Learning Curve of Laparoscopic Gastrectomy: A Multicenter Study

Annals of Surgery, vol. 277, pp. e808–e816

Abstract

OBJECTIVE: To evaluate the learning curve of laparoscopic gastrectomy (LG) after an implementation program. BACKGROUND: Although LG is increasingly being performed worldwide, little is known about the learning curve. METHODS: Consecutive patients who underwent elective LG for gastric adenocarcinoma with curative intent in each of the 5 highest-volume centers in the Netherlands were enrolled. Generalized additive models and a 2-piece model with a break point were used to determine the learning curve length. Analyses were corrected for casemix and were performed for LG and for the subgroups distal gastrectomy (LDG) and total gastrectomy (LTG). The learning curve effect was assessed for (1) anastomotic leakage; and (2) the occurrence of postoperative complications, conversions to open surgery, and short-term oncological parameters. RESULTS: In total 540 patients were included for analysis, 108 patients from each center; 268 patients underwent LDG and 272 underwent LTG. First, for LG, no learning effect regarding anastomotic leakage could be identified: the rate of anastomotic leakage initially increased, then reached a plateau after 36 cases at 10% anastomotic leakage. Second, the level of overall complications reached a plateau after 20 cases, at 38% overall complications, and at 5% conversions. For both LDG and LTG, each considered separately, fluctuations in secondary outcomes and anastomotic leakage followed fluctuations in casemix. CONCLUSION: On the basis of our study of the first 108 procedures of LG in 5 high-volume centers with well-trained surgeons, no learning curve effect could be identified regarding anastomotic leakage. A learning curve effect was found with respect to overall complications and conversion rate.

Authors 16

1. Hylke J.F. Brenkman corresponding

   University Medical Center Utrecht

   Affiliation as printed

   University Medical Center Utrecht, Utrecht, The Netherlands

2. Linda Claassen

   Radboud University Medical Center

   Affiliation as printed

   Radboud University Medical Center, Nijmegen, The Netherlands

3. Gerjon Hannink

   Radboud University Medical Center

   Affiliation as printed

   Radboud University Medical Center, Nijmegen, The Netherlands

4. Leonie R. van der Werf Aachen Dutch Institute for Clinical Auditing

   Erasmus MC · Dutch Institute for Clinical Auditing

   Affiliation as printed

   Dutch Institute for Clinical Auditing, Leiden, The Netherlands

   Erasmus University Medical Centre, Rotterdam, the Netherlands

5. Jelle P. Ruurda corresponding

   University Medical Center Utrecht

   Affiliation as printed

   University Medical Center Utrecht, Utrecht, The Netherlands

6. Grard A.P. Nieuwenhuizen

   Catharina Ziekenhuis

   Affiliation as printed

   Catharina Ziekenhuis, Eindhoven, The Netherlands

7. Misha D. P. Luyer

   Catharina Ziekenhuis

   Affiliation as printed

   Catharina Ziekenhuis, Eindhoven, The Netherlands

8. Ewout A. Kouwenhoven

   Ziekenhuis Groep Twente

   Affiliation as printed

   Ziekenhuisgroep Twente, Almelo, The Netherlands

9. Marc J. van Det

   Ziekenhuis Groep Twente

   Affiliation as printed

   Ziekenhuisgroep Twente, Almelo, The Netherlands

10. Mark I. van Berge Henegouwen

    Amsterdam University Medical Centers · Cancer Center Amsterdam · University of Amsterdam

    Affiliation as printed

    Amsterdam UMC, Cancer Center Amsterdam, University of Amsterdam, Amsterdam, The Netherlands

11. Suzanne Sarah Gisbertz

    Amsterdam University Medical Centers · Cancer Center Amsterdam · University of Amsterdam

    Affiliation as printed

    Amsterdam UMC, Cancer Center Amsterdam, University of Amsterdam, Amsterdam, The Netherlands

12. Jan H.M.B. Stoot corresponding

    University Medical Center Utrecht · Zuyderland Medisch Centrum

    Affiliation as printed

    Zuyderland Medical Center, Sittard, The Netherlands

    University Medical Center Utrecht, Utrecht, The Netherlands

13. Karel W. E. Hulsewé corresponding

    University Medical Center Utrecht · Zuyderland Medisch Centrum

    Affiliation as printed

    Zuyderland Medical Center, Sittard, The Netherlands

    University Medical Center Utrecht, Utrecht, The Netherlands

14. Frans van Workum

    Radboud University Medical Center

    Affiliation as printed

    Radboud University Medical Center, Nijmegen, The Netherlands

15. Richard van Hillegersberg corresponding

    University Medical Center Utrecht

    Affiliation as printed

    University Medical Center Utrecht, Utrecht, The Netherlands

    Richard van Hillegersberg and Camiel Rosman: share last authorship

16. Camiel Rosman

    Radboud University Medical Center

    Affiliation as printed

    Radboud University Medical Center, Nijmegen, The Netherlands

    Richard van Hillegersberg and Camiel Rosman: share last authorship