequent interest in biliary surgery. But to go back to your original question, I think that the imaging, the evolution of interventional radiology, the evolution of interventional endoscopy, and forming multidisciplinary teams to take care of patients with complex biliary problems and hepato-pancreato-biliary problems, I think one of the key jumps back in the 80s and early 90s.

Ameer Farooq  10:52

I think it’s important to get the opinion of someone like yourself who’s really has seen the breadth of the way that HPB surgery has developed over the last few decades. And I’m curious what your thoughts are about the way and the exposure that residents get to biliary surgery now, especially as it becomes a much more subspecialized field. I’m particularly thinking of, you know, open open common bile duct expirations or even open close thysterectomies. I think the majority of residents will have seen a few of those or done a few of those on their hv rotations but really not had much experience outside of that. How do you see that tension going forward? And do you think that is something that we need to address or how do you see us going forward with that?

Henry Pitt  10:54

I think that’s a very good question. And I would say, you know, when with laparoscopic cholecystectomy is the equation changed in terms of bile duct injuries. It’s fortunately gotten a little bit better now. But as surgery has become more and more specialized, and the endoscopists do a lot of this work, you’re right that the surgical residents do not get the kind of experience that we got doing cholecystectomies often. Having said that, though, I think that the current generation of attendings and residents have gotten tremendous, really good at doing procedures, minimally invasively. The few centers where there still are a lot of open workloads, I think, are a great training place for doing difficult cholecystectomies, because, as you well know, some of those patients having had stents and they get cholecystitis and then empyemas of the gallbladder and then taking those gallbladders out is always a challenge. But that does not really apply for the vast majority of the trainees, only the trainees that are specialized places and, and of course, the way the whole world has evolved. Now, the vast majority of trainees are going on to do fellowships. And that’s really where I think that expertise comes in now. And it’s very difficult for us to properly trained surgical residents, I do think that we were too quick to give up on common bile duct exploration. And I do think that that’s something going forward for those of us who are experts in the field, we really need to teach the next generation how to do a minimally invasive bile duct exploration with all the bells and whistles of choledocoscopy and completion cholangiogram, and all those things that we learned decades ago, to prevent replaying common back stones. That’s there’s been a gradual movement in that direction, but probably we need to be more.

Chad Ball  14:23

Dr. Pitt, if you’re if you’re sort of a version I don’t know what 1.52 software talk of an American biliary surgery, you’re certainly a 1.0 version in terms of being a very early leader in promoting quality in American surgery. Can you define for our audience, the concepts at their core of things like what quality is and what quality improvement is?

Henry Pitt  14:47

Sure. And you know, go back to the I have been around a while and to go back to early leader part of it, we were doing quality before we called it quality. We were doing quality before it became, you know, a specialty now. And, you know, in our current parlance, we talk about the value and value of being quality over cost. But part of what we were doing at Hopkins back in the 90s, I think, came at that equation the opposite way. And by that, I mean that the state of Maryland was the only state not to go on the diagnostic related group or DRG payment system. And, but they had a system cost commission, where they would keep all the hospitals viable they wouldn’t let them lose money. But they also would not let them make a lot of money. So the margins were thin. And as a result, you know, 30 years ago, we really needed to begin reducing length of stay, and reducing variation among groups, all those concepts that are well known now. And, again, working with Dr. Cameron and Dr. Yeo and Dr. Lillemoe, and we had a hospital administrator by the name of Toby Gordon, who had a doctoral degree from the School of Public Health in Hopkins. And, you know, we think it’s very easy now to look at big databases, but at the time, she was actually, looking at the Maryland State database, and some of those original papers in pancreas, with respect to volume outcome, was part of her helping us. And then we did similar papers with Mike Ciotti around bile outcome and liver. And we did another one, with Julie Sosa around complex biliary surgery using the state database. So those were some of the early things that we did, that were steps in the direction of where we are now. But but also something that we did, as a group with Toby was to create care pathways. And by the mid 90s, we had 50 procedures on care pathways throughout Johns Hopkins. And it was essentially the forerunner of ERAS and all of us practices that have gone into ERAS we were working on before anybody thought of that concept. So I think some of those, you know, basic principles that we learned, we had good data, we looked at the data, you know, the four of us as HPB surgeons, all background in athletics, think surgeons in general tend to be competitive surgeons, in general want the outcomes for the patients to be the best they possibly could. So when you used to slice and dice, all the Whipple data, all of the complex biliary data by the four of us, and we’d feed it back to each of us. And, you know, in theory, it was blinded, but there were only four of us. And we knew who was who. And everybody wanted to have the shortest length of stay, and have the fewest complications. And through reducing cost, it turned out that the way you were going to accomplish that was to not have any complications. So that’s why why I say, you know, we started reducing costs and in the practice of reducing costs, and having pathways and doing ERAS type of best practices, we wound up creating excellent quality.

Ameer Farooq  19:02

Such a fascinating view as to how all of this began, Dr. Pitt. Can you tell us a little bit about the origins of ACS-NSQIP, as well, and maybe for the few listeners who don’t know what that is, maybe just tell us what that is, and and how is that really changed American and truly global surgery?

Henry Pitt  19:23

Sure. So I mean, the story is actually very interesting as ACS as American College of Surgeons, and NSQIP is National Surgical Quality Improvement Program. Actually, NSQIP started in the VA hospitals in America. And, you know, as so often is the case now something gets into the news or the politicians hear about it. And it turns out that there was something in one of the Chicago newspapers about some bad outcomes of one of the Chicago VA hospitals. And that got all the way to our US Congress. And in their ultimate wisdom passed a law saying that the VA hospitals needed to have risk adjusted data. Well, there was nothing of its kind back then. I mean, we were just beginning to get computers and things like that, you know, second generation. So, fortunately, there was a man by the name of Shukri Khuri, who was a cardiac surgeon at the Boston VA, who grew up in Pittsburgh, his father, and actually, I think he was born in Beirut. And his father was a mathematician, on the faculty at Carnegie Mellon in Pittsburgh. So, so he was, you know, clearly had the math teams, and was able to create this surgical quality program within the VA system. By the end of the 90s, all 132 VA hospitals, were doing this. I was a surgical chair in Wisconsin starting in 97. And that’s when I first started seeing the NSQIP quality data from, from our VA hospital in Milwaukee. And we had data on all of the specialties, and it was highly risk adjusted. And it was very believable data, and you could discuss the data with the surgeons, and they knew where they were, in terms of their peers. And again, everybody wanted to do better. So that led to a handful of the VA hospitals that were also associated with University Hospitals, saying, well, gee, if we can, and many of the faculty were back and forth between the university and the VA hospital, if we can do this in the VA, certainly we could do this, our academic medical centers, so they actually got a grant from AHRQ. And some of the places where these pilot studies were done were Michigan and University of Virginia and Emory and Utah. And all in all, I think there were 14 AMC6’s and four affiliated community hospitals and early systems back then, so 18 hospitals, that were not VA, starting doing this work, and it was obvious that it was very doable. Scott Jones, another great HPB surgeon trained at Duke and had been the chair at Virginia, was in the middle of all of that pilot project. And then he became the president of the American College of Surgeons and really influenced the powers that they that this is something that should not just be in the VA hospitals, but also should be in the so called private sector. And he really got the American College to put all the weight of their finances and expertise behind the program to get in this group started in the American College of Surgeons. 2004 2005 was when that again, Cliff Ko became the leader of that group and Bruce Hall, shortly thereafter, was his right hand person. And within a couple of years, they were able to publish, actually present at the American Surgical Association and present a paper that showed that mortality improved in 82% of the hospitals and morbidity improved and two thirds of the hospitals within the first three years of participating in this group. So that’s really when the ball got rolling. Shortly thereafter, there was a paper out of Penn State, where they were able to demonstrate a return on investment for this scope in the year too, because it’s clear that all of these complications, whether it be superficial surgical site infections, which might cost $10,000, or organ space infections, which might cost 20 or $25,000. If you reduce a few of them over a year, you can wind up paying for the extra costs and the nurse to gather the data. And I think that’s  a key part of the equation is that these are clinicians, nurses that gather the data and they communicate with The surgeons to make sure that the data are accurate going in. And all of the variables have very well defined definitions. And that’s why surgeons I think, tend to believe this data.

Chad Ball  25:19

It’s interesting Dr. Pitt to listen to you talk about the origins of NSQIP. It makes me reflect upon Calgary specifically. And, you of course know this. But before I started training here, Peter Cruz was our chairman. And he had hired a small handful of surgical OR nurses to check every wound of every surgeon in the department every single day. And each surgeon received a report on a monthly basis, comparing their wound infection rates or their superficialis SSI rate to their colleagues. And by all accounts and talking to the almost surgeons at that time, even on a local level that had a profound impact in terms of quality improvement and bringing the herd together. So it’s clear that there’s there’s no doubt NSQIP is incredibly powerful to do that.

Henry Pitt  26:12

I am sure that Shukri Khuri knew about what was going on. And, you know, nothing in this world is new. But that those principles that were developed, there are the same principles that we have in this book today.

Chad Ball  26:28

That’s, it’s, it’s quite neat. What one of the new ways that you’ve taken the NSQIP platform, of course, is disease or subspecialty, specific markers and outcomes, and you know, obviously being bias HPB-NSQIP, this is our premier example of that. Could you talk about the history of that and the direction of that and how that’s really empowered in particular, for example, HPB surgeons going forward?

Henry Pitt  26:55

Sure. So I mean, this goes back a little bit to the origins of the Americas Hepato-Pancreato-Biliary Association. We got that all started in 1994. And it was really a decade later that NSQIP got started to the American College of Surgeons. But a number of the people who were early leaders within the AHPBA were very aware and involved in the NSQIP work. So for example, Mike Henderson had been at Emory before he went to the Cleveland Clinic. He was our first president. Sean Mulvihill, had been at Utah, where, again, some of the pilot work was was done through NSQIP, and Steve Strasberg, you know, always was in the middle of all of these things about trying to make sure that outcomes were as good as they possibly could be. You know, obviously, his work with the critical view is wanting one example of that. So we, you know, former past president of the AHPBA, actually dug into the HPB data for the first four years, I think, 2005, 2006, 2007 and 2008, and then wrote a little position paper, which was published in HPB, I think in 2009, saying that this platform could create something called HPB-NSQIP, I think that was in the title. And I started trying to influence call and there was all about this at the time. And one of the messages that we got was was we need procedure specific variables. So we had a research committee back then, and Steve Strasberg and I worked with people who are now very well known, but we’re early in their careers then Tim Pawlik, Tom Aloia, Elijah Dixon from Calgary, Nick Zyromski, and we had a series of conference calls, and came up with 24 pancreas-specific variables, and 30 hepatectomy-specific variables. Now it was very interesting because there was a committee at the time that said, well, you can only have three or four or five variables. And there was a turnover in the leadership of the committee. And somehow we snuck in and we got approval to develop all of those variables, which the vast majority of which are still in play today. And, and then we pushed a little bit hard and settle, okay, we’ve got these variables, we’d like to implement this and Klitschko and Bruce all said, well, you have to demonstrate that our surgical clinical reviewers can actually counter these data. So that we were given a permission to do a demonstration project. And that started in November of 2011 at 37 hospitals. Again, this is where we’re using our personal connections and AHPBA network to get people on board. And by the time we finished, we had 43 hospitals, where we collected the procedure-specific data. So the two months of 2011 and 12 months of 2012. And clearly, we weren’t able to do that Taylor Riall played a key role in analyzing some of the early data as did Bruce Hall. Molly Kilbane, our surgical clinical reviewer in Indiana was key in this whole process. And then we started publishing papers from the data. And it became clear in 2013, and 2014, that, that we were on to something. So the leaders of the American College of Surgeons allowed us to have hospitals voluntarily gather pancreas data in 2013, and pancreas and liver data in 2014, the, the SDRs, and the hospitals could volunteer. And it turned out that we had, you know, 75 85 hospitals volunteering, and, and then eventually I said, Well, we need to create a collaborative, and we were allowed to create the collaborative in 2015. So that’s been up and running for five years now. It turns out that currently, we have 172 hospitals around the world, gathering hepatectomy- and pancreatectomy- specific data. Not all of those hospitals are in the collaborative but the collaborative hospitals collect about 85% of those data. And then they get reports back not only, you know, their usual NSQIP data, but also their hepatectomy and pancreatectomy patients, whether they major or partial hepatectomy and also Whipples in distals and the data are all risk adjusted. And now we’ve got the usual kinds of things like superficial organ-space infections and VTE but we we also have data on pancreatic fistulas and delay gastric emptying and bile leaks and interventional biliary procedures and posthepatectomy liver failure. So it’s begun it’s become a great platform to, again, feedback, risk-adjusted data, people see if they’re a high outlier, they want to do better. And actually Joal Beane, who trained at Indiana and then at Pittsburgh and now is a junior faculty person at UCLA and I just have a paper and print in Annals have shown that the optimal outcomes of patients with pancreatectomy have actually improved over a four year period from 2014 to 2017. So so we’re doing something right.

Chad Ball  33:52

Yeah, there’s no question it’s working. It’s so interesting to pay attention to listen to how and watch how you leveraged the HPB collaborative on top of NSQIP platform, it was remarkable. One of the problems we run into in Canada sometimes with bringing some of these new technologies or concepts or platforms in is that our budgets are siloed, even within a single health care system. So for example, a nursing manager will run the budget for an operating room, which will be different from someone else who will run the ward which will be different from the emergency department. So obtaining those cost savings at the patient level, from start to finish becomes becomes quite difficult. There’s no question about that. Another really impressive leveraged benefit that that you’ve now moved into, along with Mike D’Angelica, and some others is using that NSQIP platform to actually perform very large randomized controlled prospective trials. Can you tell us about that?

Henry Pitt  34:54

Sure. Well, and let me also comment that you know, it sounds like a very nice story now 15 years later, but there were lots of obstacles along the way. And you know, like, that’s not our simple. This was one of the, you know, examples of persistence. I think that, you know, Cliff and Bruce, were always I kept on badgering and oh, well, we could do this, we could do that. You know, and I think they got tired of hearing me, and eventually they let me do things. So that that lesson, I think, just being persistent is, is important. But to answer your question about clinical trials, actually, if you go back to the origins of AHPBA, that was one of our goals. Now, it’s always been difficult to do that. Because of all the infrastructure that is required for many of these clinical trials. But it was one of the visions that we have that we have this platform now, with so many hospitals participating in his platform of this group, is actually fantastic. Because if we think of all the salaries that are being paid by each of the hospitals for the surgical clinical reviewers, earning $25,000 a year to participate in this group, which again, there’s a return on investment for this platforms worth over $20 million a year that the hospitals are already investing in, and the surgeons believe the data. So I go back to the AHPBA. Again, I go back to a time when Elijah Dixon was the president. And he actually created the clinical trials committee, which hadn’t existed before, and appointed Mike D’Angelica and Adam Yopp as the chair and co-chair of the committee. So by this time, we knew that the mean obviously the Achilles heel of local procedure, is pancreatic fistula, but also the surgical site infection rates were way too high. And if you add up the superficial, the deep and the organ space infections, it’s 20-21%. And it hasn’t changed. So we felt that if we could do a clinical trial, trying to reduce the surgical site infection rates on the NSQIP platform, that would be something that we could do without huge amounts of extra cost, and really the ability of re-institutions to volunteer to participate. Now, there’s a program in the American College of Surgeons called the Clinical Scholars Program. And part of this whole equation was that Carl and Bruce Hall really lent us the time of a couple of the clinical scholars over the last couple of years to help write the protocols and onboard the institutions. And the two people that have been involved there are Jason Liu, who’s now backing a surgical residency at the University of Chicago. And Ryan Ellis is about to go back to be a surgical resident at Northwestern. So with Mike and Adam and Jason and Ryan, and support from Cliff and Bruce and I, we have gotten and again, you know, with Elijah creating this committee, we have gotten this clinical trial up and running, took a while to get started. And they really got all the kinks worked out at Memorial Sloan Kettering when we’re Mike D’Angelica is and and then after about a year of doing that, so we onboard of more and more hospitals. And currently, we have 26 hospitals across North America. And I should make that point because there are a dozen NSQIP hospitals in Canada. And clearly when I talk about NSQIP data now I talk about North American data, not US data. And this clinical trial is a North American trial of two different antibiotics in patients having Whipple procedures. Before COVID-19 we were about two-thirds of the way there and accruing nearly 900 patients. And I believe that will be up and running again here shortly. And hopefully by the end of this calendar year, we’ll have that trial completed.

Ameer Farooq  39:56

Dr. Pitt clearly underlying all of this work that you’re done with NSQIP and all the quality work you’ve done is really the collaboration that you’ve built with the HPB community. And I think some of our listeners may not know that you were one of the founders of the AHPBA as well as the IHPB. How did you develop that organization? And what was the impetus to develop a, you know, an organization for a specialty, as you say that was in its nascent?

Henry Pitt  40:35

Yeah, well, I mean, again, we started the AHPBA in 1994. But this part of the story actually goes back to the late 70s, and goes back to UCLA. And there was a group that got together in 78. That created something called the International Biliary Association, or IBA, and Ron Tompkins another one of the faculty at UCLA was the first president.  George Berci, who’s known perhaps more for his work in minimally invasive surgery and in the origins of SAGES was one of the key people at the beginning as well. And the IBA started in 79. And then actually was challenged in 86, by Stig Bengmark from Sweden, who thought that it was too exclusive and not as far outreach into the developing world. And he created his own group called the World Association of Hepato-Pancreato-Biliary surgery, and then the IBA became the IHBPA. And then it was silly in the late 80s, and early 90s, step two groups like that. So I, I wound up being the program chair of both groups. And then when we had the first International Hepato-Pancreato-Biliary Association meeting, in 94, I was the program chair for that. So I was in the middle of all that. The Asians had actually created in 91, an Asian Society of hepatobiliary pancreatic surgery. And then we felt as though we shouldn’t have an American one, which was eventually become the Americas. And then a fellow by the name of Basil Kekis from Greece felt as though there should be a European chapter of the IHPBA. So all of those things happen, starting in the late 70s, evolved in the 80s, and then really matured in the 90s. And I should add again that it’s really Mike Henderson and Bill Meyers and I who really came at it from slightly different angles and Bill and I tend to declass a little and Mike was great at moderating the two of us. And as the three of us created a group that had some intellectual intelligence, we were missing a woman at the time. But fortunately, in the HPB, we have the HPB heroines now. Well, and let me add that we were just about finished writing all this history up. And there is a book that should be ready for primetime in about two months, called AHPBA the first 25 years. And so all of these stories written by all of the people involved are will be in there. And I am hoping that people who are interested in HPB will get the book and take a look at it.

Ameer Farooq  43:39

I can’t wait to get my hands on a copy. What do you think Dr. Pitt is the frontier and the future of quality? I mean, we’ve seen now the development of really big databases, like ACS NSQIP. But you know, there have been certainly some challenges with looking at quality from a big administrative database. So you know, whether it’s the the database type approach to quality or other challenges, where do you see quality improvement in surgery going over the next 20 years?

Henry Pitt  44:16

Yeah, so I think that we’re all kind of aware that we’re on the verge of artificial intelligence taking off. And robotics really taking off and those two things probably getting married. And now we think of the genome, as you know, it’s an old thing, and we’re talking about personalized medicine and how we can treat all of our cancer patients different differently. And those things are pretty obvious right now. And I think we’ll make the world very different in 15-20 years. But the you know, going back to my roots of being interested in biliary infections and cholangitis and cholecystitis and I think that we’re another area that we’re aware of, but really haven’t gotten as far with yet is the microbiome. And that’s another example of big data. I just reviewed a paper for a high class journal last week that use state of the art microbiome data. This paper came from China. And it looked at 45 people undergoing Whipple procedures. And they did complete fecal microbiome where they extracted all the DNA and they ran all the RNAs and measured, you know, the operational taxonomic units OTU, that’s probably something most of us have never heard of before, and looked at diversity and richness and the families and the genuses of, you know, the 10 to the 10th bacteria that are in the stool. And they showed that the microbiome changes from before to after Whipple. And they also were giving somatostatins to half the patients in a trial. And you know, surprise, somatostatins dramatically affects gut motility and physiology. Well, somatostatins changed the microbiome. And they also looked at the microbiome of people who did and did not develop a pancreatic fistula. And surprise, they were different. So I think there’s a that’s just an example of something new in terms of big data that, you know, we we will know, you know, not only which chemotherapy to give to which patient, but we will know which antibiotic cocktail to give to which patient that will dramatically reduce their surgical site infections and pancreatic cyst sores. I mean, that’s exciting to me. And I think this this study that we’re doing right now, you know, comparing Piptazo to Suboxone will seem so unsophisticated 20 years from now, but you’ve got to start somewhere.

Chad Ball  47:19

Dr. Pitt, you’re your first sentence with on the podcast today appropriately mentioned your amazing, truly amazing wife Betty. So I think it’s, it’s, it’s a perfect way to close mentioning her again and asking you, specifically, and for the listeners, maybe that don’t know, you have an oration called the Betty and Henry Pitt Quality Oration every year at our annual AHPBA meeting. And it’s really one of the highlights of that meeting, of course. So I’m curious what that what that has meant to you and to Betty, you know, the speaker list has been absolutely unbelievable. It’s been extraordinary. We know that you hand-picked those speakers. Give us what your biggest take-home messages would be for our listeners, given the many years that that’s now run.

Henry Pitt  48:08

Sure. Well, before we go there, I’m going to have to totally give credit to Betty. We’re about to be married 51 years now. So, just a testament to her ability to put up with me this long. She’s fabulous. I call her my Renaissance woman. I know a little bit of sports and a little bit of science, and she knows the rest. And she’s, she’s a great people person and a great compliment to me. So she deserves all the credit. But to back up a little bit. You know, I think the AHPBA was very good a few years back, we started a foundation and we realized that we needed to honor a few key people and the first person that we decided to honor was Bernie Langer. And, you know, Bernie, obviously, everybody in Canada knows who he is and what he did in terms of training in Toronto. And his legacy with respect to HPB surgeons is, is fabulous. So now there’s an annual fellows conference at the AHPBA meeting named after Bernie and, and Bernie received one of the Lifetime Achievement Awards a couple of years ago. Similarly, the group of Memorial decided that they really wanted to honor Les Blumgart, and they created the historical lecture, which again, has been another highlight of the meeting and, and Les, you know, has this textbook and tremendous trainees at Memorial and also was honored with with receiving a Lifetime Achievement Award. So, so that was part of the background. And, you know, when you get older like me, you start thinking about what’s your legacy might be and having gotten very interested in infections and quality all these years, Betty and I thought that one of the ways to have a legacy was to create this lecture. And it’s actually called Quality Oration. And there had been precedent within the society for the surgery of elementary tech to name things after, you know, people like Andy Warshaw, and Joe Fisher and John Cameron, and John and it also is the Doris and John Cameron Oration. So, so we plagiarized a little bit from that name and called ours an oration as well. And one of the things that I’ve tried to do, you know, through NSQIP and through this oration is to include people who are leaders of the American College of Surgeon, so, first speaker was Dave Hoyt, the director, Carlos Pelligrini, Barbara Bass, former presidents have been speakers, Cliff Ko, who runs NSQIP has been a speaker, John Birkmeyer, has been a speaker, and then this year, Pierre Clavien. And so you’re right, we have had, you know, fabulous leaders in the quality world. And, and a huge connection with NSQIP and the American College, as our speakers. So so far, I would say that, you know, one of the biggest take-home messages is that we’re not there yet. You know, when I was a resident in the 70s, we didn’t do very many Whipples, or very many hepatectomies in part because of the mortality was so high, one in four people have died from a Whipple in the 70s. You know, we’re now down to one and a half percent an order of magnitude, that’s fabulous. But we still, you know, have 40 to 50% of our people having a Whipple having having a complication, and 20%, surgical site infections, and, you know, less than 12% of pancreatic fistulas and bile leaks. So, you know, we’ve got a long ways to go. And, you know, for the next generation out there, there’s always more to do. And we’ll look back on what we’re doing now and say how unsophisticated it was. But always keep on looking forward and saying, there are more challenges out there. And the current goal for me is to reduce the morbidity and hepatectomy and pancreatectomy in the world. And one of the projects that I’m working on now is with Marc Besselink and others in north northern Europe, but to standardize all the variables so that the registries have comparable data and comparing across the Atlantic for the moment and next step across the Pacific. So we’ll get there and we’re not that far away. We just need to keep on plugging.

Ameer Farooq  53:12

You’ve been listening to Cold steel, the official podcast of the Canadian Journal of Surgery. If you’ve liked what you’ve been listening to, please leave us a review on iTunes. We’d love to hear your comments and feedback. So feel free to email us at podcast.cjs@gmail.com or connect with us on Twitter @CanJSurg. Thanks again.