The learning curve for laparoscopic colorectal surgery. Preliminary results from a prospective analysis of 1194 laparoscopic-assisted colectomies.
The learning curve for laparoscopic colorectal surgery. Preliminary results from a prospective analysis of 1194 laparoscopic-assisted colectomies.
复制标题
腹腔镜结直肠手术的学习曲线。
作者：
Charles L. Bennett;S. Stryker;M. Ferreira;J. Adams;R. Beart
背景
腹腔镜辅助结肠切除术是一种新兴的技术，用于癌症、息肉、炎症和其他类型的病理条件的患者。虽然以前的研究表明，当外科医生进行更多的手术时，腹腔镜胆囊切除术的结局更好，但没有关于外科医生数量与腹腔镜辅助结肠切除术结局之间关系的信息。
目的
评价进行腹腔镜辅助结肠切除术次数较多的外科医生是否具有更好的临床结局，以及这种关系（如果存在）是否适用于术中和术后结局。
设计
分析了1194例患者的数据集，由114名外科医生进行手术，来自美国结肠和直肠外科医生协会主办的前瞻性登记，从1991年5月至1994年10月。
主要观察指标
完成率、术中和术后并发症以及住院时间。
结果
在75%的病例中，手术是通过腹腔镜完成的，高手术量的外科医生（≥ 40例）和低手术量的外科医生之间没有差异。住院时间（平均6天）不因外科医生数量而异。术后并发症发生率为15%，高手术量的外科医生发生率明显较低（10% vs 19%; P <0.001）。术中并发症发生率为5%，高手术量外科医生的并发症发生率较低（3.7% vs 6.3%）。多变量回归分析，调整疾病类型（癌症vs炎症vs息肉）和手术难度（高vs低）表明，对于高手术量的外科医生，（校正比值比，0.56; 95%置信区间，0.32-0.97; P = 0.04）和术后并发症（校正比值比，0.48; 95%置信区间，0.34-0.68; P <0.001）。
结论
腹腔镜辅助结肠切除术在术中和术后结局方面有一个学习曲线。与其他腹腔镜手术一样，进行大量腹腔镜辅助结肠切除术的外科医生术中和术后并发症的发生率较低。
BACKGROUND
Laparoscopic-assisted colectomy is an emerging technology for patients with cancer, polyps, inflammation, and other types of pathologic conditions. While previous studies have shown better outcomes for laparoscopic cholecystectomies when surgeons perform more procedures, there is no information on the relationship between surgeon volume and outcomes for laparoscopic-assisted colectomy.
OBJECTIVE
To evaluate whether better clinical outcomes are found for surgeons who perform higher numbers of laparoscopic-assisted colectomies and whether such a relationship, if it exists, applies to both intraoperative and postoperative outcomes.
DESIGN
Analysis of a data set of 1194 patients, operated on by 114 surgeons, from a prospective registry sponsored by the American Society of Colon and Rectal Surgeons, from May 1991 to October 1994.
MAIN OUTCOME MEASURES
Completion rate, intraoperative and postoperative complications, and length of hospital stay.
RESULTS
In 75% of cases, surgery was completed laparoscopically, with no difference between high-volume surgeons (> or = 40 cases) and low-volume surgeons. Length of stay (average, 6 days) did not vary according to surgeon volume. Postoperative complications occurred in 15% of cases, with a significantly lower rate for high-volume surgeons (10% vs 19%; P < .001). Intraoperative complications occurred in 5% of cases, with a nonsignificant trend toward a lower rate for high-volume surgeons (3.7% vs 6.3%). A multivariate regression analysis, adjusting for type of disease (cancer vs inflammation vs polyps) and for level of difficulty of the procedure (high vs low) showed that for high-volume surgeons there is a lower probability of both intraoperative complications (adjusted odds ratio, 0.56; 95% confidence interval, 0.32-0.97; P = .04) and postoperative complications (adjusted odds ratio, 0.48; 95% confidence interval, 0.34-0.68; P < .001).
CONCLUSIONS
There is a learning curve for laparoscopic-assisted colectomy with respect to intraoperative and postoperative outcomes. As with other laparoscopic procedures, surgeons who perform higher volumes of laparoscopic-assisted colectomy have lower rates of intraoperative and postoperative complications.