Houssaini K, Majbar M A, Souadka A, Lahnaoui O, El Ahmadi B, Ghannam A, Houssain Belkhadir Z, Mohsine R, Benkabbou A
Surgical oncology Department, National Institute of Oncology, Rabat, Morocco.
Surgical oncology Department, National Institute of Oncology, Rabat, Morocco; Équipe de recherche en Oncologie Translationnelle (EROT), Faculty of Medicine and Pharmacy, University Mohammed V, Rabat, Morocco.
J Visc Surg. 2022 Feb;159(1):5-12. doi: 10.1016/j.jviscsurg.2021.02.006. Epub 2021 Mar 18.
To analyze the collective learning curve in the performance of safe liver resections, using the decrease of severe postoperative complications (SPC) as a proxy for overall safety competency.
This was a retrospective analysis of a prospective database in the setting of a liver surgery program implementation in a tertiary center in Morocco. The 100 first consecutive cases of elective liver resections starting from January 1st, 2018 were included in the analysis. SPC were defined as CD>IIIa during the first 90 postoperative days. We used a cumulative sum (CUSUM) technique to determine the number of cases required to achieve safety competency. We then compared case characteristics before and after the learning curve completion.
SPC occurred in 15 cases (15%), including 5 deaths (5%). The CUSUM chart revealed a learning curve completion at the 49th case, marked by an inflection point towards the decrease in SPC (24.5% vs 5.9%; P=0.009). In period 2 (after), cases were associated with less diabetes, less synchronous digestive resection, more cirrhosis, and more prolonged preoperative chemotherapy. The rates of major resection (30.6% vs 29.9%; P=0.89) and biliary reconstruction were comparable, as were the operating time, and estimated blood loss.
Approximately 50 cases were required to complete the learning curve and improve the overall safety of liver resection. In our setting, the learning curve chronology was consistent with collective measures, including team stabilization and protocol development.
以严重术后并发症（SPC）的减少作为整体安全能力的替代指标，分析安全肝切除术操作中的集体学习曲线。
这是对摩洛哥一家三级中心实施肝脏手术项目时建立的前瞻性数据库进行的回顾性分析。分析纳入了从2018年1月1日起连续的100例择期肝切除术病例。SPC定义为术后前90天内Clavien-Dindo分级>IIIa级。我们使用累积和（CUSUM）技术来确定达到安全能力所需的病例数。然后比较学习曲线完成前后的病例特征。
15例（15%）发生SPC，其中5例死亡（5%）。CUSUM图显示在第49例时学习曲线完成，其标志是SPC出现下降拐点（24.5%对5.9%；P = 0.009）。在第2阶段（之后），病例伴有糖尿病的情况较少、同期消化道切除术较少、肝硬化较多以及术前化疗时间较长。大切除率（30.6%对29.9%；P = 0.89）和胆道重建率相当，手术时间和估计失血量也相当。
完成学习曲线并提高肝切除术的整体安全性大约需要50例病例。在我们的研究环境中，学习曲线的时间进程与包括团队稳定和方案制定在内的集体措施一致。
