单孔电视辅助胸腔镜肺叶切除术的学习曲线：来自单中心的 538 例分析。
Learning curve of uniportal video-assisted thoracoscopic lobectomy: an analysis of the proficiency of 538 cases from a single centre.
机构信息
Department of Thoracic Surgery, The Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, China.
出版信息
Interact Cardiovasc Thorac Surg. 2022 May 2;34(5):799-807. doi: 10.1093/icvts/ivab378.
OBJECTIVES
Uniportal video-assisted thoracoscopic surgery (UniVATS) is widely used as a minimally invasive thoracic operation. The goal of our study was to analyse the effect of long-term experience with the UniVATS lobectomy on the learning curve.
METHODS
The learning curves were quantitatively evaluated by the unadjusted cumulative sum, and they were segmented using joinpoint linear regression analysis. The variables were compared between subgroups using trend analysis, and linear regression analysis was applied to correlate clinical characteristics at different stages of the learning curve with the duration of the operation.
RESULTS
The learning curve for the UniVATS lobectomy can be divided into 3 phases of proficiency at ∼200-300 procedures, with a fourth phase as the number of procedures increases. The 1st-52nd, 52nd-156th, 156th-244th and 244th-538th procedures comprised the preliminary learning stage, preliminary proficiency stage, proficiency stage and advanced proficiency stage, respectively. Surgical outcomes and their variability between stages improved with increasing case numbers, with the most significant addition of an auxiliary operating port and conversions. In multivariable analysis, as stages progressed, influences other than surgical experience increased the operative time, with male and extensive pleural adhesions in the preliminary proficiency stage; male and incomplete pulmonary fissures in the proficiency stage; and male, extensive pleural adhesions and incomplete pulmonary fissures in the advanced proficiency stage.
CONCLUSIONS
As the number of procedures increases, there may be 4 different proficiency stages in the UniVATS lobectomy learning curve. The surgeon enters the fourth stage at approximately the 244th procedure. Moreover, at stage 4, the perioperative indicators tend to stabilize, and influences other than surgical experience become more significant.
目的
单孔电视辅助胸腔镜手术（UniVATS）被广泛应用于微创胸腔手术。本研究旨在分析长期行 UniVATS 肺叶切除术对学习曲线的影响。
方法
采用非调整累积和法对学习曲线进行定量评估，并采用连接点线性回归分析对其进行分段。采用趋势分析比较亚组间的变量，采用线性回归分析将学习曲线不同阶段的临床特征与手术时间进行相关性分析。
结果
UniVATS 肺叶切除术的学习曲线可分为 3 个熟练阶段（约 200-300 例），第四个阶段随着手术例数的增加而出现。第 1-52 例、52-156 例、156-244 例和 244-538 例手术分别为初步学习阶段、初步熟练阶段、熟练阶段和高级熟练阶段。随着手术例数的增加，手术结果及其在各阶段的变异性均有所改善，最显著的是增加辅助操作端口和中转开胸的比例。多变量分析显示，随着阶段的进展，除手术经验外，男性和广泛胸膜粘连在初步熟练阶段、男性和不完整肺裂在熟练阶段、男性、广泛胸膜粘连和不完整肺裂在高级熟练阶段均增加手术时间。
结论
随着手术例数的增加，UniVATS 肺叶切除术的学习曲线可能存在 4 个不同的熟练阶段。外科医生在大约 244 例手术时进入第 4 阶段。此外，在第 4 阶段，围手术期指标趋于稳定，手术经验以外的因素变得更为重要。
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