Spotlight on Dr. Brendan Visser

Dr. Brendan C. Visser is a Professor of Surgery and the Section Chief of Hepato-Pancreato-Biliary (HPB) in the Division of General Surgery at Stanford. He is also the program director for the Stanford HPB Surgery fellowship program and is actively involved in the General Surgery Residency Program. 

Dr. Visser's research interests span the breath of his clinical practice. Areas of active research include the multidisciplinary treatment of pancreatic neuroendocrine cancers, technical aspects of minimally invasive pancreatic and liver surgery, and trends in the management of hepatobiliary cancers in California. In addition, Dr. Visser is one of Stanford Surgery’s Global Surgery icons and is active in promoting surgical skills and the strengthening of HPB training and service development on an international scale.                                  

Please tell us about your global collaboration with institutions in South and Central America. How did you become involved in this work?

My involvement in global surgery came by chance and mostly through personal connections. It wasn’t something I planned or had in mind.

It started about 12-13 years ago while I was attending as a guest at the Americas Hepato-Pancreato-Biliary Association (AHPBA) meeting in Miami. One of the sessions I attended was the Spanish language session. Although many of the doctors in Latin America speak medical English quite well, some do not, and the AHPBA sometimes has sessions in Spanish to make sure that the meeting is inclusive since changing the name from “American” to “Americas” to better reflect the membership. I learned Spanish as an adult after meeting my wife, whose family is from Spain. I was interested in the topics and actively seek out opportunities to improve my language skills. After a lecture on gallbladder cancer given by a Guatemalan surgeon, I approached the presenter with a question. We had a great discussion that ended with him inviting me to give a series of talks as an international visitor at their first international HPB congress in Guatemala. He specified that it is very expensive to provide real-time translation from English to Spanish (both because of the technology and the cost of skilled medical interpreters), so they planned to only invite Spanish-speaking lecturers. 

I accepted the invitation, which were to be my first medical talks in Spanish. I worked very hard on preparing the slides and planning what I’d say—I needed to be able to express myself as an expert in a second language! I was excited to give my first international talk in Spanish side by side with other “international professors”—a couple from Spain and the remainder largely US surgeons who have Latin/ Hispanic origins. It was a terrific challenge to give the talks and then answer questions from the podium in Spanish in real time. 

That first meeting in Guatemala was a terrific experience and I certainly learned as much as I offered as a teacher.  I made close friendships with a number of the Guatemalan surgeons, and we’ve stayed in close contact.  I’ve been back to “Guate” more than a half a dozen times since that first trip.  In fact, I’m going back to Guatemala in November this year to spend a day in the OR with them and to attend their HPB meeting.  And, largely from the connections I made with the HPB surgeons in Guatemala, I’ve had the opportunity to meet other Latin American surgeons which has resulted in invitations to Colombia, Mexico, Nicaragua, and Uruguay.

Tell us about your observations regarding the development of HPB programs globally, in particular where you have worked for the past many years.

For a number of years, the Guatemalan HPB surgeons have occasionally consulted me on complex cases through WhatsApp to ask my opinion. Because I’ve been there and know something about their skills (which are terrific) and resource and infrastructure challenges (which are significant), I can talk through options that are likely doable and can be safely offered in that care environment.

They were striving to “level-up” and offer more than what they have been doing in the past. Despite the large population, the volume of complex HPB surgery is not high and the equipment and infrastructure limitations are significant. To accelerate their learning curve in a thoughtful way, they are seeking partnerships with international surgeons to get them to that next level. Through such collaborations they will be able to do more aggressive operations and tackle things they hadn’t before.

Guatemala is a country that may be considered a great opportunity to positively impact HPB surgical care. Despite the size of the population, almost all major HPB operations are done in two large public hospitals and one or two private hospitals in Guatemala City. There are four surgeons at the Social Security Hospital who do HPB surgery and one at the Roosevelt Hospital, and just a couple of surgeons in private practice. There are terrific general surgeons in other cities in Guatemala who likely have the technical skills, but it is difficult to get the diagnostics, equipment, and hospital support to allow their operations to be performed safely outside of the capital city.

I’m always excited to go—the surgeons are smart and skilled, and I learn new things from them every time I go. It’s so impressive to see the complex things that they can do with the very limited resources that are available for them, a sharp contrast to those available for surgeons here.

Compared to the first time I went to Guatemala City, there has been visible improvement in their healthcare system: the infrastructure has improved, the chemotherapy has improved, they have more access to CT scans. There is now a PET scanner in a truck in Guatemala City! These changes help more patients work their way through the system a little bit faster—in a timely enough fashion to get to surgery—but still there is much that is needed.

What are the challenges that you see?

From my visits and the relationships that I formed, I realized how capable the surgeons in Latin America are but at the same time how much they are struggling with resource limitations and infrastructure challenges.

One of the most important pieces of equipment that they often lack in lower resource environments for abdominal surgery are retractors. Doing a little research, and I found out that Thompson Surgical Instruments has a foundation, and they donate older retractors (returned as “trade-ins”). The Thompson Foundation has been very generous. Now, whenever I go to give a talk, I try to take a retractor with me in my luggage! I have a Thompson in my office that I’m going to take with me in November. It’s the most critical tool that they need to do complex cases.

I’ve learned how even small differences in equipment and the availability of disposables impact the operations that you can offer or the safety of the planned operation. For example, if your laparoscopic tower is old, the picture is just bad enough to make it hard to identify the anatomy and do the dissection safely. Here at Stanford, we can do more and more—because with the technology and equipment we can take some more risk and do things that are more challenging. The lack of surgical equipment is the number one challenge.

The other challenge that I recognize as a cancer surgeon is the lack of reliable access to other elements of multimodal care. For example, in pancreatic cancer we often treat with chemotherapy before and after the surgery. But for the team in Guatemala, the chemotherapy may be a huge challenge. The supply chain is not reliable, and the planned chemo may not be available next month (even if it is in-stock now). The hospital pharmacy may run over budget at the end of a quarter or a fiscal year or the patient’s family may not be able to afford their portion of the cost or even the transportation to get the infusion. Such instabilities prevent the middle- and long-term treatment plans because you wouldn’t know what you have three months from now. Even political instability can influence patient care.

Adding to that, patients cannot find their way to proper care fast enough. So, only a small fraction of the total cancer patients works their way through the system fast enough—after developing symptoms, they get their scan, get diagnosed, get referred, get seen, and get scheduled for surgery at a timely pace before their disease progresses. It’s a huge obstacle. So, the number of patients who get these operations compared to the ones that are theoretically eligible is a fraction.

How does training and education fit into strengthening the overall care paradigm for HPB disease in Guatemala and the Latin America region?

As the program director for the HPB fellowship at Stanford, the former Chair for the AHPBA Program Directors’ Committee, and the current Chair of Education and Training for the International Hepato-Pancreato-Biliary Association (IHPBA), I think the long term answer is certainly in training more surgeons that can offer care for HPB diseases. Historically, the hope was that surgeons from LMIC countries would travel abroad to learn new skills that they would then take home with them. But this model risks contributing to brain drain, and it’s questionable if the training they receive in high resource US, European, or Asian centers is 100% relevant to the resource environment and even diseases they will treat when they return home. So, through the AHPBA, we were able to help Latin countries to form a Latin America HPB Fellowship which is the first Fellowship Council-accredited fellowship outside the US and Canada in HPB surgery.

To do that, we needed great surgeons and an adequate volume—but there aren’t too many centers in Latin America that have the volume. So ultimately, a friend at UCSF named Adnan Alseidi had the clever idea of combining centers. They put together a fellowship where the fellows rotate between three sites. They spend eight months in Mexico City, eight months in Santiago, Chile, and eight months in Sau Paulo, Brazil. Each center has different expertise, but the combined experience is astounding and rivals anything offered in US or Canadian centers.

A second challenge was that these advanced trainings were not financially supported. These are mainly government healthcare systems who train general surgery with few opportunities for further advanced training. Traditionally, surgeons in Latin America who want more advanced training have to self-fund it by working for a year or more without salary. But that’s not really going to work for the US and Canadian expectations for accreditation from the Fellowship Council. It was an issue of salary dollars and making sure that they have health insurance and a basic level of living wage. However, with lots of advocacy and the generosity of a philanthropist, the AHPBA Foundation has been able to support the LATAM HPB fellowship over the last four years (two classes of three fellows each) to move the needle on HPB training in Latin America.

You recently met with a group from Sri Lanka who hosted a symposium. Please tell us about this event, how you were involved, and what lessons you took from your participation.

A good friend of mine, Mehan Siriwardhane, invited me to Sri Lanka. Mehan is an HPB surgeon in Brisbane, Australia whose parents are originally from Sri Lanka. Mehan was born in the UK while his parents were graduate students. His parents had planned to return, but after the “Black July” genocide of Tamils in 1983, his family emigrated to Australia figuring they could never safely return home. However, Mehan’s heart has always been with the Sri Lankan people, and he has long been connected with HPB surgeons there and has been doing what he can to help.   

Mehan, working with collaborators in Sri Lanka, had arranged for a week-long trip with symposia in two university hospitals—one in Kandy and one in Anuradhapura. We were a group of about 15 international physicians, mostly surgeons but we had an interventional gastroenterologist and an anesthesiologist to broaden the services we could offer and teach. In each hospital they hosted a one-day teaching symposium with lectures from both the international faculty and local experts.  Then we spent a day in the OR demonstrating complex operations and doing some teaching of local surgeons. For example, I did a laparoscopic resection for a hepatocellular carcinoma on a cirrhotic liver—an operation that they would have otherwise done via traditional open surgery. We were able to stream the operation to an amphitheater full of surgeons (with color commentary by an HPB surgeon from the UK). It was a really amazing experience.

The two hospitals we visited in Sri Lanka are part of a program called HPBridge (HepatoPancreatoBiliaRy International Bidirectional Engagement and Collaboration), and this was a terrific opportunity to take the program to the next level.

Tells me more about HPBridge. What’s the nature and intent of the program?

Mehan really gets the credit for inspiring HPBridge. Mehan is also a member of the Education and Training Committee of the IHPBA, and he’d been establishing connections to the HPB surgeons in Sri Lanka. He knew that I had similar relationships with the HPB surgeons in Guatemala.  His inspiration was that we needed to build a program within the IHPBA that would connect interested surgeons in exactly these sorts of collaborations. 

The concept in HPBridge is to link high-volume surgeons in high-resource countries with developing groups in low- and middle-income countries (LMICs). We started by setting up different “Bridges” from different centers who can collaborate in multidisciplinary meetings.  In the first iteration, there are six international Bridges. For example, there is one group that combines three hospitals in Ethiopia, a hospital in Norway, and UCSF. The surgeons in Oslo and UCSF have both worked in Ethiopia and have insights into their resource setting. The intent is to build trust through ongoing interactions and collaborations. It starts with a regular [multidisciplinary team meeting] to discuss cases by Zoom. But we also encourage groups to travel to meet each other (in both directions) to allow growth in the collaborations. The IHPBA is soon to offer some resources to assist in this travel. And we are also soon offering specific research grants to Bridge participants and an international registry to capture outcomes from HPB surgery in LMIC countries.

Sri Lanka is one of our HPBridge sites and has regular monthly meetings. On this recent trip to Sri Lanka, I was wearing my HPBridge hat and supporting Mehan’s compassionate work there. He did the heavy lifting!

I loved Sri Lanka. Folks were incredibly welcoming. They have such a talented group of young doctors there. It was an eye-opening experience for me, and I learned from them just as they learned from me.

An exciting new aspect of the HPBridge program is the potential for tele-mentoring. At the IHPBA Congress in Cape Town recently, I met a surgeon from Tanzania named Vihar Kotecha who connected me to an NGO call Ohana One. Ohana One has partnered with a small hardware company (TeleVu) and developed the necessary software to permit live web-streaming of operations to allow remote mentoring. They have a small camera that you wear on the side of your glasses to transmit an operation. It also has a very small screen, much like those Google glasses, and a microphone and built-in speaker. A surgeon can broadcast an operation in real time to a secure website. As a mentor I can log-in and see the operation in real time. The mentor can give verbal advice or encouragement and can also freeze the picture and draw on it to give more specific mentoring. They also have a plug-in and tablet that allows the same sort of interactions for a laparoscopic operation. During my laparoscopic liver resection in Sri Lanka, we used both the laparoscopic streaming device and the head-camera so that the participants could see both feeds simultaneously to follow all aspects of the operation. We have another set of the equipment to leave in Guatemala next month to grow the program.

The other benefit from this equipment is that we hope it will be used to further elevate those expert surgeons within those LMIC countries.  The HPB surgeons at these university hospitals can use this equipment to stream their own operations to teach general surgeons and continue to improve the level of care offered even for more routine cases like laparoscopic cholecystectomy.

You have hosted a number of visiting observers and postdocs from several countries. What are the mutual benefits from this activity, and how could we improve the program?

The visiting observer (VO) program is close to my heart, and it has been very organized lately. I’ve hosted a lot of visiting observers over the years from Asia, Latin America, Europe, and Africa, and I find it to be super fun and interesting working with them. Some are relatively junior, but others are very senior in their countries. From each of them, I’ve learning new things, including an understanding of their own health system, clinical approaches, and sometimes even very specific surgical techniques. We have interesting discussions and enjoy their presence in the operations rooms.

In fact, hosting international observers at Stanford has led to some opportunities for me as their host! One of our visiting observers from China later invited me to an HPB conference in Jinan, China—an amazing experience for me.  

Even in the last year, I’ve hosted VO’s from Korea, Spain, Nigeria, Japan, and Finland—an incredible group of surgeons. A particularly memorable recent VO was Arturs Ozolins from Latvia. Arturs was actually hosted by Dr. Electron Kebebew, but his practice is in Endocrine and HPB so he spent a portion of his time with our team as well. He is a really terrific surgeon and human being. I was so pleased to be able to catch up with Arturs at the IHPBA Congress in Cape Town a few months after his time at Stanford. He told me that he is restructuring some processes in care delivery in his hospital in Riga, Lativa based on the things that he learned when he was here at Stanford! Although he didn’t scrub here, he learned so many things just by observing how we do things. He told me that they are reducing their wait times and OR times significantly. He was super grateful for his time at Stanford.

There is no doubt that VOs who come here feel like its meaningful experience, and it’s an exciting experience for our teams to work with them. Stanford has so much to share, and part of our mission is to host people and offer them an opportunity of learning, and at the same time to grow our name internationally.  It’s fundamentally what we are supposed to do.

There is no doubt that since Global Engagement got involved in organizing the process, it became much easier for us to bring visiting observers. The paperwork in the last few years became very painful and it was an obstacle for us to host—but now everything has changed for the better and we are again hosting VOs from all over the world.