Li Mengyang, Liu Qu, Zhang Tao, Gao Yuanxing, Tan Xianglong, Yin Zhuzeng, Zhao Zhiming, Liu Rong
The Faculty of Hepatopancreatobiliary Surgery, The First Medical Center, Chinese People's Liberation Army General Hospital, Beijing, China.
The Faculty of Hepatopancreatobiliary Surgery, The First Medical Center, Chinese People's Liberation Army General Hospital, Beijing, China; Organ Transplantation Department, The Third Medical Center, Chinese People's Liberation Army General Hospital, Beijing, China.
Int J Surg. 2022 May;101:106612. doi: 10.1016/j.ijsu.2022.106612. Epub 2022 Apr 18.
Radical antegrade modular pancreatosplenectomy (RAMPS), a new surgical approach for pancreatic ductal adenocarcinoma of the body and tail, has become increasingly accepted and performed in recent years. Robotic surgery has advantages over open and laparoscopic surgeries in terms of surgical vision and instrument flexibility. However, the lack of comprehension of the learning curve has limited its generalization. This study aimed to evaluate the learning curve of robotic posterior RAMPS.
Patients who underwent robotic posterior RAMPS between February 2017 and April 2021 at our institution were included in this study. Data on patient characteristics, perioperative outcomes, and pathological outcomes were summarized and analyzed. The cumulative sum (CUSUM) method was used to assess the learning curve and inflection points based on operation time and estimated blood loss.
One hundred consecutive patients who underwent robotic posterior RAMPS were enrolled. The median operation time was 235.0 (interquartile range [IQR], 210.0-270.0) min, and the estimated blood loss was 210.0 (IQR, 165.0-245.0) mL. The grade 3/4 Clavien-Dindo complication rate was 8% (8/100). According to the CUSUM plot, the inflection points of the learning curve were 25 and 65 cases, dividing the case series into the learning (1-25 cases), plateau (26-65 cases), and maturation (66-100 cases) phases. The operation time was relatively high in the learning phase, reached a plateau between 25 and 65 cases (270.0 min vs. 220.0 min, p < 0.01), and decreased significantly in the maturation phase (p < 0.01). Estimated blood loss improved in the maturation phase compared to the learning phase (150.0 vs. 245.0 mL, p < 0.01). No significant differences in conversion rate, complications, or mortality were observed among the three phases.
The inflection points of the learning and plateau phases were the 25th and 65th cases, respectively. Robotic RAMPS is safe and feasible even in the learning phase.
根治性顺行模块化胰脾切除术（RAMPS）是一种针对胰体尾导管腺癌的新型手术方法，近年来越来越被接受并得到应用。机器人手术在手术视野和器械灵活性方面优于开放手术和腹腔镜手术。然而，对学习曲线缺乏理解限制了其推广。本研究旨在评估机器人后路RAMPS的学习曲线。
本研究纳入了2017年2月至2021年4月在我院接受机器人后路RAMPS手术的患者。总结并分析了患者特征、围手术期结果和病理结果的数据。采用累积和（CUSUM）方法，根据手术时间和估计失血量评估学习曲线和拐点。
连续纳入100例行机器人后路RAMPS手术的患者。中位手术时间为235.0（四分位间距[IQR]，210.0 - 270.0）分钟，估计失血量为210.0（IQR，165.0 - 245.0）毫升。3/4级Clavien - Dindo并发症发生率为8%（8/100）。根据CUSUM图，学习曲线的拐点为第25例和第65例，将病例系列分为学习期（1 - 25例）、平台期（26 - 65例）和成熟期（66 - 100例）。学习期手术时间相对较长，在25至65例之间达到平台期（270.0分钟对220.0分钟，p < 0.01），成熟期显著缩短（p < 0.01）。与学习期相比，成熟期估计失血量有所改善（150.0对245.0毫升，p < 0.01）。三个阶段在转化率、并发症或死亡率方面未观察到显著差异。
学习期和平台期的拐点分别为第25例和第65例。即使在学习期，机器人RAMPS也是安全可行的。
