Gynecology Department, Strasbourg University Hospital, Avenue Molière, 67200 Strasbourg, France.
Gynecology Department, Strasbourg University Hospital, Avenue Molière, 67200 Strasbourg, France; I-Cube UMR 7357, laboratoire des Sciences de l'ingénieur, de l'informatique et de l'imagerie, Strasbourg University, Pôle API - Parc d'innovation, 300 boulevard Sébastien Brant - BP 10413, 67412 Illkirch Cedex, France.
Eur J Obstet Gynecol Reprod Biol. 2021 Dec;267:142-149. doi: 10.1016/j.ejogrb.2021.09.024. Epub 2021 Sep 28.
Bowel resection is frequently used when performing oncological surgery to obtain complete cytoreduction or to remove endometriosis in case of intestinal invasion. Acquiring the surgical skills to perform this kind of procedure is crucial to offer to our patients an optimal management. The aim of this study is to describe a 7-years surgical experience in bowel resections of a gynecologic surgeon and to determine his learning curves.
This is a monocentric retrospective cohort study reporting digestive resection performed between January 2013 and April 2020 in the Gynecology Department of Strasbourg University Hospital. Ninety-one consecutive patients were assigned in two groups: gynecological cancer (n = 44) and deep infiltrating endometriosis (DIE) (n = 47). The main outcome measure was the postoperative complications rate at 30 days, based on the modified Clavien-Dindo severity system. Learning curves were evaluated using cumulative sum (CUSUM) analysis of operative time and risk-adjusted cumulative sum (RA-CUSUM) analysis of severe perioperative complications. Identification of predictive factors for operation duration and severe perioperative complication occurrence was conducted using multivariate analysis.
Minor complications were found in 25% of cases. Major complication rate (Clavien-Dindo ≥ IIIa) was 14% in total and only involved patients operated for cancer. The CUSUM curve for operative time peaked at the 35th case and showed a downward slope after the 45th case. Significant predictive factors of operating time were cytoreductive tumoral surgery, size of the bowel resection and laparoscopic surgery, while learning phase 3 significantly decreased it. The RA-CUSUM curve for severe perioperative complications (Clavien-Dindo ≥ IIIa) showed a progressive decrease in the complication rate as the number of interventions increases without showing clear inflection points. Only cardiopulmonary pathologies were found as significant predictive factor of severe complications.
Proficiency in performing highly complex surgery was achieved after approximately 45 cases, cancer and DIE all together. Acceptable rates of severe perioperative complications were observed even during the initial learning period and are comparable with those found in the literature concerning bowel resection performed by gynecologic oncologists but also by general and digestive surgeons.
在进行肿瘤外科手术时，经常需要进行肠道切除术以实现完全减瘤或在肠道受累的情况下切除子宫内膜异位症。掌握进行此类手术的技能对于为我们的患者提供最佳治疗至关重要。本研究旨在描述一位妇科外科医生在肠道切除方面 7 年的手术经验，并确定他的学习曲线。
这是一项单中心回顾性队列研究，报告了 2013 年 1 月至 2020 年 4 月期间在斯特拉斯堡大学附属医院妇科进行的消化道切除术。91 例连续患者被分为两组：妇科癌症（n=44）和深部浸润性子宫内膜异位症（DIE）（n=47）。主要观察指标为基于改良 Clavien-Dindo 严重程度系统的 30 天术后并发症发生率。通过手术时间累积和（CUSUM）分析和围手术期严重并发症风险调整累积和（RA-CUSUM）分析评估学习曲线。使用多变量分析确定手术时间和围手术期严重并发症发生的预测因素。
25%的病例出现轻微并发症。总共有 14%的患者发生严重并发症（Clavien-Dindo≥IIIa），仅涉及接受癌症手术的患者。手术时间的 CUSUM 曲线在第 35 例时达到峰值，在第 45 例之后呈下降趋势。手术时间的显著预测因素是减瘤性肿瘤手术、肠道切除的大小和腹腔镜手术，而第 3 个学习阶段显著缩短了手术时间。严重围手术期并发症（Clavien-Dindo≥IIIa）的 RA-CUSUM 曲线显示，随着干预次数的增加，并发症发生率逐渐降低，没有明显的拐点。仅心肺疾病被发现是严重并发症的显著预测因素。
大约在 45 例癌症和 DIE 全部完成后，熟练掌握了高难度手术。即使在初始学习阶段，也观察到了可接受的严重围手术期并发症发生率，与文献中妇科肿瘤学家、普通和消化外科医生报告的肠道切除的并发症发生率相当。
