Section of Colorectal Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY, USA.
Colorectal Division, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea.
Surg Oncol. 2020 Sep;34:121-125. doi: 10.1016/j.suronc.2020.04.011. Epub 2020 Apr 13.
A beneficial impact of robotic proctectomy on circumferential resection margin (CRM) is expected due to the robot's articulating instruments in the pelvis. There are however concerns about a negative impact on the quality of total mesorectal excision (TME) due to the lack of tactile feedback. The aim of this study was to assess whether surgeons' learning curve impacted CRM and TME quality.
In a multicenter study, individual patient data of robotic proctectomy for resectable rectal cancer were pooled. Patients were stratified into two phases of surgeons' learning curve. Cumulative sum (CUSUM) analysis was used to determine the transition from learning phase (LP) to plateau phase (PP), which were compared. CRM was microscopically measured in mm by pathologists. TME quality was classified by pathologists as complete, nearly complete or incomplete. T-test and Chi-squared tests were used to compare continuous and categorical variables, respectively.
235 patients underwent robotic proctectomy by five surgeons. 83 LP patients were comparable to 152 PP patients for age (p = 0.20), gender (67.5% vs. 65.1% males; p = 0.72), BMI (p = 0.82), cancer stage (p = 0.36), neoadjuvant chemoradiation (p = 0.13), distance of tumor from anal verge (5.8 ± 4.4 vs. 5.5 ± 3.3; p = 0.56). CRM did not differ (7.7 ± 11.4 mm vs. 8.4 ± 10.3 mm; p = 0.62). The rate of complete TME quality was significantly improved in PP patients as compared to LP patients (73.5% vs. 92.1%; p < 0.001).
While learning had no impact on circumferential resection margins, the quality of TME significantly improved during surgeons' plateau phase as compared to their learning phase.
由于机器人在骨盆中的铰接器械，预计机器人直肠切除术对环周切缘（CRM）有有益的影响。但是，由于缺乏触觉反馈，人们担心这会对全直肠系膜切除术（TME）的质量产生负面影响。本研究旨在评估外科医生的学习曲线是否会影响 CRM 和 TME 质量。
在一项多中心研究中，汇集了可切除直肠癌机器人直肠切除术的患者个体数据。患者被分为外科医生学习曲线的两个阶段。累积和（CUSUM）分析用于确定从学习阶段（LP）到平台阶段（PP）的转变，对这两个阶段进行比较。病理学家以毫米为单位测量 CRM 的显微镜下测量值。病理学家将 TME 质量分类为完整、几乎完整或不完整。使用 t 检验和卡方检验分别比较连续变量和分类变量。
五位外科医生为 235 名患者进行了机器人直肠切除术。83 名 LP 患者与 152 名 PP 患者的年龄（p=0.20）、性别（男性 67.5%与 65.1%；p=0.72）、BMI（p=0.82）、癌症分期（p=0.36）、新辅助放化疗（p=0.13）、肿瘤距肛门缘的距离（5.8±4.4 vs. 5.5±3.3；p=0.56）无差异。CRM 无差异（7.7±11.4 vs. 8.4±10.3；p=0.62）。与 LP 患者相比，PP 患者完全 TME 质量的比例显著提高（73.5%比 92.1%；p<0.001）。
虽然学习对环周切缘没有影响，但与学习阶段相比，外科医生的平台阶段 TME 质量显著提高。
