Zhuo Ze-Guo, Li Gang, Song Tie-Niu, Alai Gu-Ha, Shen Xu, Wang Yun, Lin Yi-Dan
Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, China.
Department of Thoracic Surgery, Hospital of Chengdu Office of People's Government of Tibetan Autonomous Region, Chengdu, China.
J Thorac Dis. 2021 Mar;13(3):1543-1552. doi: 10.21037/jtd-20-2862.
Lymphadenectomy is an essential but challenging part of the surgical treatment for esophageal cancer. However, the previously reported learning curve for robotic esophagectomy primarily focused on only one surgical approach (McKeown or Ivor Lewis). However, both approaches must be mastered by a mature robotic surgical team to deal with different clinical conditions and satisfy patients' needs. This study aimed to show how an experienced esophageal surgical team became proficient in both McKeown and Ivor Lewis robotic esophagectomy.
A retrospective review of the first 100 cases of robot-assisted minimally invasive esophagectomy (RAMIE) by a single surgical team was performed. The cumulative sum (CUSUM) analysis was used to distinguish the change point during the learning course. A subgroup analysis was performed according to a surgical approach (McKeown or Ivor Lewis) to determine the effect of experience from one surgical approach on learning the other RAMIE technique.
According to the tendency of the CUSUM plot, the learning curve was divided into four phases. The subgroup analysis indicated the decline of the CUSUM plot in the 3rd phase originated from the start of the Ivor Lewis approach. The attending surgeon took 23 cases to achieve a significant improvement in the number of harvested thoracic lymph nodes using the McKeown approach. Regardless of the acquired experience of McKeown RAMIE, it took another 18 cases for the surgical team to achieve significant improvement in harvesting thoracic lymph nodes using the Ivor Lewis approach.
Twenty-three cases were needed for an experienced surgical team to improve thoracic lymphadenectomy results using McKeown RAMIE. There was another learning phase during the transition from McKeown to Ivor Lewis esophagectomy. Importantly, the acquired experience from performing McKeown RAMIE could shorten how long it takes to learn Ivor Lewis RAMIE.
淋巴结清扫是食管癌手术治疗的重要组成部分，但具有挑战性。然而，先前报道的机器人食管癌切除术的学习曲线主要仅关注一种手术方式（麦克尤恩或艾弗·刘易斯）。然而，一个成熟的机器人手术团队必须掌握这两种方式，以应对不同的临床情况并满足患者需求。本研究旨在展示一个经验丰富的食管外科团队如何熟练掌握麦克尤恩和艾弗·刘易斯机器人食管癌切除术。
对由单一手术团队进行的前100例机器人辅助微创食管癌切除术（RAMIE）进行回顾性分析。采用累积和（CUSUM）分析来区分学习过程中的变化点。根据手术方式（麦克尤恩或艾弗·刘易斯）进行亚组分析，以确定一种手术方式的经验对学习另一种RAMIE技术的影响。
根据CUSUM图的趋势，学习曲线分为四个阶段。亚组分析表明，第三阶段CUSUM图的下降源于艾弗·刘易斯手术方式的开始。主刀医生采用麦克尤恩手术方式进行23例手术后，在获取胸段淋巴结数量方面有显著改善无论之前在麦克尤恩RAMIE方面积累了多少经验，手术团队采用艾弗·刘易斯手术方式获取胸段淋巴结数量再有显著改善还需要18例手术。
经验丰富的手术团队采用麦克尤恩RAMIE改善胸段淋巴结清扫结果需要23例手术。从麦克尤恩食管癌切除术过渡到艾弗·刘易斯食管癌切除术还有另一个学习阶段。重要的是，进行麦克尤恩RAMIE所获得的经验可以缩短学习艾弗·刘易斯RAMIE所需的时间。
