Defining the learning curve in robot-assisted thoracoscopic lobectomy

Background

Robot-assisted thoracoscopic lobectomy has been shown to be a safe approach to pulmonary lobectomy. This study sought to define, mathematically, the learning curve for RATS lobectomy.

胸腔镜肺叶切除术治疗早期肺癌的学习曲线

目的 通过评估胸腔镜肺叶切除术治疗早期肺癌不同阶段的手术效果,探讨胸腔镜肺叶切除术的学习曲线.方法 回顾性分析2006年9月至2008年6月由同一手术组连续完成的60例全胸腔镜下肺叶切除加纵隔淋巴结清扫术治疗早期肺癌的病例资料.按手术先后依次分为4组(A、B、C、D),每组15例,比较各组手术时间、术中出血量、纵隔淋巴结清扫站数及个数、中转开胸率、术后并发症、术后胸管引流时间以及术后住院天数,分析不同阶段的手术效果.结果 各组病例在年龄、性别、肿瘤大小、病理分期以及手术方式等方面差异无统计学意义(P>0.05).A组手术时间(228.0±55.6)min明显长于C组(155.0±33.6)min或D组(152.7±27.4)min(P<0.001),B组手术时间(200.3±67.1)min亦明显长于C组或D组(P<0.05),而C、D两组之间差异无统计学意义(P=0.896);在术中出血量方面,A组(283.3±111.2)ml明显多于C组(156.7±86.3)ml或D组(143.3±67.8)ml(P<0.01),B组(286.7±188.4)ml亦明显多于C组或D组(P<0.01),C、D两组之间差异无统计学意义(P=0.767);各组淋巴结清扫数量、中转开胸率、术后并发症、术后胸管引流时间以及术后住院天数比较,差异均无统计学意义(P>0.05).结论 胸腔镜肺叶切除术的学习曲线大约为30例.     

Serial improvement of quality metrics in pediatric thoracoscopic lobectomy for congenital lung malformation: an analysis of learning curve

Background

Video-assisted thoracic surgery (VATS) pulmonary resection in children is a technically demanding procedure that requires a relatively long learning period. This study aimed to evaluate the serial improvement of quality metrics according to case volume experience in pediatric VATS pulmonary resection of congenital lung malformation (CLM). Methods VATS anatomical resection in CLM was attempted in 200 consecutive patients. The learning curve for the operative time was modeled by cumulative sum analysis. Quality metrics were used to measure technical achievement and efficiency outcomes. Results The median operative time was 95 min. The median length of hospital stay and chest tube indwelling time was 4 and 2 days, respectively. The improvement of operation time was observed persistently until 200 cases. However, two cut-off points, the 50th case and 110th case, were identified in the learning curve for operative time, and the 110th case was the turning point for stable outcomes with short operation time. Significant reduction of length of hospital stay and chest tube indwelling time was observed after 50 cases (p?=?.002 and p?=?.021, respectively). The complication rate decreased but continued at a low rate for entire study period and the interval decrease was not statistically significant. Conversion rate decreased significantly (p?=?.001), and technically challenging procedures were performed more frequently in later cases. Conclusions Improvements of quality metrics in operation time, conversion rate, length of hospital stay, and chest tube indwelling time were observed in proportion to case volume. Minimum experience of 50 is necessary for stable outcomes of pediatric VATS pulmonary resection.

     

Gastric tube necrosis following minimally invasive oesophagectomy is a learning curve issue

Introduction

Gastric tube necrosis following oesophagectomy is thought to have an increased association with a minimally invasive technique. Some suggest gastric ischaemic preconditioning may reduce ischaemic complications. We discuss our series of 155 consecutive minimally invasive oesophagectomies (MIOs), including a number of cases of gastric tube ischaemia, of which 4 (2.6%) developed conduit necrosis.

Methods

Data were collected prospectively of MIOs carried out by a single surgeon between 2005 and 2011. Cases of gastric tube necrosis were identified.

Results

Overall, 155 patients were identified. The inpatient mortality rate was 2.6%. Gastric tube necrosis occurred in four patients (2.6%). An ultrasonic dissector injury to the gastroepiploic arcade had occurred in two cases. In another case, the gastric tube was strangulated in the hiatus. In the remaining case, no clear mechanical cause was identified. All 4 cases occurred within the first 73 cases. The gastric tube necrosis rate of the first 50 cases versus cases 51–155 was 4% and 2% respectively (p=0.5948). The anastomotic leak rate in these two cohorts was 18% and 7% respectively (p=0.0457). There was a significant reduction in overall gastric tube complications from 22% to 10% following the learning curve of the initial 50 cases (p=0.0447).

Conclusions

In our series, gastric tube necrosis appears to be a learning curve issue. Prophylactic measures such as ischaemic preconditioning become less relevant as the operating surgeon’s experience increases. Instead, meticulous attention to preserving the gastroepiploic arcade, avoidance of tension in the tube and careful positioning of the gastric conduit through an adequately sized hiatus are key factors.     

Video-assisted thoracoscopic lobectomy vs. conventional lobectomy via open thoracotomy in patients with clinical stage IA non-small cell lung carcinoma

The aim of this study was to evaluate our personal experience with video-assisted thoracoscopic lobectomy and compare survival between this procedure and conventional lobectomy via open thoracotomy in patients with clinical stage IA non-small cell lung carcinoma. Between May 1997 and December 2004, 140 patients with clinical stage IA non-small cell lung carcinoma had either VATS lobectomy (VATS group, 84 patients) or standard lobectomy via open thoracotomy (open group, 56 patients) performed in our hospital. We compared overall survival, disease-free survival and recurrence between the two groups. The overall survival rate five years after surgery was 72% in the open group and 82% in the VATS group. There were no significant differences in the overall survival rate between the two groups. The disease-free survival rate five years after surgery was 68% in the open group and 80% in the VATS group. There were no significant differences in the disease-free survival rate between the two groups. Five patients in the open group developed distant recurrence, whereas one patient developed regional recurrence. In the VATS group six patients developed distant recurrence, whereas one patient developed regional recurrence. We consider VATS lobectomy to be one of the therapeutic options in patients with clinical stage IA non-small cell lung carcinoma.     

Sternotomy following minimally invasive thoracoscopic procedures: a word of caution

An increasing number of patients with previous minimally invasive thoracic procedures for anterior mediastinal tumors are now requiring cardiac surgery. This paper highlights the potential damage that can occur when standard sternal splitting techniques are used in these patients.     

全腔镜肺叶切除与开胸肺叶切除治疗早期肺癌的初步体会

【摘要】〓目的〓通过两种术式的比较,评价完全胸腔镜下肺叶切除治疗早期肺癌临床疗效。方法〓回顾分析性分析2012年9月至2013年05月我科行全腔镜下肺叶切除35例术前分期为pT1N0-1M0肺癌患者的资料(VATS组),全组病例均采用全腔镜四孔法完成手术。选取同期行常规开胸手术35例术前分期pT1N0-1M0肺癌患者的临床资料作为对照。比较两组之间手术时间,术中出血量,术后拔管时间,淋巴结清扫数目,术后疼痛,术后并发症发生率,术后住院时间等指标。结果〓无围手术期死亡,VATS组1例患者中转开胸。VATS组患者的术中出血量、引流时间、术后疼痛时间以及住院时间均明显低于常规开胸组患者(P<0.05);VATS组的手术时间、淋巴结清扫数与对照组的差异无统计学意义。结论〓全腔镜肺叶切除治疗早期肺癌安全可行,临床疗效满意。     

单向式全胸腔镜肺癌切除术的学习曲线分析

目的 分析单向式全胸腔镜肺癌切除术的学习曲线.方法 前瞻性收集2006年5月至2009年4月由两名医师完成的125例全胸腔镜肺癌切除术的临床资料.将手术病例按主刀医师分为A(n=24)、B(n=101)两组,并将B组按时间顺序根据患者例数分为B1(n=25)、B2(n=25)、B3(n=25)、B4(n=26)组.A组手术医师开展胸腔镜手术2年,B组手术医师开展胸腔镜手术5年.比较各组的手术时间、术中失血量、清扫淋巴结数目、中转开胸率、术后并发症发生率.结果 与B组比较,A组手术时间较长[(237±85)min比(187±43)min,P=0.013],而术中失血量、清扫淋巴结数目、中转开胸率、术后并发症发生率两组间差异无统计学意义(P＜0.05).A组与B1组比较也有相同结果.B组中从B1组到B4组手术时间逐渐缩短、术中失血量逐渐减少,但差异无统计学意义(P＜0.05).而B组中前50例(B1+B2)与后51例(B3+B4)比较术中失血量减少[(122±141)ml比(87±81),P=0.009].结论 在开展完全胸腔镜肺癌切除的早期阶段,手术时间会较长,这在腔镜手术经历较短的医生更明显,但并发症发生率无显著增加.完成50例全胸腔镜肺癌切除手术可作为评价熟练掌握该手术的指标.     

Robotic-assisted versus open pancreaticoduodenectomy: the results of a case-matched comparison

Robotic-assisted pancreaticoduodenectomy (RPD) is progressively gaining momentum. It seems to provide some potential advantages over open approach. Unfortu     

Descending necrotizing mediastinitis: a minimally invasive approach using video-assisted thoracoscopic surgery

BACKGROUND: Descending necrotizing mediastinitis is a rare but serious disease. Aggressive surgical approaches have been emphasized rather than simple medical treatment. METHODS: Four patients with descending necrotizing mediastinitis were treated surgically in our institution between January 2001 and August 2002. Three had peritonsilar abscesses and one had an odontogenic abscess. Operative procedures included drainage and debridement through a Chamberlain incision and neck incision using video-assisted thoracic surgery. RESULTS: The mean duration from symptoms to operation was 5.3 days (range, 3 to 7) and mean hospital stay was 28.8 days (range, 14 to 47). There was no perioperative mortality. Postoperative complications were found in three patents: two with localized pleural effusion and one with a hydropneumothorax. CONCLUSIONS: Video-assisted thoracic surgery is feasible and effective as a less invasive method for the surgical management of patients with descending necrotizing mediastinitis, especially when applied early.     

The learning curve in minimally invasive percutaneous nephrolitholapaxy: a 1-year retrospective evaluation of a novice and an expert

Purpose  

The aim of this study was to compare a novice surgeon with an expert surgeon independently performing minimally invasive percutaneous neprolitholapaxy (PCNL) excluding the influence of the expert in the learning curve.     

Traditional invasive vs. minimally invasive esophagectomy: a multi-center, randomized trial (TIME-trial)

Background

Surgical site infection (SSI) continues to be a major source of morbidity and mortality in developing countries despite recent advances in aseptic techniques. There is no baseline information regarding SSI in our setting therefore it was necessary to conduct this study to establish the prevalence, pattern and predictors of surgical site infection at Bugando Medical Centre Mwanza (BMC), Tanzania.

Methods

This was a cross-sectional prospective study involving all patients who underwent major surgery in surgical wards between July 2009 and March 2010. After informed written consent for the study and HIV testing, all patients who met inclusion criteria were consecutively enrolled into the study. Pre-operative, intra-operative and post operative data were collected using standardized data collection form. Wound specimens were collected and processed as per standard operative procedures; and susceptibility testing was done using disc diffusion technique. Data were analyzed using SPSS software version 15 and STATA.

Results

Surgical site infection (SSI) was detected in 65 (26.0%) patients, of whom 56 (86.2%) and 9 (13.8%) had superficial and deep SSI respectively. Among 65 patients with clinical SSI, 56(86.2%) had positive aerobic culture. Staphylococcus aureus was the predominant organism 16/56 (28.6%); of which 3/16 (18.8%) were MRSA. This was followed by Escherichia coli 14/56 (25%) and Klebsiella pneumoniae 10/56 (17.9%). Among the Escherichia coli and Klebsiella pneumoniae isolates 9(64.3%) and 8(80%) were ESBL producers respectively. A total of 37/250 (14.8%) patients were HIV positive with a mean CD4 count of 296 cells/ml. Using multivariate logistic regression analysis, presence of pre-morbid illness (OR = 6.1), use of drain (OR = 15.3), use of iodine alone in skin preparation (OR = 17.6), duration of operation ≥ 3 hours (OR = 3.2) and cigarette smoking (OR = 9.6) significantly predicted surgical site infection (SSI)

Conclusion

SSI is common among patients admitted in surgical wards at BMC and pre-morbid illness, use of drain, iodine alone in skin preparation, prolonged duration of the operation and cigarette smoking were found to predict SSI. Prevention strategies focusing on factors associated with SSI is necessary in order to reduce the rate of SSI in our setting.     

Cost analysis of minimally invasive surgery in a pediatric setting

AIMS: The aims of this study was to determine whether an active policy of cost curtailment would impact on the theater cost of laparoscopic surgery in a pediatric setting; to document the extent of cost changes over time and to identify factors that adversely influence expenditure; and to investigate whether the surgeon is a significant factor in the price of the procedure. MATERIALS AND METHODS: A prospective audit of laparoscopic procedures was performed in a single unit over a 36-month period. Detailed costs of theater inventory for all procedures were compiled on a case-by-case basis and recorded on a database. The cost of six index procedures were collated and changes over the period of the study analyzed. The factors responsible for increased expenditure were flagged and appraised to enable the implementation of cost-saving measures. The prices of the laparoscopic equipment were based on invoiced figures provided by hospital managers, and no long-term outcome measures were taken into account. RESULTS: A total of 179 cases were performed by six surgeons over a 3-year period between January 1, 2003 and December 31, 2005, with no adverse intraoperative events. The procedures studied in further detail were appendicectomy (n = 50), fundoplication (n = 25), cholecystectomy (n = 12), nephrectomy (n = 10), Fowler Stevens for undescended testes (n = 10), and modified Palomo operations for varicocoele (n = 7). The mean cost of these procedures fell year by year over the period of study but was significant only in appendicectomy (P = 0.017). For this procedure, there was a significant difference in costs between the various surgeons (P = 0.007), but this trend was not noted with the other procedures. There were no major intraoperative events, although 2 patients required conversion owing to technical difficulties posed by the cases. Among the factors that influenced costs were the use of disposables, particularly for hemostasis and suctioning, and an inability to procure reuseable instruments. CONCLUSIONS: The costs of commonly performed laparoscopic procedures are falling year by year. The surgeon is a factor in the costs of some procedures. A cost-saving strategy has not been compromised of patient safety; however, some cost-saving measures, though attractive, are labor intensive and are not practical. An overall commitment to the sensible use of health care resources translates into savings for hospitals, thereby strengthening the case for laparoscopic surgery.     

Implementation of minimally invasive percutaneous nephrolithotomy (MIP): comparison of the initial learning curve with the later on clinical routine in a tertiary centre

Objective

We report on the comparison of clinical results of the early phase of implementation of minimally invasive PNL (MIP) in a mentor-based approach with the later on clinical routine in a tertiary centre.

Patients and methods

From January 2010 until January 2015 MIP was performed in 190 patients. Stone and patient characteristics were recorded in prospective manner. Perioperative complications were recorded within the Clavien-Classification. The first 120 consecutive patients undergoing MIP were evaluated and divided into three groups of 40 patients each. Mentor-based introduction of MIP was done within the first 40 patients (group A). Further patients were treated on routine clinical practice basis (group B and C). Treatment outcome was compared within the three groups.

Results

The groups did not significantly differ with regard to patient characteristics, operation time and decline in haemoglobin. In the mentor-based series mean stone size was 21.7 ± 12.6 vs. 15.6 ± 7.9 and 16.1 ± 8.4 mm in group B and C (p = 0.033). Primary stone-free rates were 65, 87.5 and 87.5% for the three groups (p = 0.015). Stone-free rate was higher in smaller and simple stones. Overall, complication rate was 41.7% including 36.7% Clavien grade I and II complications.

Conclusions

MIP can be implemented safe and effectively with mentor-based approach. MIP has a high safety profile, which allows high safety and efficacy of MIP at the time of implementation.

     

全胸腔镜肺叶切除与开胸肺叶切除对非小细胞肺癌病人术后化疗的影响对比

目的 对比全胸腔镜(VATS)肺叶切除术与开胸肺叶切除术对非小细胞肺癌病人术后化疗情况的影响.方法 回顾性分析2005年4月至2009年6月102例行肺叶切除并术后化疗的非小细胞肺癌病人资料.按手术方式分为VATS组和开胸组,总结病人术前一般资料、手术相关指标和化疗的完成情况.结果 VATS组45例,开胸组57例;两组病人年龄,术前肺功能、合并症,术后分期、肿瘤大小、胸腔引流时间、住院天数等差异无统计学意义.VATS组在术中出血、手术时间、术后并发症略少.与开胸组比较,VATS组完成3个或3个以上疗程的术后化疗的病人比例(86.7%对70.2%,P=0.048)、按期全剂量、全疗程完成化疗病人比例(48.9%对29.8%,P=0.049)均高于开胸组,因化疗不耐受而减量化疗比例低于开胸组(0对10.5%,P=0.033).两组间术后开始化疗的时间、化疗毒性反应级别差异无统计学意义.结论 胸腔镜肺叶切除术后病人有更好的化疗依从性,按计划完成化疗者比例高.