Son Gyung-Mo, Kim Jun-Gi, Lee Jae-Chung, Suh Young-Jin, Cho Hyeon-Min, Lee Yoon-Suk, Lee In-Kyu, Chun Chung-Soo
Department of Surgery, St. Vincent's Hospital, The Catholic University of Korea , Suwon, Korea.
J Laparoendosc Adv Surg Tech A. 2010 Sep;20(7):609-17. doi: 10.1089/lap.2010.0007.
The need for an initial learning experience in laparoscopic colorectal cancer surgery has been well established. However, the inherent differences in the complexity and results of laparoscopic rectal cancer surgery, as compared to colon surgery, warrant a study to analyze the learning curve exclusively for rectal cancer resections.
four hundred thirty-one patients operated on between April 1994 and March 2006 were analyzed retrospectively for changes in surgical outcomes according to case sequence. A multidimensional analysis was done, based on the following parameters: conversion to laparotomy, intraoperative complications, postoperative complications, reoperations, operative time, and transfusion volumes. Multiple statistical methods were used for evaluation of the learning curve, which included the cumulative sum (CUSUM) method, risk-adjusted CUSUM, moving average method, and analysis of variance (ANOVA).
The risk factors for conversion were prior abdominal surgery (hazard ratio, 2.52; 95% CI, 1.04-6.10; P = 0.04) and tumor size > or =3.5 cm (hazard ratio, 5.05; 95% CI, 1.95-13.08; P = 0.001). Risk-adjusted CUSUM analysis showed that case 61 was the peak change point for conversion. Postoperative complications occurred in 56 patients (13.0%), and the rate was associated significantly with case sequence (P < 0.001). The turning point in the CUSUM model occurred at case 79, and the complication rates decreased thereafter. Operative time and intraoperative transfusion volumes stabilized over cases 61-75 and declined thereafter.
Multidimensional analysis considering various surgical outcomes is necessary to evaluate the learning curve for laparoscopic rectal cancer surgery. The effective surgical learning curve was approximately 60-80 procedures in this series.
腹腔镜结直肠癌手术初期学习经验的必要性已得到充分证实。然而，与结肠癌手术相比，腹腔镜直肠癌手术在复杂性和结果方面存在固有差异，因此有必要专门针对直肠癌切除术的学习曲线进行研究。
回顾性分析1994年4月至2006年3月期间接受手术的431例患者，根据病例顺序分析手术结果的变化。基于以下参数进行多维分析：转为开腹手术、术中并发症、术后并发症、再次手术、手术时间和输血量。采用多种统计方法评估学习曲线，包括累积和（CUSUM）法、风险调整CUSUM法、移动平均法和方差分析（ANOVA）。
转为开腹手术的危险因素为既往腹部手术（风险比，2.52；95%可信区间，1.04 - 6.10；P = 0.04）和肿瘤大小≥3.5 cm（风险比，5.05；95%可信区间，1.95 - 13.08；P = 0.001）。风险调整CUSUM分析显示，第61例是转为开腹手术的峰值变化点。56例患者发生术后并发症（13.0%），发生率与病例顺序显著相关（P < 0.001）。CUSUM模型的转折点出现在第79例，此后并发症发生率下降。手术时间和术中输血量在第61 - 75例病例中趋于稳定，此后下降。
评估腹腔镜直肠癌手术的学习曲线需要考虑各种手术结果的多维分析。本系列中有效的手术学习曲线约为60 - 80例手术。
