Department of Surgery, VU University Medical Center, Boelelaan 1117, 1081HV, Amsterdam, The Netherlands.
Department of Surgery, Hospital Gelderse Vallei, Ede, The Netherlands.
Tech Coloproctol. 2018 Apr;22(4):279-287. doi: 10.1007/s10151-018-1771-8. Epub 2018 Mar 22.
Transanal total mesorectal excision (TaTME) provides an excellent view of the resection margins for rectal cancer from below, but is challenging due to few anatomical landmarks. During implementation of this technique, patient safety and optimal outcomes need to be ensured. The aim of this study was to evaluate the learning curve of TaTME in patients with rectal cancer in order to optimize future training programs.
All consecutive patients after TaTME for rectal cancer between February 2012 and January 2017 were included in a single-center database. Influence of surgical experience on major postoperative complications, leakage rate and operating time was evaluated using cumulative sum charts and the splitting model. Correction for potential case-mix differences was performed.
Over a period of 60 months, a total of 138 patients were included in this study. Adjusted for case-mix, improvement in postoperative outcomes was clearly seen after the first 40 patients, showing a decrease in major postoperative complications from 47.5 to 17.5% and leakage rate from 27.5 to 5%. Mean operating time (42 min) and conversion rate (from 10% to zero) was lower after transition to a two-team approach, but neither endpoint decreased with experience. Readmission and reoperation rates were not influenced by surgical experience.
The learning curve of TaTME affected major (surgical) postoperative complications for the first 40 patients. A two-team approach decreased operative time and conversion rate. When implementing this new technique, a thorough teaching and supervisory program is recommended to shorten the learning curve and improve the clinical outcomes of the first patients.
经肛门全直肠系膜切除术（TaTME）可从下方提供出色的直肠癌切除边缘视野，但由于解剖学标志较少，因此具有挑战性。在实施该技术时，需要确保患者安全和获得最佳效果。本研究旨在评估直肠癌 TaTME 的学习曲线，以优化未来的培训计划。
在 2012 年 2 月至 2017 年 1 月期间，将所有连续接受 TaTME 治疗的直肠癌患者均纳入单中心数据库。使用累积和图和拆分模型评估手术经验对主要术后并发症、漏诊率和手术时间的影响。对潜在病例混杂差异进行了校正。
在 60 个月的时间内，共有 138 例患者纳入本研究。在调整病例混杂后，在前 40 例患者中明显看到术后结果的改善，主要术后并发症从 47.5%下降至 17.5%，漏诊率从 27.5%下降至 5%。采用双团队方法后，手术时间（42 分钟）和转化率（从 10%降至 0）降低，但经验并没有使这两个终点降低。再入院率和再手术率不受手术经验的影响。
TaTME 的学习曲线在前 40 例患者中影响主要（手术）术后并发症。双团队方法降低了手术时间和转化率。在实施新技术时，建议采用彻底的教学和监督计划，以缩短学习曲线并提高前几位患者的临床效果。
