Duke University Medical Center, Department of Surgery, Durham, NC 27710, USA.
Ann Surg. 2012 May;255(5):940-5. doi: 10.1097/SLA.0b013e31824c1d06.
To assess the impact of surgeon, patient, and case-specific factors on the learning curve of robot-assisted laparoscopic biliopancreatic diversion with duodenal switch (RA-LBPD/DS).
The BPD/DS has better resolution of diabetes and hypercholesterolemia, and the best long-term weight loss compared to the laparoscopic gastric band or the Roux-en-Y gastric bypass. Despite excellent results, the BPD/DS is least commonly performed because of greater malabsorption, longer operative duration, and higher technical complication rates. A reduction in technical complications and operative duration will enable the BPD/DS to be offered more frequently.
Consecutive patients (N = 120) undergoing RA-LBPD/DS between October 2000 and August 2008 were analyzed using univariate and multivariate logistic regression to determine the influence of surgeon and patient factors on complications and operative duration. Independent variables were case number, age, gender, body mass index, American Society of Anesthesiologists (ASA) score, difficult anatomy, and need for extensive adhesiolysis. Dependent variables were complications (leaks, bleeding, and conversion) and operative duration. The best-fit model predicted the risk factors for complications, and a risk-adjusted cumulative sum analysis estimated the learning curve.
: Operative duration decreased an average of 3 minutes with each successive case (P < 0.001, R² = 0.63) and with patient's female gender. Adhesiolysis, difficult anatomy, liver biopsy, and higher ASA score increased operative duration. The incidence of high blood loss (13.3%), conversion (2.2%), and leaks (5.8%) were experienced by a total of 22 patients (18.3%). There was no mortality. Complications declined after 50 cases and were strongly predicted by increasing surgeon case number.
The learning curve for the RA-LBPD/DS is 50 cases. Risk factors influencing outcomes were identified.
评估外科医生、患者和病例特定因素对机器人辅助腹腔镜胆胰分流术与十二指肠转位（RA-LBPD/DS）学习曲线的影响。
与腹腔镜胃带或 Roux-en-Y 胃旁路术相比，BPD/DS 对糖尿病和高胆固醇血症的治疗效果更好，长期减肥效果最佳。尽管效果很好，但由于吸收不良更多、手术时间更长和技术并发症发生率更高，BPD/DS 的实施最少。减少技术并发症和手术时间将使 BPD/DS 更频繁地实施。
对 2000 年 10 月至 2008 年 8 月期间连续接受 RA-LBPD/DS 手术的 120 例患者进行分析，采用单变量和多变量逻辑回归分析确定外科医生和患者因素对并发症和手术时间的影响。自变量为手术例数、年龄、性别、体重指数、美国麻醉医师协会（ASA）评分、困难解剖结构和广泛粘连松解的需要。因变量为并发症（渗漏、出血和转换）和手术时间。最佳拟合模型预测并发症的危险因素，并进行风险调整累积和分析估计学习曲线。
手术时间平均每例减少 3 分钟（P < 0.001，R² = 0.63），与患者的女性性别有关。粘连松解、困难解剖、肝活检和更高的 ASA 评分增加了手术时间。共有 22 例（18.3%）患者发生大出血（13.3%）、转换（2.2%）和渗漏（5.8%）。无死亡病例。并发症在 50 例后下降，并且强烈受到外科医生手术例数增加的预测。
RA-LBPD/DS 的学习曲线为 50 例。确定了影响结果的危险因素。
