Le Reste Pierre-Jean, Henaux Pierre-Louis, Riffaud Laurent, Haegelen Claire, Morandi Xavier
Department of Neurosurgery, Pontchaillou University Hospital, 2, Rue Henri Le Guilloux, Rennes, France,
Acta Neurochir (Wien). 2015 Jan;157(1):1-7. doi: 10.1007/s00701-014-2241-3. Epub 2014 Sep 25.
The expansion of endovascular techniques for intracranial aneurysms has led to a global decrease in vascular neurosurgery activity. This situation might impact neurosurgeons' level of expertise, even though they all might have to deal with this surgically challenging pathology. In that context, we wanted to assess the impact of cumulative surgical experience on the outcome of patients with poor-grade subarachnoid haemorrhage (SAH) and intracerebral haemorrhage (ICH) treated by microsurgery.
Sixty-seven patients who underwent surgery for a ruptured aneurysm with SAH and ICH, and a WFNS scale of IV/V, were included. Surgeries were performed by five surgeons, whose experience was judged by the total number of aneurysm surgeries performed. The outcome was assessed by three indicators: intraoperative rupture (IOR), early mortality, and the modified Rankin Scale at last follow-up. The time of IOR was reported on an IOR score. The correlation between surgical experience and outcome was assessed by linear regression. Nonlinear regression was used to assess the correlation of the data with a learning curve model.
The analysis showed an influence of surgical experience on intraoperative rupture, with no effect on long-term outcome. No influence was found on early mortality. Increased surgical experience seems to reduce IOR during aneurysm dissection and clip repositioning. Intraoperative rupture data fit Wright's learning curve model.
This study suggests a direct impact of cumulative experience on the course of ruptured aneurysm surgery and pleads for the use of training and simulation programmes dedicated to neurovascular surgery.
颅内动脉瘤血管内治疗技术的发展导致全球血管神经外科手术量下降。尽管所有神经外科医生都可能需要处理这种具有手术挑战性的疾病，但这种情况可能会影响他们的专业水平。在此背景下，我们希望评估累积手术经验对接受显微手术治疗的低级别蛛网膜下腔出血（SAH）和脑出血（ICH）患者预后的影响。
纳入67例因SAH和ICH行破裂动脉瘤手术且世界神经外科联合会（WFNS）分级为IV/V级的患者。手术由5名外科医生进行，其经验通过动脉瘤手术总数来判断。通过三个指标评估预后：术中破裂（IOR）、早期死亡率和末次随访时的改良Rankin量表评分。IOR时间以IOR评分报告。通过线性回归评估手术经验与预后之间的相关性。使用非线性回归评估数据与学习曲线模型的相关性。
分析显示手术经验对术中破裂有影响，但对长期预后无影响。未发现对早期死亡率有影响。手术经验的增加似乎可降低动脉瘤夹闭和夹片重新定位期间的IOR。术中破裂数据符合赖特学习曲线模型。
本研究表明累积经验对破裂动脉瘤手术过程有直接影响，并呼吁使用专门针对神经血管手术的培训和模拟程序。
