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Agnes A, Peacock O, Manisundaram N, Kim Y, Stanietzky N, Vikram R, Bednarski BK, Konishi T, You YN, Chang GJ. The Learning Curve for Robotic Lateral Pelvic Lymph Node Dissection for Rectal Cancer: A View From the West. Dis Colon Rectum 2024; 67:1281-1290. [PMID: 38959454 DOI: 10.1097/dcr.0000000000003424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/05/2024]
Abstract
BACKGROUND Lateral pelvic lymph node dissection is performed for selected patients with rectal cancer with persistent lateral nodal disease after neoadjuvant therapy. This technique has been slow to be adopted in the West because of concerns regarding technical difficulty. This is the first report on the learning curve for lateral pelvic lymph node dissection in the United States or Europe. OBJECTIVE This study aimed to analyze the learning curve associated with robotic lateral pelvic lymph node dissection. DESIGN Retrospective observational cohort. SETTING Tertiary academic cancer center. PATIENTS Consecutive patients from 2012 to 2021. INTERVENTION All patients underwent robotic lateral pelvic lymph node dissection. MAIN OUTCOME MEASURES The primary end points were the learning curves for the maximum number of nodes retrieved and urinary retention, which was evaluated with simple cumulative sum and 2-sided Bernoulli cumulative sum charts. RESULTS Fifty-four procedures were included. A single-surgeon learning curve (n = 35) and an institutional learning curve are presented in the analysis. In the single-surgeon learning curve, a turning point marking the end of a learning phase was detected at the 12th procedure for the number of retrieved nodes and at the 20th procedure for urinary retention. In the institutional learning curve analysis, 2 turning points were identified at the 13th procedure, indicating progressive improvements for the number of retrieved nodes, and at the 27th procedure for urinary retention. No sustained alarm signals were detected at any time point. LIMITATIONS The retrospective nature, small sample size, and the referral center nature of the reporting institution may limit generalizability. CONCLUSIONS In a setting of institutional experience with robotic colorectal surgery, including beyond total mesorectal excision resections, the learning curve for robotic lateral pelvic lymph node dissection is acceptably short. Our results demonstrate the feasibility of the acquisition of this technique in a controlled setting, with sufficient case volume and proctoring to optimize the learning curve. See Video Abstract. LA CURVA DE APRENDIZAJE DE LA DISECCIN ROBTICA DE LOS GANGLIOS LINFTICOS PLVICOS LATERALES EN EL CNCER DE RECTO UNA VISIN DESDE OCCIDENTE ANTECEDENTES:La disección lateral de los ganglios linfáticos pélvicos se realiza en pacientes seleccionados con cáncer de recto con enfermedad ganglionar lateral persistente tras el tratamiento neoadyuvante. La adopción de esta técnica en Occidente ha sido lenta debido a la preocupación por su dificultad técnica. Éste es el primer informe sobre la curva de aprendizaje de la disección de los ganglios linfáticos pélvicos laterales en EE.UU. o Europa.OBJETIVO:El objetivo de este estudio fue analizar la curva de aprendizaje asociada a la disección robótica de los ganglios linfáticos pélvicos laterales.DISEÑO:Cohorte observacional retrospectiva.LUGAR:Centro oncológico académico terciario.PACIENTES:Pacientes consecutivos desde 2012 al 2021.INTERVENCIÓN:Todos los pacientes fueron sometieron a disección robótica de ganglios linfáticos pélvicos laterales.PRINCIPALES MEDIDAS DE RESULTADO:Los criterios de valoración primarios fueron las curvas de aprendizaje tomando en cuenta el mayor número de ganglios recuperados y la retención urinaria que fueron evaluados con gráficos de suma acumulativa simple y de suma acumulativa de Bernoulli de dos caras.RESULTADOS:Fueron incluidos 54 procedimientos. En el análisis se presentan una curva de aprendizaje de un solo cirujano (n = 35) y una curva de aprendizaje institucional. En la curva de aprendizaje de un solo cirujano, se detectó un punto de inflexión que marcaba el final de una fase de aprendizaje en el duodécimo procedimiento para el número de ganglios extraídos y en el vigésimo para la retención urinaria. En el análisis de la curva de aprendizaje institucional, se identificaron dos puntos de inflexión en las intervenciones 13.ª y 26.ª, que indicaron mejoras progresivas en el número de ganglios extraídos, y en la 27.ª en la retención urinaria. No se detectaron señales de alarma sostenidas en ningún momento.LIMITACIONES:La naturaleza retrospectiva, el pequeño tamaño de la muestra y la naturaleza de centro de referencia de la institución informante que pueden limitar la capacidad de generalizarse.CONCLUSIONES:En un entorno de experiencia institucional con cirugía robótica colorrectal incluyendo más allá de las resecciones TME, la curva de aprendizaje para la disección robótica de ganglios linfáticos pélvicos laterales es aceptablemente corta. Nuestros resultados demuestran la viabilidad de la adquisición de esta técnica en un entorno controlado, con un volumen de casos suficiente y una supervisión que puede optimizar la curva de aprendizaje. (Traducción-Dr. Osvaldo Gauto ).
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Affiliation(s)
- Annamaria Agnes
- Department of Colon and Rectal Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
- General Surgery Unit, Fondazione Policlinico Universitario A Gemelli, Rome, Italy
| | - Oliver Peacock
- Department of Colon and Rectal Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Naveen Manisundaram
- Department of Colon and Rectal Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Youngwan Kim
- Department of Colon and Rectal Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Nir Stanietzky
- Department of Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Raghunandan Vikram
- Department of Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Brian K Bednarski
- Department of Colon and Rectal Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Tsuyoshi Konishi
- Department of Colon and Rectal Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Y Nancy You
- Department of Colon and Rectal Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - George J Chang
- Department of Colon and Rectal Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Wiboonkhwan NA, Thongkan T, Sangkhathat S, Pruphetkaew N, Pitakteerabundit T. Perioperative Outcomes of Laparoscopic Liver Resection and Risk Factors for Adverse Events. Surg Laparosc Endosc Percutan Tech 2022; 32:305-310. [PMID: 35125465 DOI: 10.1097/sle.0000000000001036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 11/16/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE The perioperative outcomes and risk factors associated with adverse events (AEs) after initial laparoscopic liver resection (LLR) are unclear. We studied the outcomes of LLR and identified the predictive factors for AEs. MATERIALS AND METHODS Data from 100 adults who underwent LLR between April 2014 and February 2020 were reviewed. Baseline characteristics, surgery details, intraoperative data, and postoperative outcomes were tabulated. The AEs included conversion to open surgery, morbidity, and mortality. RESULTS Major and minor LLRs accounted for 16% and 84% of cases, respectively. Of the indications for LLR, 88% were malignancies. Conversion to open surgery was necessary for 7% of the patients, the overall morbidity rate was 21%, the major morbidity rate was 7%, and the 90-day mortality rate was 1%. Although the incidence of AEs was higher after major LLR (37.5%) than after minor LLR (21.4%), the difference was not statistically significant (P=0.095); the rate of AEs in the resection of posterosuperior segments (43.7%) did not significantly differ from that of the anteroinferior segments (19.2%; P=0.095). Multivariable analysis revealed that the significant predictors of AEs included American Society of Anesthesiologists (ASA) class III (odds ratio, 5.76; 95% confidence interval, 1.74-19.1; P=0.003) and an operative time longer than 5 hours (odds ratio, 9.20; 95% confidence interval, 2.41-35.07; P<0.001). CONCLUSION To improve outcomes in LLR, patients with ASA class III and those in whom surgery is expected to last longer than 5 hours should be taken into account for better patient selection.
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Affiliation(s)
| | | | | | - Nannapat Pruphetkaew
- Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla Province, Thailand
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External validation of different difficulty scoring systems of laparoscopic liver resection for hepatocellular carcinoma. Surg Endosc 2022; 36:3732-3749. [PMID: 34406470 DOI: 10.1007/s00464-021-08687-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 08/07/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND Several difficulty scoring systems (DSSs) have been proposed for evaluating difficulty of laparoscopic liver resection (LLR) and no study has validated their performance in a hepatocellular carcinoma (HCC)-only cohort at the same time. METHODS All cases with HCC that underwent LLR from January 2015 to December 2020 in our center were retrospectively collected. Performance of the IWATE-DSS, Halls-DSS, Hasegawa-DSS, and Kawaguchi-DSS in predicting perioperative outcomes was evaluated. Subgroup analyses were conducted to compare perioperative outcomes between surgeons on the learning curve and surgeons that have gone through the learning curve. RESULTS For all four DSSs, there were significant distributions of applying bleeding control, surgical time, estimated blood loss, postoperative major complications, and postoperative hospital stay among different groups of each DSS (P all < 0.05). Conversion to laparotomy or not was significantly distributed in different groups of the IWATE-DSS (P = 0.006) and Halls-DSS (P = 0.022), while it was not in the Hasegawa-DSS (P = 0.056) and Kawaguchi-DSS (P = 0.183). Trend tests showed that the conversion rates increased with higher DSS points in the IWATE-DSS (P < 0.001) and the Kawaguchi-DSS (P = 0.021), while not in the Halls-DSS (P = 0.064) and the Hasegawa-DSS (P = 0.068). In the medium and advanced/expert difficulty-level subgroups defined by the IWATE-DSS, there were larger estimated blood loss (P in medium-difficulty group = 0.009; P in the advanced/expert difficulty group = 0.004) and longer postoperative hospital stay (P in the medium-difficulty group = 0.012; P in the advanced/expert group = 0.035) in the learner-performed cases. CONCLUSIONS All DSSs performed well in predicting applying bleeding control, surgical time, estimated blood loss, postoperative major complications, and postoperative hospital stay, while only the IWATE-DSS was able to predict whether conversion to laparotomy or not for HCC patients underwent LLR. The IWATE-DSS was also able to help surgeons on the LLR learning curve choose cases and guide clinical practices.
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Ivanecz A, Plahuta I, Mencinger M, Perus I, Magdalenic T, Turk S, Potrc S. The learning curve of laparoscopic liver resection utilising a difficulty score. Radiol Oncol 2021; 56:111-118. [PMID: 34492748 PMCID: PMC8884855 DOI: 10.2478/raon-2021-0035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 07/16/2021] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND This study aimed to quantitatively evaluate the learning curve of laparoscopic liver resection (LLR) of a single surgeon. PATIENTS AND METHODS A retrospective review of a prospectively maintained database of liver resections was conducted. 171 patients undergoing pure LLRs between April 2008 and April 2021 were analysed. The Halls difficulty score (HDS) for theoretical predictions of intraoperative complications (IOC) during LLR was applied. IOC was defined as blood loss over 775 mL, unintentional damage to the surrounding structures, and conversion to an open approach. Theoretical association between HDS and the predicted probability of IOC was utilised to objectify the shape of the learning curve. RESULTS The obtained learning curve has resulted from thirteen years of surgical effort of a single surgeon. It consists of an absolute and a relative part in the mathematical description of the additive function described by the logarithmic function (absolute complexity) and fifth-degree regression curve (relative complexity). The obtained learning curve determines the functional dependency of the learning outcome versus time and indicates several local extreme values (peaks and valleys) in the learning process until proficiency is achieved. CONCLUSIONS This learning curve indicates an ongoing learning process for LLR. The proposed mathematical model can be applied for any surgical procedure with an existing difficulty score and a known theoretically predicted association between the difficulty score and given outcome (for example, IOC).
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Affiliation(s)
- Arpad Ivanecz
- Clinical Department of Abdominal and General Surgery, University Medical Centre Maribor, Maribor, Slovenia
- Department of Surgery, Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Irena Plahuta
- Clinical Department of Abdominal and General Surgery, University Medical Centre Maribor, Maribor, Slovenia
| | - Matej Mencinger
- Faculty of Civil Engineering, Transportation Engineering and Architecture, University of Maribor, Maribor, Slovenia
- Centre of Applied Mathematics and Theoretical Physics, University of Maribor, Maribor, Slovenia
- Institute of Mathematics, Physics and Mechanics, Ljubljana, Slovenia
| | - Iztok Perus
- Department of Surgery, Faculty of Medicine, University of Maribor, Maribor, Slovenia
- Faculty of Natural Science and Engineering, University of Ljubljana, Ljubljana, Slovenia
| | - Tomislav Magdalenic
- Clinical Department of Abdominal and General Surgery, University Medical Centre Maribor, Maribor, Slovenia
| | - Spela Turk
- Clinical Department of Abdominal and General Surgery, University Medical Centre Maribor, Maribor, Slovenia
| | - Stojan Potrc
- Clinical Department of Abdominal and General Surgery, University Medical Centre Maribor, Maribor, Slovenia
- Department of Surgery, Faculty of Medicine, University of Maribor, Maribor, Slovenia
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Michelakos T, Kontos F, Sekigami Y, Qadan M, Cai L, Catalano O, Deshpande V, Patel MS, Yamada T, Elias N, Dageforde LA, Kimura S, Kawai T, Tanabe KK, Markmann JF, Yeh H, Ferrone CR. Hepatectomy for Solitary Hepatocellular Carcinoma: Resection Margin Width Does Not Predict Survival. J Gastrointest Surg 2021; 25:1727-1735. [PMID: 32779082 DOI: 10.1007/s11605-020-04765-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 07/23/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND The survival benefit of negative margins for hepatocellular carcinoma (HCC) has been demonstrated. However, there is no consensus regarding the optimal resection margin width. We assessed the impact of hepatic resection margin width for solitary HCC on overall (OS), recurrence-free (RFS), and liver-specific recurrence-free survival (LSRFS). METHODS Clinicopathologic data were retrospectively collected for solitary HCC patients who underwent a negative margin hepatectomy (1992-2015). Margin width was categorized in tertiles as "narrow" (≤ 0.3 cm), "intermediate" (0.31-1.0 cm), or "wide" (> 1.0 cm). Survival was compared among groups. RESULTS Of the 178 included patients, most were male (76%); median age, MELD score, and tumor size were 63 years, 8, and 5.2 cm, respectively; 93% were Child-Pugh class A. Median margin width was 0.5 cm. Median follow-up and OS were 47.8 months and 76.7 months, respectively. There was no significant survival difference among narrow, intermediate, and wide margin groups with a median OS of 53 months (IQR 21-not reached [NR]), 74 months (IQR 14-138), and 97 months (IQR 37-142) (p = 0.87), respectively. Median RFS was 33.0 months; again, there was no difference among narrow, intermediate, and wide margin groups with a median of 31 months (IQR 18-NR), 45 months (IQR 14-NR), and 27 months (IQR 11-NR), respectively (p = 0.66). Median LSRFS was 63.0 months (IQR 14-NR) with no difference among groups (p = 0.87). In multivariate analyses, margin width was not associated with OS (p = 0.77), RFS (p = 0.74), or LSRFS (p = 0.92). Findings were similar in all subgroups analyzed (≤ 5 cm, > 5 cm, microvascular invasion, T1, T2/T3, anatomical or non-anatomical resection, major or minor hepatectomy). CONCLUSIONS Narrow margins appear to be oncologically safe and the feasibility of achieving wide margins should not determine resectability.
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Affiliation(s)
- Theodoros Michelakos
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Filippos Kontos
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Yurie Sekigami
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Lei Cai
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Onofrio Catalano
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Vikram Deshpande
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Madhukar S Patel
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Teppei Yamada
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Nahel Elias
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Leigh Anne Dageforde
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Shoko Kimura
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Tatsuo Kawai
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Kenneth K Tanabe
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - James F Markmann
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Heidi Yeh
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Cristina R Ferrone
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA.
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Swaid F, Sucandy I, Tohme S, Marsh JW, Bartlett DL, Tsung A, Geller DA. Changes in Performance of More Than 1000 Minimally Invasive Liver Resections. JAMA Surg 2021; 155:986-988. [PMID: 32857161 PMCID: PMC7450397 DOI: 10.1001/jamasurg.2020.2623] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Forat Swaid
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Samer Tohme
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - James W Marsh
- Department of Surgery, West Virginia University, Morgantown
| | - David L Bartlett
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Allan Tsung
- Department of Surgery, The Ohio State University, Columbus
| | - David A Geller
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Guilbaud T, Fuks D, Berdah S, Birnbaum DJ, Beyer Berjot L. Development of a novel educational tool to assess skills in laparoscopic liver surgery using the Delphi methodology: the laparoscopic liver skills scale (LLSS). Surg Endosc 2021; 36:2321-2333. [PMID: 33871719 DOI: 10.1007/s00464-021-08507-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 04/07/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND No specific performance assessment scales have been reported in laparoscopic liver resection. This study aimed at developing an objective scale specific for the assessment of technical skills for wedge resection in anterior segments (WRAS) and left lateral sectionectomy (LLS). METHODS A laparoscopic liver skills scale (LLSS) was developed using a hierarchical task analysis. A Delphi method obtained consensus among five international experts on relevant steps that should be included into the LLSS for assessment of operative performances. The consensus was predefined using Cronbach's alpha > 0.80. RESULTS A semi-structured review extracted 15 essential subtasks for full laparoscopic WRAS and LLS for evaluation in the Delphi survey. Two rounds of the survey were conducted. Three over 15 subtasks did not reach the predefined level of consensus. Based on the expert's comments, 13 subtasks were reformulated, 4 subtasks were added, and a revised skills scale was developed. After the 2nd round survey (Cronbach's alpha 0.84), 19 subtasks were adopted. The LLSS was composed of three main parts: patient positioning and intraoperative preparation (task 1 to 8), the core part of the WRAS and LLS procedure (tasks 9 to 14), and completion of procedure (task 15 to 19). CONCLUSIONS The LLSS was developed for measuring the skill set for the education of safe and secure laparoscopic WRAS and LLS procedures in a dedicated training program. After validation, this scale could be also used as an assessment tool in the operating room and extrapolated as an operative roadmap to other complex procedures.
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Affiliation(s)
- Théophile Guilbaud
- Department of Digestive Surgery, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille Université, Chemin Des Bourrely, 13015, Marseille, France. .,Center for Surgical Teaching and Research (CERC), Aix-Marseille University, Marseille, France.
| | - David Fuks
- Department of Digestive, Oncological and Metabolic Surgery, Institut Mutualiste Montsouris, Université Paris Descartes, 42 Boulevard Jourdan, 75014, Paris, France
| | - Stéphane Berdah
- Department of Digestive Surgery, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille Université, Chemin Des Bourrely, 13015, Marseille, France.,Center for Surgical Teaching and Research (CERC), Aix-Marseille University, Marseille, France
| | - David Jérémie Birnbaum
- Department of Digestive Surgery, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille Université, Chemin Des Bourrely, 13015, Marseille, France.,Center for Surgical Teaching and Research (CERC), Aix-Marseille University, Marseille, France
| | - Laura Beyer Berjot
- Department of Digestive Surgery, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille Université, Chemin Des Bourrely, 13015, Marseille, France.,Center for Surgical Teaching and Research (CERC), Aix-Marseille University, Marseille, France
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Ziogas IA, Esagian SM, Giannis D, Hayat MH, Kosmidis D, Matsuoka LK, Montenovo MI, Tsoulfas G, Geller DA, Alexopoulos SP. Laparoscopic versus open hepatectomy for intrahepatic cholangiocarcinoma: An individual patient data survival meta-analysis. Am J Surg 2021; 222:731-738. [PMID: 33840443 DOI: 10.1016/j.amjsurg.2021.03.052] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 03/15/2021] [Accepted: 03/20/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND We compared the outcomes of laparoscopic hepatectomy (LH) vs. open hepatectomy (OH) for intrahepatic cholangiocarcinoma (iCCA). METHODS A systematic review of the MEDLINE, EMBASE, Scopus, and Cochrane Library databases was performed using PRISMA guidelines (end-of-search date: 08-June-2020). Individual patient data on overall survival (OS) and recurrence-free survival (RFS) were extracted. Random-effects meta-analyses, and one- and two-stage survival analyses were conducted. RESULTS Eight retrospective cohort studies comparing LH (n = 544) vs. OH (n = 2256) were identified. LH demonstrated lower overall complication (Risk ratio [RR] = 0.64, 95% confidence interval [CI]: 0.46-0.90; p = 0.01), surgical lymphadenectomy (RR = 0.74, 95% CI: 0.58-0.93; p = 0.01) and margin-positive resection (RR = 0.78, 95% CI: 0.62-0.99; p = 0.04) rates, and higher recurrence-free rate (RR = 1.24, 95% CI: 1.01-1.51; p = 0.04) vs. OH. In Cox regression, no difference was observed regarding OS (Hazard Ratio [HR] = 1.11, 95% CI: 0.65-1.91; p = 0.70) and RFS (HR = 1.19, 95% CI: 0.74-1.90; p = 0.47). CONCLUSION The use of LH should be considered when feasible in well-selected iCCA patients by hepatobiliary surgeons with experience in minimally-invasive surgery.
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Affiliation(s)
- Ioannis A Ziogas
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, TN, USA; Surgery Working Group, Society of Junior Doctors, Athens, Greece
| | - Stepan M Esagian
- Oncology Working Group, Society of Junior Doctors, Athens, Greece
| | - Dimitrios Giannis
- Surgery Working Group, Society of Junior Doctors, Athens, Greece; Institute of Health Innovations and Outcomes Research, Northwell Health Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | - Muhammad H Hayat
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Dimitrios Kosmidis
- Surgery Working Group, Society of Junior Doctors, Athens, Greece; Oncology Working Group, Society of Junior Doctors, Athens, Greece
| | - Lea K Matsuoka
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Martin I Montenovo
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Georgios Tsoulfas
- Department of Transplant Surgery, Aristotle University of Thessaloniki School of Medicine, Thessaloniki, Greece
| | - David A Geller
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Sophoclis P Alexopoulos
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, TN, USA.
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Ziogas IA, Evangeliou AP, Mylonas KS, Athanasiadis DI, Cherouveim P, Geller DA, Schulick RD, Alexopoulos SP, Tsoulfas G. Economic analysis of open versus laparoscopic versus robotic hepatectomy: a systematic review and meta-analysis. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2021; 22:585-604. [PMID: 33740153 DOI: 10.1007/s10198-021-01277-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 02/25/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Following the publication of reports from landmark international consensuses (Louisville 2008 and Morioka 2014), minimally invasive hepatectomy became widely accepted as a legitimate alternative to open surgery. We aimed to compare the operative, hospitalization, and total economic costs of open (OLR) vs. laparoscopic (LLR) vs. robotic liver resection (RLR). METHODS We performed a systematic literature review (end-of-search date: July 3, 2020) according to the PRISMA statement. Random-effects meta-analyses were conducted. Quality assessment was performed with the Cochrane Risk of Bias tool for randomized controlled trials, and the Newcastle-Ottawa Scale for non-randomized studies. RESULTS Thirty-eight studies reporting on 3847 patients (1783 OLR; 1674 LLR; 390 RLR) were included. The operative costs of LLR were significantly higher than those of OLR, while subgroup analysis also showed higher operative costs in the LLR group for major hepatectomy, but no statistically significant difference for minor hepatectomy. Hospitalization costs were significantly lower in the LLR group, with subgroup analyses indicating lower costs for LLR in both major and minor hepatectomy series. No statistically significant difference was observed regarding total costs between LLR and OLR both overall and on subgroup analyses in either major or minor hepatectomy series. Meta-analyses showed higher operative, hospitalization, and total costs for RLR vs. LLR, but no statistically significant difference regarding total costs for RLR vs. OLR. CONCLUSION LLR's higher operative costs are offset by lower hospitalization costs compared to OLR leading to no statistically significant difference in total costs, while RLR appears to be a more expensive alternative approach.
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Affiliation(s)
- Ioannis A Ziogas
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, 1313 21st Avenue South, Nashville, TN, 37232-4753, USA. .,Surgery Working Group, Society of Junior Doctors, Athens, Greece.
| | - Alexandros P Evangeliou
- Surgery Working Group, Society of Junior Doctors, Athens, Greece.,Aristotle University of Thessaloníki School of Medicine, Thessaloníki, Greece
| | - Konstantinos S Mylonas
- Surgery Working Group, Society of Junior Doctors, Athens, Greece.,National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | - Dimitrios I Athanasiadis
- Surgery Working Group, Society of Junior Doctors, Athens, Greece.,Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - David A Geller
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Richard D Schulick
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Sophoclis P Alexopoulos
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, 1313 21st Avenue South, Nashville, TN, 37232-4753, USA
| | - Georgios Tsoulfas
- Department of Transplant Surgery, Aristotle University of Thessaloniki School of Medicine, Thessaloníki, Greece
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10
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Learning Curve in Laparoscopic Liver Resection, Educational Value of Simulation and Training Programmes: A Systematic Review. World J Surg 2020; 43:2710-2719. [PMID: 31384997 DOI: 10.1007/s00268-019-05111-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The laparoscopic approach is widely accepted as the procedure of choice for abdominal surgery. However, laparoscopic liver resection (LLR) has advanced slowly due to the significant learning curve (LC), and only few publications have dealt with advanced training in LLR. METHODS Two reviewers conducted systematic research through MEDLINE and EMBASE with combinations of the following keywords: (learning curve OR teaching OR training OR simulation OR education) AND (liver OR hepatic) AND (laparoscopic OR laparoscopy). Robotic-assisted, hand-assisted and hybrid LLRs were excluded. RESULTS Nineteen studies were retrieved. Overall, the level of evidence was low. Thirteen articles assessed the LC during real-life LLR, and six articles focussed on simulation and training programmes in LLR. The LC in minor LLR comprised 60 cases overall, and 15 cases for standardised left lateral sectionectomy. For major LLR (MLLR), the LC was 50 cases for most studies, but was reported to be 15-20 cases in more recent studies, provided MLLR is performed progressively in selected patients. However, there was heterogeneity in the literature regarding the number of minor LLRs required before MLLR, with 60 minor LLRs reported as the minimum. Six studies showed a potential benefit of simulation and training programmes in this field. The gradual implementation of LLR combined with simulation-based training programmes could reduce the clinical impact of LC. CONCLUSIONS The LC in LLR is a long process, and MLLR should be gradually implemented under the supervision of experienced surgeons. Training outside the operating room may reduce the LC in real-life situations.
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11
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Mosteanu BI, Han HS, Cho JY, Lee B. When should we choose a laparoscopic approach? A high-volume center recommendation score. Surg Oncol 2020; 34:208-211. [PMID: 32891332 DOI: 10.1016/j.suronc.2020.04.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 04/19/2020] [Accepted: 04/25/2020] [Indexed: 02/07/2023]
Abstract
Laparoscopic liver resection is a demanding procedure that is undergoing continuous development. The surgeon's skill is constantly improving, new surgical instruments are being introduced, and the indications for this procedure are expanding. However, there is still great concern about patient safety during the procedure and it is not commonly performed in many centers, although numerous studies have confirmed the safety and feasibility of laparoscopic liver techniques. Our center tries to use laparoscopy routinely for most cases and we do not consider conversion to open surgery to be a complication. We present our current opinion on patient selection for laparoscopic liver resection in the hope of encouraging more centers to adopt and develop this technique. Although laparoscopic liver resection is not an official standard of care, it should be considered according to the surgeon's experience and available resources.
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Affiliation(s)
- Benone-Iulian Mosteanu
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seoul, South Korea; Department of Surgery, Fundeni Clinical Institute, Bucharest, Romania
| | - Ho-Seong Han
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seoul, South Korea.
| | - Jai Young Cho
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seoul, South Korea
| | - Boram Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seoul, South Korea
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12
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Goh BKP, Prieto M, Syn N, Koh Y, Lim K. Critical appraisal of the learning curve of minimally invasive hepatectomy: experience with the first 200 cases of a Southeast Asian early adopter. ANZ J Surg 2020; 90:1092-1098. [DOI: 10.1111/ans.15683] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 12/17/2019] [Accepted: 12/22/2019] [Indexed: 12/11/2022]
Affiliation(s)
- Brian K. P. Goh
- Department of Hepatopancreatobiliary and Transplant SurgerySingapore General Hospital Singapore
- Duke‐National University of Singapore Medical School Singapore
| | - Mikel Prieto
- Hepatobiliary Surgery and Liver Transplantation UnitCruces University Hospital Bilbao Spain
| | - Nicholas Syn
- Yong Loo Lin School of MedicineNational University of Singapore Singapore
| | - Ye‐Xin Koh
- Department of Hepatopancreatobiliary and Transplant SurgerySingapore General Hospital Singapore
| | - Kai‐Inn Lim
- Department of AnaesthesiologySingapore General Hospital Singapore
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13
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Ivanecz A, Plahuta I, Magdalenić T, Mencinger M, Peruš I, Potrč S, Krebs B. The external validation of a difficulty scoring system for predicting the risk of intraoperative complications during laparoscopic liver resection. BMC Surg 2019; 19:179. [PMID: 31775813 PMCID: PMC6882247 DOI: 10.1186/s12893-019-0645-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 11/14/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND This study aimed to externally validate and upgrade the recent difficulty scoring system (DSS) proposed by Halls et al. to predict intraoperative complications (IOC) during laparoscopic liver resection (LLR). METHODS The DSS was validated in a cohort of 128 consecutive patients undergoing pure LLRs between 2008 and 2019 at a single tertiary referral center. The validated DSS includes four difficulty levels based on five risk factors (neoadjuvant chemotherapy, previous open liver resection, lesion type, lesion size and classification of resection). As established by the validated DSS, IOC was defined as excessive blood loss (> 775 mL), conversion to an open approach and unintentional damage to surrounding structures. Additionally, intra- and postoperative outcomes were compared according to the difficulty levels with usual statistic methods. The same five risk factors were used for validation done by linear and advanced nonlinear (artificial neural network) models. The study was supported by mathematical computations to obtain a mean risk curve predicting the probability of IOC for every difficulty score. RESULTS The difficulty level of LLR was rated as low, moderate, high and extremely high in 36 (28.1%), 63 (49.2%), 27 (21.1%) and 2 (1.6%) patients, respectively. IOC was present in 23 (17.9%) patients. Blood loss of >775 mL occurred in 8 (6.2%) patients. Conversion to open approach was required in 18 (14.0%) patients. No patients suffered from unintentional damage to surrounding structures. Rates of IOC (0, 9.5, 55.5 and 100%) increased gradually with statistically significant value among difficulty levels (P < 0.001). The relations between the difficulty level, need for transfusion, operative time, hepatic pedicle clamping, and major postoperative morbidity were statistically significant (P < 0.05). Linear and nonlinear validation models showed a strong correlation (correlation coefficients 0.914 and 0.948, respectively) with the validated DSS. The Weibull cumulative distribution function was used for predicting the mean risk probability curve of IOC. CONCLUSION This external validation proved this DSS based on patient's, tumor and surgical factors enables us to estimate the risk of intra- and postoperative complications. A surgeon should be aware of an increased risk of complications before starting with more complex procedures.
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Affiliation(s)
- Arpad Ivanecz
- Department of Abdominal and General Surgery, University Medical Center Maribor, Ljubljanska 5, 2000, Maribor, Slovenia.
| | - Irena Plahuta
- Department of Abdominal and General Surgery, University Medical Center Maribor, Ljubljanska 5, 2000, Maribor, Slovenia
| | - Tomislav Magdalenić
- Department of Abdominal and General Surgery, University Medical Center Maribor, Ljubljanska 5, 2000, Maribor, Slovenia
| | - Matej Mencinger
- Faculty of Civil Engineering, Transportation Engineering and Architecture, University of Maribor, Smetanova ulica 17, 2000, Maribor, Slovenia
- Center of Applied Mathematics and Theoretical Physics, University of Maribor, Mladinska 3, 2000, Maribor, Slovenia
- Institute of Mathematics, Physics and Mechanics, Jadranska 19, 1000, Ljubljana, Slovenia
| | - Iztok Peruš
- Faculty of Civil Engineering, Transportation Engineering and Architecture, University of Maribor, Smetanova ulica 17, 2000, Maribor, Slovenia
- Faculty of Natural Science and Engineering, University of Ljubljana, Aškerčeva cesta 12, 1000, Ljubljana, Slovenia
| | - Stojan Potrč
- Department of Abdominal and General Surgery, University Medical Center Maribor, Ljubljanska 5, 2000, Maribor, Slovenia
| | - Bojan Krebs
- Department of Abdominal and General Surgery, University Medical Center Maribor, Ljubljanska 5, 2000, Maribor, Slovenia
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14
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Kim JH, Kim H. Modified liver hanging maneuver in laparoscopic major hepatectomy: the learning curve and evolution of indications. Surg Endosc 2019; 34:2742-2748. [PMID: 31712899 DOI: 10.1007/s00464-019-07248-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 11/03/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND Laparoscopic major hepatectomy is a technically challenging procedure requiring a steep learning curve. The liver hanging maneuver is a useful technique in liver resection, especially for large or invasive tumors, a relative contraindication of the laparoscopic approach. Therefore, this study aimed to evaluate the learning curve for laparoscopic major hepatectomy using the liver hanging maneuver and extended indications. METHODS Patients who underwent laparoscopic major hepatectomy using the liver hanging maneuver by a single surgeon from January 2013 and September 2018 were retrospectively reviewed. Our hanging technique involves placing the hanging tape along the inferior vena cava for right-sided hepatectomy or the ligamentum venosum for left-sided hepatectomy. The upper end of the tape was placed at the lateral side of the major hepatic veins. The learning curve for operating time and blood loss was evaluated using the cumulative sum (CUSUM) method. RESULTS Among 53 patients, 18 underwent right hepatectomy, 26 underwent left hepatectomy, and 9 underwent right posterior sectionectomy. CUSUM analysis showed that operative time and blood loss improved after the 30th laparoscopic major hepatectomy. The 53 consecutive patients were divided into two groups (early, patients 1-30; late, patients 31-53). The median operative time was lower in the late group, but the difference was not statistically significant (270 vs. 245 min, p = 0.261). The median blood loss was also significantly lower in the late group (350 vs. 150 ml, p < 0.001). Large tumors (measuring > 10 cm) and tumors in proximity to major vessels were significantly higher in the late group (0 vs. 17.4%, p = 0.018; 3.3 vs. 21.7%, p = 0.036; respectively). CONCLUSION This study shows that laparoscopic major hepatectomy using the modified liver hanging maneuver has a learning curve of 30 cases. After procedure standardization, the indications have gradually been extended to large or invasive tumors.
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Affiliation(s)
- Ji Hoon Kim
- Department of Surgery, Eulji University College of Medicine, Dunsan 2(i)-dong, Seo-gu, Daejeon, Republic of Korea.
| | - Hyeyoung Kim
- Department of Surgery, Eulji University College of Medicine, Dunsan 2(i)-dong, Seo-gu, Daejeon, Republic of Korea
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15
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Sultana A, Nightingale P, Marudanayagam R, Sutcliffe RP. Evaluating the learning curve for laparoscopic liver resection: a comparative study between standard and learning curve CUSUM. HPB (Oxford) 2019; 21:1505-1512. [PMID: 30992198 DOI: 10.1016/j.hpb.2019.03.362] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 12/19/2018] [Accepted: 03/13/2019] [Indexed: 02/09/2023]
Abstract
BACKGROUND Laparoscopic liver resection (LLR) requires training in both hepatobiliary surgery and advanced laparoscopy. Available data on LLR learning curves are derived from pioneer surgeons. The aims of this study were to evaluate the LLR learning curve for second generation surgeons, and to compare different CUSUM methodology with and without risk adjustment. METHODS Retrospective analysis of a prospective database of 111 consecutive patients who underwent LLR by two surgeons at a single centre between 2011 and 2016. The LLR learning curve for minor hepatectomy (MH) was evaluated for each surgeon using standard CUSUM before and after risk-adjusting for operative difficulty using the Iwate index, and compared with Learning Curve (LC) CUSUM. The end points were operative time and conversion rate. RESULTS Standard CUSUM analysis identified a learning curve of 50-60 MH procedures. The corresponding learning curve reduced to 25-30 after risk-adjusting for operative difficulty, whilst LC-CUSUM identified a learning curve of 17-25 procedures. CONCLUSIONS The learning curve for laparoscopic minor liver resection by second generation surgeons is shorter than that for pioneer surgeons. Laparoscopic HPB fellowship programmes may further shorten the learning curve, facilitating safe expansion of LLR. The LC-CUSUM method is an alternative technique that warrants further study.
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Affiliation(s)
- Asma Sultana
- Department of HPB Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Peter Nightingale
- Institute of Translational Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ravi Marudanayagam
- Department of HPB Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Robert P Sutcliffe
- Department of HPB Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
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16
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Berardi G, Aghayan D, Fretland ÅA, Elberm H, Cipriani F, Spagnoli A, Montalti R, Ceelen WP, Aldrighetti L, Abu Hilal M, Edwin B, Troisi RI. Multicentre analysis of the learning curve for laparoscopic liver resection of the posterosuperior segments. Br J Surg 2019; 106:1512-1522. [PMID: 31441944 DOI: 10.1002/bjs.11286] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Revised: 04/12/2019] [Accepted: 05/27/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Laparoscopic liver resection demands expertise and a long learning curve. Resection of the posterosuperior segments is challenging, and there are no data on the learning curve. The aim of this study was to evaluate the learning curve for laparoscopic resection of the posterosuperior segments. METHODS A cumulative sum (CUSUM) analysis of the difficulty score for resection was undertaken using patient data from four specialized centres. Risk-adjusted CUSUM analysis of duration of operation, blood loss and conversions was performed, adjusting for the difficulty score of the procedures. A receiver operating characteristic (ROC) curve was used to identify the completion of the learning curve. RESULTS According to the CUSUM analysis of 464 patients, the learning curve showed an initial decrease in the difficulty score followed by an increase and, finally, stabilization. More patients with cirrhosis or previous surgery were operated in the latest phase of the learning curve. A smaller number of wedge resections and a larger number of anatomical resections were performed progressively. Dissection using a Cavitron ultrasonic surgical aspirator and the Pringle manoeuvre were used more frequently with time. Risk-adjusted CUSUM analysis showed a progressive decrease in operating time. Blood loss initially increased slightly, then stabilized and finally decreased over time. A similar trend was found for conversions. The learning curve was estimated to be 40 procedures for wedge and 65 for anatomical resections. CONCLUSION The learning curve for laparoscopic liver resection of the posterosuperior segments consists of a stepwise process, during which accurate patient selection is key.
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Affiliation(s)
- G Berardi
- Department of Human Structure and Repair, Faculty of Medicine, Ghent University, Belgium
| | - D Aghayan
- Intervention Centre, Oslo University Hospital - Rikshospitalet, Oslo, Norway
| | - Å A Fretland
- Intervention Centre, Oslo University Hospital - Rikshospitalet, Oslo, Norway
- Department of Hepatopancreatobiliary Surgery, Oslo University Hospital - Rikshospitalet, Oslo, Norway
| | - H Elberm
- Hepatobiliary and Pancreatic Surgical Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - F Cipriani
- Hepatobiliary Surgery, Department of Surgery, San Raffaele Hospital Milan, Milan, Italy
| | - A Spagnoli
- Department of Statistical Sciences, Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - R Montalti
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - W P Ceelen
- Department of Human Structure and Repair, Faculty of Medicine, Ghent University, Belgium
| | - L Aldrighetti
- Hepatobiliary Surgery, Department of Surgery, San Raffaele Hospital Milan, Milan, Italy
| | - M Abu Hilal
- Hepatobiliary and Pancreatic Surgical Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - B Edwin
- Intervention Centre, Oslo University Hospital - Rikshospitalet, Oslo, Norway
- Department of Hepatopancreatobiliary Surgery, Oslo University Hospital - Rikshospitalet, Oslo, Norway
- Institute of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway
| | - R I Troisi
- Department of Human Structure and Repair, Faculty of Medicine, Ghent University, Belgium
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
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17
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Aldrighetti L, Cipriani F, Fiorentini G, Catena M, Paganelli M, Ratti F. A stepwise learning curve to define the standard for technical improvement in laparoscopic liver resections: complexity-based analysis in 1032 procedures. Updates Surg 2019; 71:273-283. [PMID: 31119579 DOI: 10.1007/s13304-019-00658-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 04/29/2019] [Indexed: 02/07/2023]
Abstract
The objective of this study is to define the learning curve in a series of procedures grouped according to their complexity calculated by difficulty index to define a standard for technical improvement. 1032 laparoscopic liver resections performed in a single tertiary referral center were stratified by difficulty scores: low difficulty (LD, n = 362); intermediate difficulty (ID, n = 332), and high difficulty (HD, n = 338). The learning curve effect was analyzed using the cumulative sum (CUSUM) method taking into consideration the expected risk of conversion. The ratio of laparoscopic/total liver resections increased from 5.8% (2005) to 71.1% (2018). The CUSUM analysis per group showed that the average value of the conversion rate was reached at the 60th case in the LD Group and at the 15th in the ID and HD groups. The evolution from LD to ID and HD procedures occurred only when learning curve in LD resections was concluded. Reflecting different degree of complexity, procedures showed significantly different blood loss, morbidity, and conversions among groups. A standard educational model-stepwise and progressive-is mandatory to allow surgeons to define the technical and technological backgrounds to deal with a specific degree of difficulty, providing a help in the definition of indications to laparoscopic approach in each phase of training.
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Affiliation(s)
- Luca Aldrighetti
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132, Milan, Italy.
| | - Federica Cipriani
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132, Milan, Italy
| | - Guido Fiorentini
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132, Milan, Italy
| | - Marco Catena
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132, Milan, Italy
| | - Michele Paganelli
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132, Milan, Italy
| | - Francesca Ratti
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132, Milan, Italy
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18
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Efanov MG, Alikhanov RB, Tsvirkun VV, Prostov MY, Kazakov IV, Vankovich AN, Kim PP, Grendal KD. [Early outcomes of robot-assisted liver resection]. Khirurgiia (Mosk) 2018:24-30. [PMID: 30531749 DOI: 10.17116/hirurgia201811124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
AIM To assess an experience of robot-assisted liver resection using CUSUM-test. MATERIAL AND METHODS The results of 46 robot-assisted liver resections were retrospectively analyzed by using of CUSUM-test. RESULTS There were 3 periods in development of the technology. The 1st period - procedures with the lowest index of difficulty (n=16), the 2nd period - expansion of the indications for difficult resections (n=18) and the 3rd period - stabilization of the results (n=12). The dynamics of difficulty index, intraoperative blood loss, duration of procedure and morbidity (Clavien-Dindo Grade II-V) were evaluated. Five liver resections were needed to decrease blood loss and duration of the procedure. Expansion of indications was feasible after 16 procedures. Stable results were obtained after 34 liver resections.
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Affiliation(s)
- M G Efanov
- A.S. Loginov Moscow Clinical Scientific Center, Moscow, Russia
| | - R B Alikhanov
- A.S. Loginov Moscow Clinical Scientific Center, Moscow, Russia
| | - V V Tsvirkun
- A.S. Loginov Moscow Clinical Scientific Center, Moscow, Russia
| | - M Yu Prostov
- A.S. Loginov Moscow Clinical Scientific Center, Moscow, Russia
| | - I V Kazakov
- A.S. Loginov Moscow Clinical Scientific Center, Moscow, Russia
| | - A N Vankovich
- A.S. Loginov Moscow Clinical Scientific Center, Moscow, Russia
| | - P P Kim
- A.S. Loginov Moscow Clinical Scientific Center, Moscow, Russia
| | - K D Grendal
- A.S. Loginov Moscow Clinical Scientific Center, Moscow, Russia
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19
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Ziogas IA, Tsoulfas G. Advances and challenges in laparoscopic surgery in the management of hepatocellular carcinoma. World J Gastrointest Surg 2017; 9:233-245. [PMID: 29359029 PMCID: PMC5752958 DOI: 10.4240/wjgs.v9.i12.233] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 11/04/2017] [Accepted: 12/05/2017] [Indexed: 02/06/2023] Open
Abstract
Hepatocellular carcinoma is the fifth most common malignancy and the third most common cause of cancer-related mortality worldwide. From the wide variety of treatment options, surgical resection and liver transplantation are the only therapeutic ones. However, due to shortage of liver grafts, surgical resection is the most common therapeutic modality implemented. Owing to rapid technological development, minimally invasive approaches have been incorporated in liver surgery. Liver laparoscopic resection has been evaluated in comparison to the open technique and has been shown to be superior because of the reported decrease in surgical incision length and trauma, blood loss, operating theatre time, postsurgical pain and complications, R0 resection, length of stay, time to recovery and oral intake. It has been reported that laparoscopic excision is a safe and feasible approach with near zero mortality and oncologic outcomes similar to open resection. Nevertheless, current indications include solid tumors in the periphery < 5 cm, especially in segments II through VI, while according to the consensus laparoscopic major hepatectomy should only be performed by surgeons with high expertise in laparoscopic and hepatobiliary surgery in tertiary centers. It is necessary for a surgeon to surpass the 60-cases learning curve observed in order to accomplish the desirable outcomes and preserve patient safety. In this review, our aim is to thoroughly describe the general principles and current status of laparoscopic liver resection for hepatocellular carcinoma, as well as future prospects.
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Affiliation(s)
- Ioannis A Ziogas
- Medical School, Aristotle University of Thessaloniki, Thessaloniki 54453, Greece
| | - Georgios Tsoulfas
- Associate Professor of Surgery, 1st Department of Surgery, Aristotle University of Thessaloniki, Thessaloniki 54453, Greece
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20
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Goh BKP, Teo JY, Lee SY, Kam JH, Cheow PC, Jeyaraj P, Chow PKH, Ooi LLPJ, Chung AYF, Chan CY. Critical appraisal of the impact of individual surgeon experience on the outcomes of laparoscopic liver resection in the modern era: collective experience of multiple surgeons at a single institution with 324 consecutive cases. Surg Endosc 2017; 32:1802-1811. [PMID: 28916894 DOI: 10.1007/s00464-017-5864-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 08/22/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND Most studies analyzing the learning experience of laparoscopic liver resection (LLR) focused on the experience of one or two expert pioneering surgeons. This study aims to critically analyze the impact of individual surgeon experience on the outcomes of LLR based on the contemporary collective experiences of multiple surgeons at single institution. METHODS Retrospective review of 324 consecutive LLR from 2006 to 2016. The cases were performed by 10 surgeons over various time periods. Four surgeons had individual experience with <20 cases, four surgeons with 20-30 cases, and two surgeons with >90 cases. The cohort was divided into two groups: comparing a surgeon's experience between the first 20, 30, 40, and 50 cases with patients treated thereafter. Similarly, we performed subset analyses for anterolateral lesions, posterosuperior lesions, and major hepatectomies. RESULTS As individual surgeons gained increasing experience, this was significantly associated with older patients being operated, decreased hand-assistance, larger tumor size, increased liver resections, increased major resections, and increased resections of tumors located at the posterosuperior segments. This resulted in significantly longer operation time and increased use of Pringle maneuver but no difference in other outcomes. Analysis of LLR for tumors in the posterosuperior segments demonstrated that there was a significant decrease in conversion rates after a surgeon had experience with 20 LLR. For major hepatectomies, there was a significant decrease in morbidity, mortality, and length of stay after acquiring experience with 20 LLR. CONCLUSION LLR can be safely adopted today especially for lesions in the anterolateral segments. LLR for lesions in the difficult posterosuperior segments and major hepatectomies especially in cirrhosis should only be attempted by surgeons who have acquired a minimum experience with 20 LLR.
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Affiliation(s)
- Brian K P Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Level 5, 20 College Road, Academia, Singapore, 169856, Singapore. .,Duke-National University of Singapore Medical School, Singapore, Singapore.
| | - Jin-Yao Teo
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Level 5, 20 College Road, Academia, Singapore, 169856, Singapore.,Duke-National University of Singapore Medical School, Singapore, Singapore
| | - Ser-Yee Lee
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Level 5, 20 College Road, Academia, Singapore, 169856, Singapore.,Duke-National University of Singapore Medical School, Singapore, Singapore
| | - Juinn-Huar Kam
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Level 5, 20 College Road, Academia, Singapore, 169856, Singapore.,Duke-National University of Singapore Medical School, Singapore, Singapore
| | - Peng-Chung Cheow
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Level 5, 20 College Road, Academia, Singapore, 169856, Singapore.,Duke-National University of Singapore Medical School, Singapore, Singapore
| | - Premaraj Jeyaraj
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Level 5, 20 College Road, Academia, Singapore, 169856, Singapore.,Duke-National University of Singapore Medical School, Singapore, Singapore
| | - Pierce K H Chow
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Level 5, 20 College Road, Academia, Singapore, 169856, Singapore.,Duke-National University of Singapore Medical School, Singapore, Singapore
| | - London L P J Ooi
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Level 5, 20 College Road, Academia, Singapore, 169856, Singapore.,Duke-National University of Singapore Medical School, Singapore, Singapore
| | - Alexander Y F Chung
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Level 5, 20 College Road, Academia, Singapore, 169856, Singapore.,Duke-National University of Singapore Medical School, Singapore, Singapore
| | - Chung-Yip Chan
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Level 5, 20 College Road, Academia, Singapore, 169856, Singapore.,Duke-National University of Singapore Medical School, Singapore, Singapore
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21
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Efanov M, Alikhanov R, Tsvirkun V, Kazakov I, Melekhina O, Kim P, Vankovich A, Grendal K, Berelavichus S, Khatkov I. Comparative analysis of learning curve in complex robot-assisted and laparoscopic liver resection. HPB (Oxford) 2017; 19:818-824. [PMID: 28599892 DOI: 10.1016/j.hpb.2017.05.003] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Revised: 05/01/2017] [Accepted: 05/09/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND There is no comparative analysis of the learning curves for robot-assisted and laparoscopic liver resection. We aimed to compare learning curves in complex robotic and conventional laparoscopic liver resections with regards to estimation of the difficulty index score. METHODS The results of 131 consecutive liver resections were analyzed retrospectively (40 robot-assisted and 91 laparoscopic). The learning curve evaluation was based on calculation of procedures number before significant change of the difficulty index for minimally invasive liver resection or the rate of posterosuperior segments resection. Groups of early and late experience were compared in every type of approach (robot-assisted and laparoscopic). RESULTS Significant increase of difficulty index (from 5.0 [3.0-7.7] to 7.3 [4.3-10.2]) of robotic procedures required 16 procedures. It was necessary to perform 29 laparoscopic resections in order to significantly increase the rate of laparoscopic posterosuperior segments resection but without significant increase of difficulty index. The implementation of minimally invasive liver resection started with the robotic approach. CONCLUSION The learning curve for robot-assisted liver resections is shorter in comparison with laparoscopic resections. The inclusion of robot-assisted resections in a minimally invasive liver surgery program may be useful to rapidly increase the complexity of laparoscopic liver resections.
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Affiliation(s)
- Mikhail Efanov
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Scientific Center, 11123, Shosse Entuziastov, 86, Moscow, Russia.
| | - Ruslan Alikhanov
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Scientific Center, 11123, Shosse Entuziastov, 86, Moscow, Russia
| | - Victor Tsvirkun
- Moscow Clinical Scientific Center, 11123, Shosse Entuziastov, 86, Moscow, Russia
| | - Ivan Kazakov
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Scientific Center, 11123, Shosse Entuziastov, 86, Moscow, Russia
| | - Olga Melekhina
- Department of Interventional Radiology, Moscow Clinical Scientific Center, 11123, Shosse Entuziastov, 86, Moscow, Russia
| | - Pavel Kim
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Scientific Center, 11123, Shosse Entuziastov, 86, Moscow, Russia
| | - Andrey Vankovich
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Scientific Center, 11123, Shosse Entuziastov, 86, Moscow, Russia
| | - Konstantin Grendal
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Scientific Center, 11123, Shosse Entuziastov, 86, Moscow, Russia
| | - Stanislav Berelavichus
- Department of Abdominal Surgery, A.V. Vishnevsky Institute of Surgery, 11123, B. Serpukhovskaya, 27, Moscow, Russia
| | - Igor Khatkov
- Moscow Clinical Scientific Center, 11123, Shosse Entuziastov, 86, Moscow, Russia
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22
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Kleive D, Sahakyan MA, Berstad AE, Verbeke CS, Gladhaug IP, Edwin B, Fosby B, Line PD, Labori KJ. Trends in indications, complications and outcomes for venous resection during pancreatoduodenectomy. Br J Surg 2017; 104:1558-1567. [DOI: 10.1002/bjs.10603] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 02/28/2017] [Accepted: 04/25/2017] [Indexed: 01/08/2023]
Abstract
Abstract
Background
Pancreatoduodenectomy with superior mesenteric–portal vein resection has become a common procedure in pancreatic surgery. The aim of this study was to compare standard pancreatoduodenectomy with pancreatoduodenectomy plus venous resection at a high-volume centre, and to examine trends in management and outcome over a decade for the latter procedure.
Methods
This retrospective observational study included all patients undergoing pancreatoduodenectomy with or without venous resection at Oslo University Hospital between January 2006 and December 2015. Trends were evaluated by assessing preoperative clinical and radiological characteristics, as well as perioperative outcomes in three time intervals (early, intermediate and late).
Results
A total of 784 patients had a pancreatoduodenectomy, of whom 127 (16·2 per cent) underwent venous resection. Venous resection resulted in a longer operating time (median 422 versus 312 min; P = 0·001) and greater estimated blood loss (EBL) (median 700 versus 500 ml; P = 0·004) than standard pancreatoduodenectomy. The rate of severe complications was significantly higher for pancreatoduodenectomy with venous resection (37·0 versus 26·3 per cent; P = 0·014). The overall burden of complications, evaluated using the Comprehensive Complication Index (CCI), did not differ (median score 8·7 versus 8·7; P = 0·175). Trends in venous resection over time showed a significant reduction in EBL (median 1050 versus 375 ml; P = 0·001) and duration of hospital stay (median 14 versus 9 days; P = 0·011) between the early and late periods. However, despite an improvement in the intermediate period, severe complication rates returned to baseline in the late period (18 of 43 versus 9 of 42 versus 20 of 42 patients in early, intermediate and late periods respectively; P = 0·032), as did CCI scores (median 20·9 versus 0 versus 20·9; P = 0·041).
Conclusion
Despite an initial improvement in severe complications for venous resection during pancreatoduodenectomy, this was not maintained over time. Every fourth patient with venous resection needed relaparotomy, most frequently for bleeding.
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Affiliation(s)
- D Kleive
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - M A Sahakyan
- Intervention Centre, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - A E Berstad
- Department of Radiology, Oslo University Hospital, Oslo, Norway
| | - C S Verbeke
- Department of Pathology, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - I P Gladhaug
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - B Edwin
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway
- Intervention Centre, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - B Fosby
- Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - P-D Line
- Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - K J Labori
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway
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23
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Siddaiah-Subramanya M, Smith S, Lonie J. Mastery learning: how is it helpful? An analytical review. ADVANCES IN MEDICAL EDUCATION AND PRACTICE 2017; 8:269-275. [PMID: 28435346 PMCID: PMC5388198 DOI: 10.2147/amep.s131638] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
The desire to be good at one's work grows out of the aspiration, competition, and a yearning to be the best. Surgeons, in their aim to provide the best care possible to their patients, adopt this behavior to achieve high levels of expert performance through mastery learning, and the surgical training attempts to prepare them optimally to lead a virtuous and productive life. The proponents of the framework reject evidence that suggests that other variables are also necessary to achieve high levels of expert performance. Here, we review various models and designs to achieve mastery along with their pros and cons to help us understand how mastery learning is helpful in surgical practice.
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Affiliation(s)
| | - Sabin Smith
- Department of General Surgery, Townsville Hospital, Townsville, QLD, Australia
| | - James Lonie
- Department of General Surgery, Townsville Hospital, Townsville, QLD, Australia
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24
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Keane MC, Mills RAD, Coster DJ, Williams KA. Is there evidence for a surgeon learning curve for endothelial keratoplasty in Australia? Clin Exp Ophthalmol 2017; 45:575-583. [DOI: 10.1111/ceo.12921] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 01/10/2017] [Accepted: 01/12/2017] [Indexed: 12/23/2022]
Affiliation(s)
- Miriam C Keane
- Department of Ophthalmology; Flinders University; Adelaide Australia
| | - Richard AD Mills
- Department of Ophthalmology; Flinders University; Adelaide Australia
| | - Douglas J Coster
- Department of Ophthalmology; Flinders University; Adelaide Australia
| | - Keryn A Williams
- Department of Ophthalmology; Flinders University; Adelaide Australia
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25
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Assessing Surgeons' Technical Performance and Effect on Outcomes: Still Early Days. Ann Surg 2017; 267:e75-e76. [PMID: 28230664 DOI: 10.1097/sla.0000000000002182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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