Department of Surgery and the Royal Adelaide Hospital, University of Adelaide, Level 5, Eleanor Harrald Building, Royal Adelaide Hospital, 5000 Adelaide, South Australia, Australia.
J Gastrointest Surg. 2013 Jul;17(7):1173-80. doi: 10.1007/s11605-013-2211-8. Epub 2013 May 8.
There is a learning curve associated with laparoscopic antireflux surgery which has an impact on patient outcomes. It is unclear, however, whether this can be eliminated by supervision of early cases by experienced surgeons. The aim of this study was to evaluate the impact of training under supervision on outcomes for laparoscopic fundoplication.
Patients undergoing primary laparoscopic antireflux surgery from 1995 to 2009 were identified from a prospective database. Patients were classified according to whether they were operated on by an experienced consultant or supervised trainee, and sub-categorised according to the presence of a very large hiatus hernia. A standardised questionnaire was used to assess outcomes for heartburn, dysphagia and satisfaction at 1 and 5 years follow-up. Outcomes for the study groups were compared.
One thousand seven hundred and ten patients underwent surgery; 1,112 were operated on by consultants and 598 by trainees. The peri-operative complication rate was not different between the groups, although in patients operated on by trainees, there were increased rates of endoscopic dilatation (9 vs. 5 % p = 0.014) and re-operation (9 vs. 6 %, p = 0.031), and a lower satisfaction rate (76 vs. 82 %, p = 0.044) within 5 years of surgery. All other outcomes were similar for trainees vs. consultants.
The learning curve for laparoscopic fundoplication had a small, but statistically significant, impact on patient outcomes, with slightly lesser outcomes when surgery was undertaken by trainees, even when supervised by experienced surgeons. Although the differences were not large, they raise questions about equipoise and highlight ethical dilemmas with teaching new generations of surgeons.
腹腔镜抗反流手术存在学习曲线，这会影响患者的治疗效果。然而，经验丰富的外科医生监督早期病例是否可以消除这种影响尚不清楚。本研究旨在评估在监督下进行培训对腹腔镜胃底折叠术治疗效果的影响。
从一个前瞻性数据库中确定了 1995 年至 2009 年间接受初次腹腔镜抗反流手术的患者。根据患者是否由经验丰富的顾问或监督的受训者进行手术进行分类，并根据巨大裂孔疝的存在进行亚分类。使用标准化问卷评估术后 1 年和 5 年时的烧心、吞咽困难和满意度。比较研究组的结果。
1710 例患者接受了手术；1112 例由顾问进行手术，598 例由受训者进行手术。两组患者的围手术期并发症发生率无差异，但受训者组内镜扩张（9%比 5%，p=0.014）和再次手术（9%比 6%，p=0.031）的发生率更高，术后 5 年内满意度（76%比 82%，p=0.044）较低。受训者组与顾问组的所有其他结果相似。
腹腔镜胃底折叠术的学习曲线对患者的治疗效果有轻微但统计学显著的影响，即使由经验丰富的外科医生监督，由受训者进行手术时，结果略差。尽管差异不大，但它们引发了关于平衡的问题，并强调了向新一代外科医生传授技能所带来的伦理困境。
