Department of Otorhinolaryngology, Eye, Ear, Nose, and Throat Hospital, Fudan University, 83 Fenyang Road, Shanghai, 200031, China.
Surg Endosc. 2018 Jul;32(7):3181-3191. doi: 10.1007/s00464-018-6035-1. Epub 2018 Jan 24.
To determine the learning curve with cumulative sum analysis for endoscopic resection of juvenile nasopharyngeal angiofibroma (JNA) and investigate whether the surgeon's expertise is a risk factor for recurrence.
We reviewed the medical records of patients with JNA who underwent endoscopic or endoscopic-assisted surgery between 2006 and 2015. We used cumulative sum (Cusum) analysis to plot the learning curve for operation time versus chronological sequence, and verified the Cusum curve by risk-adjusted Cusum (RA-Cusum) analysis. We identified three phases of expertise. The recurrence rate was analyzed using the Kaplan-Meier method and log-rank tests. A multivariable Cox regression analysis was performed to identify the independent risk factors for recurrence.
We included 154 JNA patients with a median age of 16 years. The surgeon overcame the learning curve after case 80 with increasing surgical efficiency and competence. The learning curve plotted by Cusum analysis divided the cases into three phases: phase 1, accumulation of initial experience (cases 1-41); phase 2, further accumulation of experience (cases 42-117); and phase 3, mastering the procedure (cases 118-154). Pearson's χ tests showed that tumor stage (P = 0.021), blood loss (P = 0.001), operation time (P < 0.001), and phase (P < 0.001) were associated with recurrence. The log-rank test showed that time to recurrence was significantly shorter in phase 1 than in phases 2 and 3. Blood loss and phase were independently prognostic factors for time to recurrence, with P values of 0.023 and 0.009, respectively. The RA-Cusum analysis identified two inflection points of the curve at case 44 and 83, and verified the results of Cusum analysis.
Surgical experience and competence with endoscopic resection affect the recurrence rate in JNA patients.
采用累积和（Cusum）分析来确定内镜下青少年鼻咽血管纤维瘤（JNA）切除术的学习曲线，并探讨术者经验是否为肿瘤复发的危险因素。
回顾性分析 2006 年至 2015 年间接受内镜或内镜辅助手术治疗的 JNA 患者的病历资料。采用 Cusum 分析绘制手术时间与时间顺序的学习曲线，并通过风险调整的 Cusum（RA-Cusum）分析验证 Cusum 曲线。确定三个经验阶段。采用 Kaplan-Meier 法和对数秩检验分析复发率。采用多变量 Cox 回归分析确定复发的独立危险因素。
共纳入 154 例 JNA 患者，中位年龄为 16 岁。术者在第 80 例时克服了学习曲线，手术效率和能力逐渐提高。Cusum 分析绘制的学习曲线将病例分为三个阶段：第 1 阶段，初始经验积累（病例 1-41）；第 2 阶段，进一步积累经验（病例 42-117）；第 3 阶段，熟练掌握手术（病例 118-154）。Pearson χ 检验显示，肿瘤分期（P=0.021）、术中出血量（P=0.001）、手术时间（P<0.001）和阶段（P<0.001）与肿瘤复发有关。对数秩检验显示，第 1 阶段的肿瘤复发时间明显短于第 2 阶段和第 3 阶段。术中出血量和阶段是肿瘤复发时间的独立预后因素，P 值分别为 0.023 和 0.009。RA-Cusum 分析确定了曲线的两个拐点，分别为第 44 例和第 83 例，验证了 Cusum 分析的结果。
内镜下切除青少年鼻咽血管纤维瘤的手术经验和能力影响患者的复发率。
4 级
