TY - JOUR
T1 - Learning Curves of Minimally Invasive Distal Pancreatectomy in Experienced Pancreatic Centers
AU - Lof, Sanne
AU - Claassen, Linda
AU - Hannink, Gerjon
AU - Al-Sarireh, Bilal
AU - Björnsson, Bergthor
AU - Boggi, Ugo
AU - Burdio, Fernando
AU - Butturini, Giovanni
AU - Capretti, Giovanni
AU - Casadei, Riccardo
AU - Dokmak, Safi
AU - Edwin, Bjørn
AU - Esposito, Alessandro
AU - Fabre, Jean M.
AU - Ferrari, Giovanni
AU - Fretland, Asmund A.
AU - Ftériche, Fadhel S.
AU - Fusai, Giuseppe K.
AU - Giardino, Alessandro
AU - Groot Koerkamp, Bas
AU - D'Hondt, Mathieu
AU - Jah, Asif
AU - Kamarajah, Sivesh K.
AU - Kauffmann, Emanuele F.
AU - Keck, Tobias
AU - van Laarhoven, Stijn
AU - Manzoni, Alberto
AU - Marino, Marco V.
AU - Marudanayagam, Ravi
AU - Molenaar, Izaak Q.
AU - Pessaux, Patrick
AU - Rosso, Edoardo
AU - Salvia, Roberto
AU - Soonawalla, Zahir
AU - Souche, Regis
AU - White, Steven
AU - van Workum, Frans
AU - Zerbi, Alessandro
AU - Rosman, Camiel
AU - Stommel, Martijn W. J.
AU - European Consortium on Minimally Invasive Pancreatic Surgery (E-MIPS)
AU - Abu Hilal, Mohammed
AU - Besselink, Marc G.
N1 - Publisher Copyright: © 2023 American Medical Association. All rights reserved.
PY - 2023/9/13
Y1 - 2023/9/13
N2 - Importance: 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. Objective: 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. Exposures: The learning curve for MIDP was estimated by pooling data from all centers. Main Outcomes and Measures: 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. Results: 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. Conclusion and Relevance: 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.
AB - Importance: 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. Objective: 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. Exposures: The learning curve for MIDP was estimated by pooling data from all centers. Main Outcomes and Measures: 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. Results: 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. Conclusion and Relevance: 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.
UR - http://www.scopus.com/inward/record.url?scp=85171202585&partnerID=8YFLogxK
U2 - https://doi.org/10.1001/jamasurg.2023.2279
DO - https://doi.org/10.1001/jamasurg.2023.2279
M3 - Article
C2 - 37378968
SN - 2168-6254
VL - 158
SP - 927
EP - 933
JO - Jama surgery
JF - Jama surgery
IS - 9
ER -