Parikh D, Johnson M, Chagla L, Lowe D, McCulloch P
Fazakerley Hospital, UK.
Br J Surg. 1996 Nov;83(11):1595-9. doi: 10.1002/bjs.1800831134.
A 3-year prospective study of the learning curve for D2 gastrectomy was carried out by one surgeon beginning to perform the operation independently after intensive specialist training. Some 38 patients were treated; there were four postoperative deaths and 22 patients had complications. Postoperative morbidity decreased significantly with time (rS = -0.38, P = 0.02, 95 per cent confidence interval -0.62 to -0.07). The physiological component of POSSUM (Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity) was significantly lower in the third year (median value 15, 16 and 14 for years 1, 2 and 3, n = 31, chi 2 = 7.5, 2 d.f., P = 0.02, Kruskal-Wallis test), but the operative POSSUM scores and the number of lymph nodes found were not decreased (median operative POSSUM score 19, 18 and 21, n = 31, chi 2 = 0.2, 2 d.f., P = 0.91, Kruskal-Wallis test). The results suggest a learning curve lasting about 18-24 months or 15 to 25 procedures before a plateau is reached. Improved results were associated with changes in case selection and operative tactics but not with reduced extent of lymphadenectomy. D2 gastrectomy should be restricted to specialist centres where adequate training and supervision can be provided during the learning curve.
一位外科医生在接受强化专科培训后开始独立进行手术，对D2胃切除术的学习曲线进行了为期3年的前瞻性研究。共治疗了约38例患者；术后有4例死亡，22例患者出现并发症。术后发病率随时间显著下降（rS = -0.38，P = 0.02，95%置信区间为-0.62至-0.07）。POSSUM（用于计算死亡率和发病率的生理和手术严重程度评分）的生理成分在第三年显著降低（第1年、第2年和第3年的中位数分别为15、16和14，n = 31，卡方检验χ2 = 7.5，自由度为2，P = 0.02，Kruskal-Wallis检验），但手术POSSUM评分和发现的淋巴结数量并未减少（手术POSSUM评分中位数分别为19、18和21，n = 31，卡方检验χ2 = 0.2，自由度为2，P = 0.91，Kruskal-Wallis检验）。结果表明，学习曲线持续约18 - 24个月或进行15至25例手术后达到平稳期。结果的改善与病例选择和手术策略的改变有关，但与淋巴结清扫范围的减少无关。D2胃切除术应仅限于能够在学习曲线期间提供充分培训和监督的专科中心。
