Xue Menghua, Lan Ke, Yan Xiaolong, Jiang Tao, Wang Xiaoping, Tian Feng, Ni Yunfeng, Zhao Jinbo
Department of Thoracic Surgery, The Second Affiliated Hospital (Tangdu Hospital) of Air Force Medical University, Xi'an, China.
Transl Lung Cancer Res. 2024 Oct 31;13(10):2561-2572. doi: 10.21037/tlcr-24-337. Epub 2024 Oct 28.
Electromagnetic navigation bronchoscopy (ENB) has been widely used to mark small peripheral pulmonary nodules (PPNs) in video-assisted thoracic surgery (VATS) resection. This technique offers the advantages of a high accuracy and fewer complications. However, few studies have analyzed the learning curve of ENB-guided preoperative localization. We aimed to describe the learning curve and factors influencing ENB-guided thoracoscopic pulmonary nodule resection.
This study included 300 consecutive patients with PPNs who underwent ENB-guided localization by the same endoscopist in our department between November 2019 and December 2021. The cumulative sum (CUSUM) method was used to analyze the learning curve of ENB-guided localization and the learning curve in different lobes, while logistic regression was used to analyze the risk factors affecting ENB operative time (OT).
In 184 patients with 300 nodules, three learning phases were identified through turning points of the learning curve: Phase I (the 16 nodule), Phase II (the 17 to the 107 nodule), and Phase III (the 107 to the 300 nodule). No significant difference was found in the success rate of ENB-guided localization in each phase of the learning curve (100%, 96.7%, and 97.9%, P=0.78). The distance from the localization to the pleura in Phase I was statistically significantly shorter than that in Phase II and Phase III (0.6±0.4 1.1±0.6 1.0±0.5 cm, P=0.001 and P=0.003). Furthermore, the learning curves for nodules in different lobes were different. The learning curve for the upper lobe nodules was divided into two phases; the learning curve for the middle lobe disclosed more negative values; and the learning curve for the lower lobe nodules displayed no obvious pattern. Significant differences were found in nodule location, distance from the localization to the pleura and learning curve phase (P=0.003, P<0.001, P=0.02). The independent factors for OT included gender, smoking history, nodule type, distance from localization to the pleura, and learning curve phase.
ENB OT at the 107 nodule leveled off and showed a downward trend. Different lobes have different learning curves, the middle lobe is the easiest lobe to learn with ENB and can be used as the first lobe of choice for beginners. The learning curve can objectively evaluate the accuracy of ENB location and help endoscopists identify areas for improvement.
电磁导航支气管镜检查（ENB）已广泛应用于电视辅助胸腔镜手术（VATS）切除中对小的周围型肺结节（PPN）进行标记。该技术具有准确性高和并发症少的优点。然而，很少有研究分析ENB引导下术前定位的学习曲线。我们旨在描述ENB引导下胸腔镜肺结节切除的学习曲线及影响因素。
本研究纳入了2019年11月至2021年12月期间在我科由同一位内镜医师对300例连续的PPN患者进行ENB引导下定位。采用累积和（CUSUM）法分析ENB引导下定位的学习曲线以及不同肺叶的学习曲线，同时采用逻辑回归分析影响ENB手术时间（OT）的危险因素。
在184例有300个结节的患者中，通过学习曲线的转折点确定了三个学习阶段：第一阶段（第1至16个结节）、第二阶段（第17至107个结节）和第三阶段（第107至300个结节）。学习曲线各阶段ENB引导下定位的成功率无显著差异（100%、96.7%和97.9%，P = 0.78）。第一阶段定位点到胸膜的距离在统计学上显著短于第二阶段和第三阶段（0.6±0.4、1.1±0.6、1.0±0.5 cm，P = 0.001和P = 0.003）。此外，不同肺叶结节的学习曲线不同。上叶结节的学习曲线分为两个阶段；中叶的学习曲线显示出更多负值；下叶结节的学习曲线无明显规律。结节位置、定位点到胸膜的距离和学习曲线阶段存在显著差异（P = 0.003，P < 0.001，P = 0.02）。OT的独立影响因素包括性别、吸烟史、结节类型、定位点到胸膜的距离和学习曲线阶段。
ENB手术时间在第107个结节时趋于平稳并呈下降趋势。不同肺叶有不同的学习曲线，中叶是ENB学习最容易的肺叶，可作为初学者的首选肺叶。学习曲线可客观评估ENB定位的准确性，并帮助内镜医师确定改进的领域。
