Operation time as a simple indicator to predict the overcoming of the learning curve in gastric cancer surgery: a multicenter cohort study
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The aim of this study is to identify an indicator to predict the overcoming of the learning curve of distal gastrectomy in gastric cancer surgery.
A retrospective multicenter cohort study was conducted in 2100 patients who underwent radical distal gastrectomy performed by nine surgeons in eight hospitals between 2001 and 2006. For each surgeon, an individual CUSUM chart was formulated in terms of operation time or clinical outcomes, including severe complications, number of retrieved lymph nodes, positive resection margin, and hospital stay. The actual changing points (CPs) of the CUSUM charts were analyzed. Based on the CP, patients were divided into pre-CP and post-CP groups, and the clinicopathologic outcomes and survival data were compared between the groups.
CP determined by operation time was more reliable than CP determined by a combination of clinical outcomes, as the former was correlated not only with short-term outcomes but also with survival. The outcomes were superior in the post-CP group in terms of numbers of harvested lymph nodes, sufficient lymph node harvesting (> 15), and negative proximal margins. In a survival analysis, the post-CP group showed better survival than the pre-CP group in stage II (76% vs 86.1% p = 0.010) and stage III (51.5% vs 60.6% p = 0.042).
Overcoming the learning curve of distal gastrectomy for gastric cancer can be better predicted by operation time rather than by a combination of postoperative clinical parameters. It is recommended that surgeons initially operate on early stage cancer patients before overcoming the learning curve.
KeywordsGastrectomy Learning Cancer
No financial interest to disclose.
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflict of interest.
Human rights statement
All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1964 and later versions.
- 1.Kim YW, Baik YH, Yun YH, Nam BH, Kim DH, Choi IJ, et al. Improved quality of life outcomes after laparoscopy-assisted distal gastrectomy for early gastric cancer: results of a prospective randomized clinical trial. Ann Surg. 2008;248(5):721–7. https://doi.org/10.1097/SLA.0b013e318185e62e. (PubMed PMID: 18948798).CrossRefGoogle Scholar
- 3.Vilallonga R, Fort JM, Gonzalez O, Caubet E, Boleko A, Neff KJ, et al. The initial learning curve for robot-assisted sleeve gastrectomy: a surgeon’s experience while introducing the robotic technology in a bariatric surgery department. Minim Invasive Surg. 2012;2012:347131. https://doi.org/10.1155/2012/347131. (Epub 2012/10/03. PubMed PMID: 23029610; PubMed Central PMCID: PMCPMC3457625).Google Scholar
- 6.Fujiwara M, Kodera Y, Miura S, Kanyama Y, Yokoyama H, Ohashi N, et al. Laparoscopy-assisted distal gastrectomy with systemic lymph node dissection: a phase II study following the learning curve. J Surg Oncol. 2005;91(1):26–32. https://doi.org/10.1002/jso.20166 (PubMed PMID: 15999355. Epub 2005/07/07).CrossRefGoogle Scholar
- 8.Zhao LY, Zhang WH, Sun Y, Chen XZ, Yang K, Liu K, et al. Learning curve for gastric cancer patients with laparoscopy-assisted distal gastrectomy: 6-year experience from a single institution in western China. Medicine (Baltimore). 2016;95(37):e4875. https://doi.org/10.1097/M.0000000000004875 (Epub 2016/09/16. PubMed PMID: 27631257; PubMed Central PMCID: PMCPMC5402600).CrossRefGoogle Scholar
- 10.Bege T, Lelong B, Esterni B, Turrini O, Guiramand J, Francon D, et al. The learning curve for the laparoscopic approach to conservative mesorectal excision for rectal cancer: lessons drawn from a single institution’s experience. Ann Surg. 2010;251(2):249 – 53. https://doi.org/10.1097/SLA.0b013e3181b7fdb0 (PubMed PMID: 20040854. Epub 2009/12/31).CrossRefGoogle Scholar
- 12.Lin CW, Tsai TJ, Cheng TY, Wei HK, Hung CF, Chen YY, et al. The learning curve of laparoscopic liver resection after the Louisville statement 2008: will it be more effective and smooth? Surg Endosc. 2016;30(7):2895–2903. https://doi.org/10.1007/s00464-015-4575-1 (Epub 2015/10/22. PubMed PMID: 26487203).CrossRefGoogle Scholar
- 16.Lee KG, Lee HJ, Yang JY, Oh SY, Bard S, Suh YS, et al. Risk factors associated with complication following gastrectomy for gastric cancer: retrospective analysis of prospectively collected data based on the Clavien-Dindo system. J Gastrointest Surg. 2014;18(7):1269–77. https://doi.org/10.1007/s11605-014-2525-1 (PubMed PMID: 24820136).CrossRefGoogle Scholar
- 18.Kim TH, Suh YS, Huh YJ, Son YG, Park JH, Yang JY, et al. The comprehensive complication index (CCI) is a more sensitive complication index than the conventional Clavien-Dindo classification in radical gastric cancer surgery. Gastric Cancer. 2017. https://doi.org/10.1007/s10120-017-0728-3. (Epub 2017/06/10. PubMed PMID: 28597328).Google Scholar
- 27.Song JH, Choi YY, An JY, Kim DW, Hyung WJ, Noh SH. Short-term outcomes of laparoscopic total gastrectomy performed by a single surgeon experienced in open gastrectomy: review of initial experience. J Gastric Cancer. 2015;15(3):159–166. https://doi.org/10.5230/jgc.2015.15.3.159 (PubMed PMID: 26468413; PubMed Central PMCID: PMCPMC4604330).CrossRefGoogle Scholar
- 29.Japanese Gastric Cancer A. Japanese gastric cancer treatment guidelines 2014 (ver. 4). Gastric Cancer. 2017;20(1):1–19. https://doi.org/10.1007/s10120-016-0622-4 (Epub 2016/06/28. PubMed PMID: 27342689; PubMed Central PMCID: PMCPMC5215069 Phamaceutical, Sanofi, Merck Serono, Yakult Honsha, Daiichi Sankyo, Otsuka Pharmaceutical Factory, Takeda Pharmaceutical, Johnson & Johnson, Asahi Kasei Pharma, Eli Lilly Japan, Pfizer Japan, AJINOMOTO Pharmaceuticals, ONO Pharmaceutical and Kaken Pharmaceutical and grants from Covidien Japan, Shionogi, Bristol Myers Squib, Japan Blood Products Organization, Torii Pharmaceutical, Mitsubishi Tanabe Pharma, bbVie GK, Otsuka Pharmaceutical, Yoshindo, Eizai, Abbott Japan, CSL Behring, Teijin Pharma, Tsumura, Nippon Kayaku, Miyarisan Pharmaceutical, Novartis Pharmaceuticals Japan, KCI, Toyama Chemical, Maruho, Hogy Medical and MSD, outside the submitted work. Dr. Sano reports personal fees from Chugai Phamaceutical, Covidien Japan, Eli Lilly Japan, Johnson & Johnson, Olympus, Otsuka Pharmaceutical Factory, Taiho Pharmaceutical and Yakult Honsha).CrossRefGoogle Scholar
- 30.Biau DJ, Resche-Rigon M, Godiris-Petit G, Nizard RS, Porcher R. Quality control of surgical and interventional procedures: a review of the CUSUM. Qual Saf Health Care. 2007;16(3):203–207. https://doi.org/10.1136/qshc.2006.020776 (PubMed PMID: 17545347; PubMed Central PMCID: PMCPMC2464981. Epub 2007/06/05).CrossRefGoogle Scholar
- 32.Miskovic D, Ni M, Wyles SM, Tekkis P, Hanna GB. Learning curve and case selection in laparoscopic colorectal surgery: systematic review and international multicenter analysis of 4852 cases. Dis Colon Rectum. 2012;55(12):1300–1310. https://doi.org/10.1097/DCR.0b013e31826ab4dd (Epub 2012/11/09. PubMed PMID: 23135590).CrossRefGoogle Scholar
- 33.Kim W, Kim HH, Han SU, Kim MC, Hyung WJ, Ryu SW, et al. Decreased morbidity of laparoscopic distal gastrectomy compared with open distal gastrectomy for stage i gastric cancer: short-term outcomes from a multicenter randomized controlled trial (KLASS-01). Ann Surg. 2016;263(1):28–35. https://doi.org/10.1097/SLA.0000000000001346 (Epub 2015/09/10. PubMed PMID: 26352529).CrossRefGoogle Scholar