scholarly journals P-OGC26 Learning curves in minimally invasive esophagectomy- a systematic review and evaluation of benchmarking parameters

2021 ◽  
Vol 108 (Supplement_9) ◽  
Author(s):  
Pooja Prasad ◽  
Lauren Wallace ◽  
Maziar Navidi ◽  
Alexander Phillips
Keyword(s):  
Minimally Invasive ◽  
Learning Curve ◽  
Patient Outcomes ◽  
Minimally Invasive Esophagectomy ◽  
Operating Time ◽  
Learning Curves ◽  
Curve Progression ◽  
Current Evidence ◽  
Invasive Esophagectomy ◽  
Multiple Parameters

Abstract Background Minimally invasive techniques are increasingly used in the treatment of esophageal cancer. The learning curve for minimally invasive oesophagectomy (MIO) is variable and can impact on patient outcomes. The aim of this study was to review the current evidence on learning curves in MIO and identify which parameters are used for benchmarking. Methods A search of the major reference databases (PubMed, Medline, Cochrane) was performed with no time limits up to February 2020. Results were screened in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were included if an assessment of the learning curve was reported on, regardless of which (if any) statistical method was used.  Results Twenty-nine studies comprising 3741 patients were included. Twenty-two studies reported on a combination of thoracoscopic, hybrid and total MIO, 6 studies reported robotic assisted MIO (RAMIE) alone and 1 study evaluated both RAMIE and thoracoscopic esophagectomies. Operating time was the most frequently used parameter to determine learning curve progression (23/39 studies), with number of resected lymph nodes, morbidity and blood loss also frequently used. Learning curves were found to plateau at 7-60 cases for thoracoscopic esophagectomy, 12-175 cases for total and thoracoscopic/hybrid esophagectomy and 9-85 cases for RAMIE.  Conclusions Multiple parameters are employed to gauge MIO learning curve progression. However, there are no validated or approved sets of outcomes. Further work is required to determine the optimum parameters that should be utilised to ensure best patient outcomes and required length of proctoring. 

P99 A STRUCTURED TRAINING PATHWAY TO IMPLEMENT ROBOT-ASSISTED MINIMALLY INVASIVE ESOPHAGECTOMY (RAMIE): LEARNING CURVE RESULTS FROM A HIGH VOLUME CENTER

2019 ◽  
Vol 32 (Supplement_2) ◽  
Author(s):  
Kingma BF ◽  
Hadzijusufovic E ◽  
van der Sluis PC ◽  
Lang H ◽  
Ruurda JP ◽  
...  
Keyword(s):  
Blood Loss ◽  
Minimally Invasive ◽  
Learning Curve ◽  
Minimally Invasive Esophagectomy ◽  
Operating Time ◽  
Learning Curves ◽  
Perioperative Outcomes ◽  
Intraoperative Blood Loss ◽  
Robot Assisted ◽  
Invasive Esophagectomy

Abstract Aim The aim of this study was to describe the results of a structured training pathway that was developed to implement robot-assisted minimally invasive esophagectomy (RAMIE) in new centers. Background & Methods To safely and effectively implement RAMIE in new centers, the learning process needs to be optimized. In this context, a structured training pathway was created (Table 1). The results of this training pathway were investigated by evaluating consecutive patients who underwent RAMIE by a single surgeon who followed the structured training pathway. These patients were included from the trainee center’s prospective database. Cumulative sum (CUSUM) learning curves were plotted for thoracic operating time and intraoperative blood loss. Perioperative outcomes were compared between patients who underwent surgery before and after a learning curve plateau occurred. Results Between 2017-2018, the trainee team adhered to the structured training pathway and a total of 70 patients were included. The learning curves showed plateaus after 22 cases. In cases 23-70, the operating time was shorter for both the thoracic phase (median 215 vs. 249 minutes, P=0.001) and overall procedure (median 394 vs. 440 minutes, P=0.005), intraoperative blood loss was less (median 210 vs. 400 milliliters, P=0.029), and lymph node yield was higher (median 32 vs. 23 nodes, P=0.001) when compared to the first 22 cases. No significant differences were found for conversion rates, postoperative complications, length of hospital stay, radicality, or mortality. Conclusions The structured RAMIE training pathway results in a short learning curve and is an effective way to introduce RAMIE without compromising the oncological outcomes and complication rates. The pathway is therefore advised to surgeons who are willing to adopt this technique.

scholarly journals A structured training pathway to implement robot-assisted minimally invasive esophagectomy: the learning curve results from a high-volume center

2020 ◽  
Vol 33 (Supplement_2) ◽  
Author(s):  
B Feike Kingma ◽  
Edin Hadzijusufovic ◽  
Pieter C Van der Sluis ◽  
Erida Bano ◽  
Hauke Lang ◽  
...  
Keyword(s):  
Blood Loss ◽  
Learning Curve ◽  
Minimally Invasive Esophagectomy ◽  
Operating Time ◽  
High Volume ◽  
Learning Curves ◽  
Intraoperative Blood Loss ◽  
Robot Assisted ◽  
Invasive Esophagectomy ◽  
High Volume Center

ABSTRACT To ensure safe implementation of robot-assisted minimally invasive esophagectomy (RAMIE), the learning process should be optimized. This study aimed to report the results of a surgeon who implemented RAMIE in a German high-volume center by following a tailored and structured training pathway that involved proctoring. Consecutive patients who underwent RAMIE during the course of the program were included from a prospective database. A single surgeon, who had prior experience in conventional MIE, performed all RAMIE procedures. Cumulative sum (CUSUM) learning curves were plotted for the thoracic operating time and intraoperative blood loss. Perioperative outcomes were compared between patients who underwent surgery before and after a learning curve plateau occurred. Between 2017 and 2018, the adopting center adhered to the structured training pathway, and a total of 70 patients were included in the analysis. The CUSUM learning curves showed plateaus after 22 cases. In consecutive cases 23 to 70, the operating time was shorter for both the thoracic phase (median 215 vs. 249 minutes, P = 0.001) and overall procedure (median 394 vs. 440 minutes, P = 0.005), intraoperative blood loss was less (median 210 vs. 400 milliliters, P = 0.029), and lymph node yield was higher (median 32 vs. 23 nodes, P = 0.001) when compared to cases 1 to 22. No significant differences were found in terms of conversion rates, postoperative complications, length of stay, completeness of resection, or mortality. In conclusion, the structured training pathway resulted in a short and safe learning curve for RAMIE in this single center’s experience. As the pathway seems effective in implementing RAMIE without compromising the early oncological outcomes and complication rates, it is advised for surgeons who are wanting to adopt this technique.

Two-Stage Indicators to Assess Learning Curves for Minimally Invasive Ivor Lewis Esophagectomy

2016 ◽  
Vol 66 (05) ◽  
pp. 362-369 ◽  
Author(s):  
Qi Wang ◽  
Zixiang Wu ◽  
Gang Chen ◽  
Sai Zhang ◽  
Gang Shen ◽  
...  
Keyword(s):  
Minimally Invasive ◽  
Learning Curve ◽  
Minimally Invasive Esophagectomy ◽  
Learning Curves ◽  
Differential Analysis ◽  
Ivor Lewis ◽  
Invasive Esophagectomy ◽  
Three Phase ◽  
Relevant Variables ◽  
General Competence

Background Minimally invasive esophagectomy (MIE) Ivor Lewis has been increasingly performed over the last two decades. To guide the implementation of this technically demanding procedure, a comprehensive assessment of MIE-Ivor Lewis learning curves should include both the general competence to accomplish the procedure and the ability to generate oncological benefits. These objectives are believed to be associated with different phases of the learning curve. Methods A retrospective review of the first 109 patients who underwent MIE-Ivor Lewis by a single qualified surgeon was conducted. Relevant variables were collected and assessed by regression analysis to identify suitable indicators for patient stratification and learning curve assessment. Thereafter, the differential analysis was performed among groups to validate the learning curve model. Results Two variables, intrathoracic gastroesophageal anastomosis time and bilateral recurrent laryngeal nerve (RLN) lymphadenectomy number, which plateaued, respectively, after the 26th and 88th cases, were selected as meaningful indicators to identify different competence levels. Therefore, 109 patients were chronologically subcategorized into three groups (the first 26 MIEs as the early group, the next 62 cases as the middle group, and 21 most recent cases as the late group). Perioperative data were compared between groups with positive results to indicate a three-phase model for a learning curve for MIE-Ivor Lewis. Conclusions An MIE-Ivor Lewis learning curve should include three discrete phases that indicate, successively, unskilled operation (general competence to accomplish, less proficiency), surgical proficiency, and oncological efficacy. Intrathoracic anastomosis time and bilateral RLN lymphadenectomy were identified as suitable indicators delineate the different stages of an MIE-Ivor Lewis learning curve.

411 LEARNING CURVES IN MINIMALLY INVASIVE ESOPHAGECTOMY: A SYSTEMATIC REVIEW

2020 ◽  
Vol 33 (Supplement_1) ◽  
Author(s):  
P Prasad ◽  
L Wallace ◽  
M Navidi ◽  
S Wahed ◽  
A Immanuel ◽  
...  
Keyword(s):  
Minimally Invasive ◽  
Learning Curve ◽  
Minimally Invasive Esophagectomy ◽  
Learning Curves ◽  
Minimally Invasive Techniques ◽  
Robotic Assisted ◽  
Invasive Esophagectomy ◽  
Training Programmes ◽  
Meta Analyses ◽  
Invasive Techniques

Abstract   Minimally invasive techniques are being increasingly used in the treatment of esophageal cancer. The learning curve for minimally invasive esophagectomy (MIE) is variable and can have an impact upon training delivered within residency and fellowship programmes. The aims of this review are to critically appraise current literature on the learning curve for MIE, identify what parameter(s) is used to quantify achieving competence and determine if there is evidence of resultant impact on surgical training. Methods A search of the major reference databases (MEDLINE, EMBASE, Cochrane) was performed with no time limits up to the date of the search (February 2020). Results were screened in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and study quality assessed using the Newcastle-Ottawa Scale for cohort studies. Results Twenty-one studies comprising 2720 patients were included- 17 studies reported on a combination of thoracoscopic, hybrid and total MIE, 3 studies reported robotic assisted alone and 1 study evaluated robotic assisted and thoracoscopic esophagectomy. 3 studies used a cumulative sum (CUSUM) analysis to define learning, 1 study used CUSUM and another parameter and 17 studies used one or more parameters. Quantification of surgical competence was variable and ranged from 12–80 cases for robotic surgery and 12–60 cases for other modes of MIE. One study reported trainees achieving MIE skills quicker if mentoring surgeons had attained proficiency on the learning curve. Conclusion Learning curves in MIE remain ill-defined with limited evidence on impact upon training received by residents and fellows. Additionally, the parameters used to define achievement of surgical competency is heterogenous. As minimally invasive techniques are increasingly adopted, specific standards to help define competence need to be identified and agreed on. This could help in designing training programmes and improve the rate of achieving competency.

Learning Curve and Associated Morbidity of Minimally Invasive Esophagectomy

2019 ◽  
Vol 269 (1) ◽  
pp. 88-94 ◽  
Author(s):  
Frans van Workum ◽  
Marianne H. B. C. Stenstra ◽  
Gijs H. K. Berkelmans ◽  
Annelijn E. Slaman ◽  
Mark I. van Berge Henegouwen ◽  
...  
Keyword(s):  
Minimally Invasive ◽  
Learning Curve ◽  
Minimally Invasive Esophagectomy ◽  
Invasive Esophagectomy

Minimally Invasive Pediatric Surgery: The Learning Curve

2020 ◽  
Vol 30 (02) ◽  
pp. 172-180
Author(s):  
Marie Uecker ◽  
Joachim F. Kuebler ◽  
Benno M. Ure ◽  
Nagoud Schukfeh
Keyword(s):  
Postoperative Complications ◽  
Minimally Invasive ◽  
Learning Curve ◽  
Clinical Outcomes ◽  
Surgical Procedures ◽  
Operative Time ◽  
Learning Curves ◽  
Current Evidence ◽  
Stenosis Rate ◽  
Mucosal Perforation

AbstractThe use of minimally invasive surgery (MIS) in pediatric patients has increased over the past decades. The process of mastering a new procedure is termed the learning curve, during which the ability to operate increases but poorer outcomes are produced. We aim to analyze the current evidence on learning curves in pediatric MIS and evaluate its impact on patient's clinical outcomes. A systematic literature search was performed for studies listed on PubMed that reported on the learning curve for MIS surgical procedures. Studies were included if they stated the number of procedures required to reach a consistency in outcomes or if they compared outcomes between early and late period of MIS experience regarding the endpoints operative time, conversions, and intra-/postoperative complications. A total of 22 articles reporting on 11 surgical procedures were included in the study. Most authors reported a significant decrease in operative time as well as peri- and postoperative complications with increasing experience of the surgeon. Complications ranged from minor to major, the latter being especially severe for patients receiving pyloromyotomy (5–7% higher risk of mucosal perforation), esophageal atresia repair (15% higher leakage rate and 19–77% higher stenosis rate), or Kasai portoenterostomy (26–35% more liver transplants in the first year after surgery) during the learning curve period. Pediatric MIS comes with a considerable learning curve that may have a significant impact on the patient's clinical outcomes. Efforts should be made to minimize the effect of the learning curve on the patients.

O100 WORLDWIDE TECHNIQUES AND OUTCOMES OF ROBOT-ASSISTED MINIMALLY INVASIVE ESOPHAGECTOMY (RAMIE): RESULTS FROM THE INTERNATIONAL UGIRA REGISTRY

2019 ◽  
Vol 32 (Supplement_2) ◽  
Author(s):  
B F Kingma ◽  
P P Grimminger ◽  
M J van Det ◽  
Y K Chao ◽  
P Chiu ◽  
...  
Keyword(s):  
Minimally Invasive ◽  
Minimally Invasive Esophagectomy ◽  
Operating Time ◽  
Case Series ◽  
Radical Resection ◽  
Pulmonary Complications ◽  
Cardiac Complications ◽  
Robot Assisted ◽  
Invasive Esophagectomy ◽  
The Mean

Abstract Aim The aim of this study was to gain insight in the techniques and outcomes of RAMIE worldwide. Background & Methods Although robot-assisted minimally invasive esophagectomy (RAMIE) is increasingly adopted. The current literature on RAMIE mainly consists of single-center case series with considerable variation in reported techniques and outcomes. To gain an overview of the worldwide practice in RAMIE, an online registry was established by the Upper GI International Robotic Association (UGIRA). The collected data involve patient- and treatment characteristics, as well as postoperative outcomes that include complications as defined by the Esophageal Complications Consensus Group, length of stay, re-admissions (i.e. <30 days after discharge), mortality (i.e. in-hospital or <30 days after surgery), and pathological results. The outcomes were descriptively analyzed for this interim report. Results A total of 434 patients who underwent RAMIE for esophageal cancer between 2016-2019 were included in this interim analysis. The mean age was 63 years (SD ±9.7), the majority was male (n=359, 83%), and nearly all patients had an ASA score ≥2 (n=398, 92%). Adenocarcinoma (n=253, 58%) and squamous cell carcinoma (n=162, 37%) were most prevalent. The usual surgical approach was transthoracic (n=428, 99%) with the patient in semiprone position (n=393, 91%). Gastric conduit reconstruction was performed in all except one patient, who received a colonic interposition. The anastomosis was created by hand-sewing (n=207, 48%), circular stapling (n=142, 32%), or linear stapling (n=85, 20%). The median intraoperative blood loss was 120 milliliters (IQR 70-280) and the median operating time was 392 minutes (IQR 353-455). Postoperative complications occurred in 251 patients (59%) and mainly involved pulmonary complications (n=138, 32%), anastomotic leakage (n=80, 18%), and cardiac complications (n=55, 13%). Mortality occurred in 9 patients (2%) and re-admission because of complications was required in 57 patients (14%). A median of 28 lymph nodes (IQR 21-35) were removed and a radical resection was achieved in 400 patients (92%). Conclusion The presented results are the first to provide an overview of the techniques that are commonly used in RAMIE. By demonstrating results that are in line with recent benchmarking literature, this study demonstrates the safety and feasibility of RAMIE.

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