Waters Joshua A, Chihara Ray, Moreno Jose, Robb Bruce W, Wiebke Eric A, George Virgilio V
Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana 46202, USA.
JSLS. 2010 Jul-Sep;14(3):325-31. doi: 10.4293/108680810X12924466006800.
As minimally invasive colon and rectal resection has become increasingly prevalent over the past decade, the role that fellowship training plays has become an important question. This analysis examines the learning curve of one fellowship-trained colorectal surgeon in his first 100 cases.
This was a prospectively collected retrospective analysis of the first 100 laparoscopic colon and rectal resections performed between July 2007 and July 2008 by a colorectal (CRS) fellowship trained surgeon at a Veteran's Administration (VA) and county hospital. Included were all emergent and nonemergent laparoscopic cases.
Mean age was 63(range, 36 to 91). The 100 resections included 42 right, 6 left, 32 sigmoid, 13 rectal, and 7 total abdominal colectomies. Indications were 55% cancer, 20% unresectable polyp, 18% diverticular, 4% inflammatory, and 3% other. Overall mortality was 3%. Overall morbidity including wound infection was 24%. Early and late groups were similar in age, ASA score, and indication. Conversion rate was 4%. No statistical difference was seen in mortality, morbidity, EBL, LOS, margin, lymph nodes, or conversions between the first and second 50 cases (P<0.05). Right and sigmoid colectomy operative time decreased by 40.0% and 19.6%, respectively.
Prior investigators have demonstrated a significant learning curve for laparoscopic colorectal surgery. In the first 100 cases, there is no difference in mortality or morbidity between early and late cases. Alternatively, operative times decreased with experience. Laparoscopic training during CRS fellowship surpasses the learning curve in regard to safety and outcome, whereas operative efficiency improves over the first year of practice.
在过去十年中，微创结肠和直肠切除术日益普及，专科培训所起的作用已成为一个重要问题。本分析研究了一位接受过专科培训的结直肠外科医生在其完成的前100例手术中的学习曲线。
这是一项前瞻性收集的回顾性分析，研究对象为2007年7月至2008年7月间，一位在退伍军人管理局（VA）和县医院接受过结直肠外科（CRS）专科培训的外科医生所进行的前100例腹腔镜结肠和直肠切除术。纳入所有急诊和非急诊腹腔镜手术病例。
平均年龄为63岁（范围36至91岁）。100例切除术包括42例右半结肠、6例左半结肠、32例乙状结肠、13例直肠和7例全腹结肠切除术。手术指征为55%为癌症，20%为不可切除息肉，18%为憩室病，4%为炎症性疾病，3%为其他。总体死亡率为3%。包括伤口感染在内的总体发病率为24%。早期和晚期组在年龄、美国麻醉医师协会（ASA）评分和手术指征方面相似。中转率为4%。前50例和后50例在死亡率、发病率、术中出血量、住院时间、切缘、淋巴结或中转方面无统计学差异（P<0.05）。右半结肠和乙状结肠切除术的手术时间分别减少了40.0%和19.6%。
先前的研究表明腹腔镜结直肠手术存在显著的学习曲线。在前100例病例中，早期和晚期病例在死亡率或发病率方面无差异。相反，手术时间随着经验的增加而减少。CRS专科培训期间的腹腔镜培训在安全性和结局方面超过了学习曲线，而手术效率在执业的第一年有所提高。
