Amsterdam UMC, Department of Surgery, University of Amsterdam, the Netherlands.
Cancer Center Amsterdam, the Netherlands.
JAMA Surg. 2023 Sep 1;158(9):927-933. doi: 10.1001/jamasurg.2023.2279.
Understanding the learning curve of a new complex surgical technique helps to reduce potential patient harm. Current series on the learning curve of minimally invasive distal pancreatectomy (MIDP) are mostly small, single-center series, thus providing limited data.
To evaluate the length of pooled learning curves of MIDP in experienced centers.
DESIGN, SETTING, AND PARTICIPANTS: This international, multicenter, retrospective cohort study included MIDP procedures performed from January 1, 2006, through June 30, 2019, in 26 European centers from 8 countries that each performed more than 15 distal pancreatectomies annually, with an overall experience exceeding 50 MIDP procedures. Consecutive patients who underwent elective laparoscopic or robotic distal pancreatectomy for all indications were included. Data were analyzed between September 1, 2021, and May 1, 2022.
The learning curve for MIDP was estimated by pooling data from all centers.
The learning curve was assessed for the primary textbook outcome (TBO), which is a composite measure that reflects optimal outcome, and for surgical mastery. Generalized additive models and a 2-piece linear model with a break point were used to estimate the learning curve length of MIDP. Case mix-expected probabilities were plotted and compared with observed outcomes to assess the association of changing case mix with outcomes. The learning curve also was assessed for the secondary outcomes of operation time, intraoperative blood loss, conversion to open rate, and postoperative pancreatic fistula grade B/C.
From a total of 2610 MIDP procedures, the learning curve analysis was conducted on 2041 procedures (mean [SD] patient age, 58 [15.3] years; among 2040 with reported sex, 1249 were female [61.2%] and 791 male [38.8%]). The 2-piece model showed an increase and eventually a break point for TBO at 85 procedures (95% CI, 13-157 procedures), with a plateau TBO rate at 70%. The learning-associated loss of TBO rate was estimated at 3.3%. For conversion, a break point was estimated at 40 procedures (95% CI, 11-68 procedures); for operation time, at 56 procedures (95% CI, 35-77 procedures); and for intraoperative blood loss, at 71 procedures (95% CI, 28-114 procedures). For postoperative pancreatic fistula, no break point could be estimated.
In experienced international centers, the learning curve length of MIDP for TBO was considerable with 85 procedures. These findings suggest that although learning curves for conversion, operation time, and intraoperative blood loss are completed earlier, extensive experience may be needed to master the learning curve of MIDP.
了解新的复杂手术技术的学习曲线有助于减少潜在的患者伤害。目前关于微创远端胰腺切除术（MIDP）学习曲线的系列研究大多是小型的、单中心的系列研究，因此提供的数据有限。
评估 MIDP 在经验丰富的中心的 pooled 学习曲线的长度。
设计、设置和参与者：这项国际、多中心、回顾性队列研究纳入了 2006 年 1 月 1 日至 2019 年 6 月 30 日期间，8 个国家的 26 个欧洲中心进行的 MIDP 手术，每个中心每年至少进行 15 例远端胰腺切除术，总体经验超过 50 例 MIDP 手术。纳入了因所有适应症而接受择期腹腔镜或机器人远端胰腺切除术的连续患者。数据于 2021 年 9 月 1 日至 2022 年 5 月 1 日之间进行分析。
通过汇总所有中心的数据来估计 MIDP 的学习曲线。
评估了 MIDP 的学习曲线的主要教科书结果（TBO），这是一个反映最佳结果的综合衡量指标，以及手术掌握情况。使用广义加性模型和具有断点的两段线性模型来估计 MIDP 的学习曲线长度。绘制了病例混合预期概率图，并将其与观察到的结果进行比较，以评估病例混合变化与结果的关系。还评估了手术时间、术中失血量、转为开放率和术后胰腺瘘 B/C 级的次要结果。
从总共 2610 例 MIDP 手术中，对 2041 例手术进行了学习曲线分析（平均[标准差]患者年龄为 58[15.3]岁；在 2040 例有报告性别的患者中，1249 例为女性[61.2%]，791 例为男性[38.8%]）。两段模型显示 TBO 在 85 例（95%CI，13-157 例）时增加，最终出现了一个转折点，而 TBO 率的稳定平台为 70%。学习相关的 TBO 率损失估计为 3.3%。对于转换，估计转折点在 40 例（95%CI，11-68 例）；对于手术时间，在 56 例（95%CI，35-77 例）；对于术中失血量，在 71 例（95%CI，28-114 例）。对于术后胰腺瘘，无法估计转折点。
在经验丰富的国际中心，MIDP 的 TBO 学习曲线长度相当长，需要 85 例。这些发现表明，尽管转换、手术时间和术中失血量的学习曲线完成得更早，但可能需要广泛的经验才能掌握 MIDP 的学习曲线。
