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How Can We Measure Learning Curves in Complex Laparoscopic Pancreas Resections?
Uwe A. Wittel*, Simon Küsters, Frank Makowiec, Tobias Keck, Ulrich T. Hopt
General- and Visceral Sugery, Universitaetsklinikum Freiburg, Freiburg, Germany
Background: Laparoscopic pancreas resections however, greatly vary in their technical difficulty. This implies that surgeons have to wisely select appropriate patients according to their technical skill while they pass through their individual learning curve. With our analyses we try to identify parameters that are indicators of success during the personal learning curve using 2 independent learning curves with 30 hybrid laparoscopically assisted pancreatoduodenectomies for each surgeon.
Material and Methods: Between 2010 and 2015 106 laparoscopic hybrid pancreatoduodenectomies with open reconstruction were performed at the Clinic of General and Visceral Surgery, University of Freiburg. These operations were performed by two surgeons independently responsible for patient selection and operative procedures. Data of operative procedures and the postoperative clinical course was continuously collected in a SPSS database. Statistical significance was tested using the Mann-Whitney-U-Test, Fischers exact test and Chi-square tests.
Results: The first 30 operations done by each surgeon were analyzed. Analysis of histopathological diagnosis revealed a difference in patient selection with more patients with adenocarcinoma resected by one surgeon (23% vs. 43%). Patients selected by one surgeon were also significantly older (65 ± 12.5 vs. 71 ± 11.6). Mortality was low with 1 death by one surgeon (3.3%) and no lethality within the first 30 resections by the second surgeon. Perioperative complications were comparable to open procedures. Grade C POPFs (0% vs. 3.3%) were more common in one series due to a change in complication management to early conversion of high volume fistulas after pancreatojejunostomy to pancreatogastrostomy. Operation time and blood loss differed between both series with longer operation times and higher blood loss in the series with more pancreatic adenocarcinomas (operation time 381 ± 79 min vs. 454 ± 71 min p< 0.001; median blood loss 350 ml vs. 650 ml, p<0.001).
While in one surgeon operation time reduced between the first and second 15 patients (437 ± 51 min vs. 320 ± 68, p<0.001) this effect was not observed for the second surgeon. Longitudinal analysis of the first 15 versus the second 15 patients in each series did not show different patient outcomes, patient characteristics or blood loss, indicating that these parameters are possibly not suitable do measure surgical competence during an individual learning curve.
Conclusion: During the individual learning curve, patient selection appears to be of exceptional importance. Complications, conversion rates and operative time are insufficient parameters of competence due to changes in patient selection. The variability in technical complexity of hybrid laparoscopic pancreatoduodenectomy is the reason that the individual learning curve has not reached a plateau after 30 procedures.
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