Sungho Kim1, Yoo-Seok Yoon2, Ho-Seong Han3, Jai Young Cho3, YoungRok Choi3, Boram Lee3. 1. Department of Surgery, Korea University Ansan Hospital, Ansan-si, Korea. 2. Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 166 Gumi-ro, Bundang-gu, Seongnam-si, 463-707, Korea. yoonys@snubh.org. 3. Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 166 Gumi-ro, Bundang-gu, Seongnam-si, 463-707, Korea.
Abstract
BACKGROUND: Laparoscopic pancreaticoduodenectomy (LPD) is technically demanding and there is much controversy about its safety. We evaluated the learning curve for pure LPD based on the clinical outcomes of consecutive patients treated by a single surgeon. METHODS: We reviewed the medical records of 119 consecutive patients who underwent LPD by a single surgeon between June 2013 and August 2018. The learning curve was evaluated using the cumulative summation (CUSUM) and risk-adjusted CUSUM (RA-CUSUM) methods. Perioperative outcomes were compared among the learning curve phases. RESULTS: CUSUM analysis of the operation time showed that the operation time improved after the 47th case. RA-CUSUM analysis showed the learning curve for surgical failure, defined as severe complications (Clavien-Dindo grade ≥ 3) or open conversion, comprised three phases (phase 1: cases 1-60; phase 2: cases 61-83; phase 3: cases 84-119). There were no significant differences in operation time among the three phases. Intraoperative blood loss decreased significantly over the three phases (P = 0.032). There were no postoperative deaths. The rates of postoperative complications, pancreatic fistula (grade B/C), and post-pancreatic hemorrhage were significantly lower in phase 3 than in phase 2 (2.8% vs. 21.7%, P = 0.019; 2.8% vs. 17.4%, P = 0.049; 0% vs. 13.0%, P = 0.026), but not between phases 1 and 2. Postoperative hospital stay decreased progressively, and was significantly shorter in phase 3 than in phase 1 (9.1 vs. 16.7 days, P = 0.001). CONCLUSIONS: The LPD failure rate decreased after the first 60 cases and stabilized after 84 cases. For safe dissemination of LPD, it is important to shorten the long learning curve and decrease the unfavorable outcomes in the early phase of the learning curve.
BACKGROUND: Laparoscopic pancreaticoduodenectomy (LPD) is technically demanding and there is much controversy about its safety. We evaluated the learning curve for pure LPD based on the clinical outcomes of consecutive patients treated by a single surgeon. METHODS: We reviewed the medical records of 119 consecutive patients who underwent LPD by a single surgeon between June 2013 and August 2018. The learning curve was evaluated using the cumulative summation (CUSUM) and risk-adjusted CUSUM (RA-CUSUM) methods. Perioperative outcomes were compared among the learning curve phases. RESULTS: CUSUM analysis of the operation time showed that the operation time improved after the 47th case. RA-CUSUM analysis showed the learning curve for surgical failure, defined as severe complications (Clavien-Dindo grade ≥ 3) or open conversion, comprised three phases (phase 1: cases 1-60; phase 2: cases 61-83; phase 3: cases 84-119). There were no significant differences in operation time among the three phases. Intraoperative blood loss decreased significantly over the three phases (P = 0.032). There were no postoperative deaths. The rates of postoperative complications, pancreatic fistula (grade B/C), and post-pancreatic hemorrhage were significantly lower in phase 3 than in phase 2 (2.8% vs. 21.7%, P = 0.019; 2.8% vs. 17.4%, P = 0.049; 0% vs. 13.0%, P = 0.026), but not between phases 1 and 2. Postoperative hospital stay decreased progressively, and was significantly shorter in phase 3 than in phase 1 (9.1 vs. 16.7 days, P = 0.001). CONCLUSIONS: The LPD failure rate decreased after the first 60 cases and stabilized after 84 cases. For safe dissemination of LPD, it is important to shorten the long learning curve and decrease the unfavorable outcomes in the early phase of the learning curve.
Authors: Camilo Correa-Gallego; Helen E Dinkelspiel; Isabel Sulimanoff; Sarah Fisher; Eduardo F Viñuela; T Peter Kingham; Yuman Fong; Ronald P DeMatteo; Michael I D'Angelica; William R Jarnagin; Peter J Allen Journal: J Am Coll Surg Date: 2013-11-23 Impact factor: 6.113
Authors: David A Kooby; Theresa Gillespie; David Bentrem; Attila Nakeeb; Max C Schmidt; Nipun B Merchant; Alex A Parikh; Robert C G Martin; Charles R Scoggins; Syed Ahmad; Hong Jin Kim; Jaemin Park; Fabian Johnston; Matthew J Strouch; Alex Menze; Jennifer Rymer; Rebecca McClaine; Steven M Strasberg; Mark S Talamonti; Charles A Staley; Kelly M McMasters; Andrew M Lowy; Johnita Byrd-Sellers; William C Wood; William G Hawkins Journal: Ann Surg Date: 2008-09 Impact factor: 12.969
Authors: Susan M Sharpe; Mark S Talamonti; Chihsiung E Wang; Richard A Prinz; Kevin K Roggin; David J Bentrem; David J Winchester; Robert D W Marsh; Susan J Stocker; Marshall S Baker Journal: J Am Coll Surg Date: 2015-04-28 Impact factor: 6.113
Authors: Mohamed Abdelgadir Adam; Kingshuk Choudhury; Michaela A Dinan; Shelby D Reed; Randall P Scheri; Dan G Blazer; Sanziana A Roman; Julie A Sosa Journal: Ann Surg Date: 2015-08 Impact factor: 12.969
Authors: Jony van Hilst; Thijs de Rooij; Koop Bosscha; David J Brinkman; Susan van Dieren; Marcel G Dijkgraaf; Michael F Gerhards; Ignace H de Hingh; Tom M Karsten; Daniel J Lips; Misha D Luyer; Olivier R Busch; Sebastiaan Festen; Marc G Besselink Journal: Lancet Gastroenterol Hepatol Date: 2019-01-24
Authors: Francesco Santullo; Carlo Abatini; Miriam Attalla El Halabieh; Federica Ferracci; Claudio Lodoli; Lorenzo Barberis; Francesco Giovinazzo; Andrea Di Giorgio; Fabio Pacelli Journal: Front Surg Date: 2022-05-18
Authors: Michele Mazzola; Alessandro Giani; Jacopo Crippa; Lorenzo Morini; Andrea Zironda; Camillo Leonardo Bertoglio; Paolo De Martini; Carmelo Magistro; Giovanni Ferrari Journal: Indian J Surg Oncol Date: 2021-08-16