Maya Antonio, Vorenberg Andrew, Oviedo Myrian, da Silva Giovanna, Wexner Steven D, Sands Dana
Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA.
Surg Endosc. 2014 May;28(5):1407-12. doi: 10.1007/s00464-013-3341-5. Epub 2013 Dec 24.
Transanal endoscopic microsurgery (TEM) was first published by the late Professor Buess in 1983. The procedure initially had a slow acceptance due to its perceived difficulty, the cost of the equipment, and limited indications. However, the widespread adoption of laparoscopic colorectal surgery provided an impetus to increase the penetration of the platform. The purpose of this study was to evaluate the TEM learning curve (LC).
After institutional review board approval, all patients who underwent TEM, from November 2005 to October 2008 were identified from a prospective database. The operations were performed by a single, board-certified colorectal surgeon (DRS), after learning the technique from Professor Buess. Patient, operative, and postoperative variables were obtained by retrospective chart review. Rates of excision in minutes per cm(2) of tissue were calculated. The CUSUM method was used to plot the LC. Variables were compared using χ (2) and Student's t test. A p < 0.05 was considered significant.
Twenty-three patients underwent TEM (median age 61 years, 69.5 % male). Mean operative time was 130.5 (range 39-254) min, and the mean specimen size was 16.6 (7.4-42) cm(2). Average rate of excision (ARE) was 8.9 min/cm(2). A stabilization of the LC was observed after the first four cases, showing an ARE of 13.8 min/cm(2) for the first four cases versus 7.9 min/cm(2) for the last 19 cases (p = 0.001). An additional rising and leveling of the LC was observed after the first 10 cases, when an increasing number of lesions located cephalad to 8 cm from the dentate line were being resected (lesions above 8 cm in the first 10 cases: 20 % vs. last 13 cases: 61 %; p = 0.04).
The ARE significantly declined after the first four cases. The LC for TEM is associated with a significant decrease in operative time after four cases.
经肛门内镜显微手术（TEM）由已故的布斯教授于1983年首次发表。由于其操作难度大、设备成本高以及适应证有限，该手术最初的接受度较低。然而，腹腔镜结直肠手术的广泛应用推动了该平台的普及。本研究的目的是评估TEM的学习曲线（LC）。
经机构审查委员会批准后，从一个前瞻性数据库中确定了2005年11月至2008年10月期间所有接受TEM手术的患者。手术由一位获得委员会认证的结直肠外科医生（DRS）进行，该医生是在向布斯教授学习该技术后开展手术的。通过回顾性病历审查获取患者、手术和术后变量。计算每平方厘米组织的切除时间（分钟）。使用累积和（CUSUM）方法绘制学习曲线。使用χ²检验和学生t检验比较变量。p<0.05被认为具有统计学意义。
23例患者接受了TEM手术（中位年龄61岁，69.5%为男性）。平均手术时间为130.5（范围39 - 254）分钟，平均标本大小为16.6（7.4 - 42）平方厘米。平均切除率（ARE）为8.9分钟/平方厘米。在前四例手术后观察到学习曲线趋于稳定，前四例的ARE为13.8分钟/平方厘米，而后19例为7.9分钟/平方厘米（p = 0.001）。在前10例手术后观察到学习曲线出现了额外的上升和趋于平稳，此时切除的距齿状线8厘米以上头侧的病变数量增加（前10例中8厘米以上的病变：20% vs. 后13例：61%；p = 0.04）。
前四例手术后ARE显著下降。TEM的学习曲线与四例手术后手术时间的显著缩短相关。
