直肠癌侧方盆腔淋巴结清扫术的学习曲线分析——结果随经验积累而改善。
Learning curve analysis for lateral pelvic lymph node dissection in rectal cancers - Outcomes improve with experience.
作者信息
Sukumar Vivek, Kazi Mufaddal, Gori Jayesh, Ankathi Suman Kumar, Baheti Akshay, Ostwal Vikas, Desouza Ashwin, Saklani Avanish
机构信息
Division of Colorectal Surgery, Department of Surgical Oncology, Tata Memorial Hospital and Homi Bhabha National Institute, Mumbai, Maharashtra, 400012, India.
Department Radiodiagnosis, Tata Memorial Hospital and Homi Bhabha National Institute, Mumbai, Maharashtra, 400012, India.
出版信息
Eur J Surg Oncol. 2022 May;48(5):1110-1116. doi: 10.1016/j.ejso.2021.12.003. Epub 2021 Dec 5.
INTRODUCTION
Lateral pelvic lymph node dissection (LPLND) is a technically challenging procedure and its learning curve has not been analysed against an oncologically relevant outcome. The purpose of the study was to determine the learning curve for LPLND in rectal cancers using nodal retrieval as performance measure.
METHODS
Consecutive LPLND for rectal adenocarcinomas from a single institution were retrospectively analysed. Cumulative sum (CUSUM) control charts were used to detect difference in performance with respect to lymph node yield. Negative binomial regression was used to determine factors influencing nodal harvest using Incidence Risk Ratios (IRR). Separate CUSUM curves were generated for open and minimally invasive surgeries (MIS).
RESULTS
One-hundred and twenty patients were included and all received preoperative radiation. MIS was used in 53.3%. Median lymph node yield was 6 with 20% nodal positivity. Increasing experience (IRR - 1.196) and MIS (IRR - 1.586) were the only factors that influenced nodal harvest. CUSUM charts revealed that learning curve was achieved after the 83rd case overall and after the 19 operations in MIS. There was a 20% increase in nodal yield after every 30 MIS LPLND performed.
CONCLUSIONS
Learning curve for LPLND is relatively long and only increasing experience and minimally invasive operations increased nodal yield.
引言
侧方盆腔淋巴结清扫术（LPLND）是一项技术要求较高的手术，其学习曲线尚未根据肿瘤学相关结局进行分析。本研究的目的是使用淋巴结获取情况作为性能指标来确定直肠癌LPLND的学习曲线。
方法
对来自单一机构的连续直肠腺癌LPLND病例进行回顾性分析。使用累积和（CUSUM）控制图来检测淋巴结获取量方面的性能差异。采用负二项回归，使用发病风险比（IRR）来确定影响淋巴结收获的因素。分别为开放手术和微创手术（MIS）生成CUSUM曲线。
结果
纳入120例患者，所有患者均接受术前放疗。53.3%的患者采用了MIS。淋巴结获取量中位数为6，淋巴结阳性率为20%。经验增加（IRR - 1.196）和MIS（IRR - 1.586）是影响淋巴结收获的唯一因素。CUSUM图显示，总体上第83例手术后达到学习曲线，MIS组在第19例手术后达到学习曲线。每进行30例MIS LPLND，淋巴结获取量增加20%。
结论
LPLND的学习曲线相对较长，只有经验增加和微创手术能提高淋巴结获取量。
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