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.

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 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. 

FA01.04: HIGH HOSPITAL VOLUME IS ASSOCIATED WITH SHORTER LEARNING CURVES AND LESS LEARNING ASSOCIATED MORBIDITY AFTER MINIMALLY INVASIVE ESOPHAGECTOMY

2018 ◽  
Vol 31 (Supplement_1) ◽  
pp. 2-2
Author(s):  
Frans Workum ◽  
Linda Claassens ◽  
Maroeska Rovers ◽  
Camiel Rosman
Keyword(s):  
Patient Safety ◽  
Learning Curve ◽  
Hospital Volume ◽  
Minimally Invasive Esophagectomy ◽  
Group Versus ◽  
High Volume ◽  
Learning Curves ◽  
Ivor Lewis ◽  
Invasive Esophagectomy ◽  
Volume Group

Abstract Background Ivor Lewis totally minimally invasive esophagectomy (TMIE) is associated with a long learning curve and high learning associated morbidity. Factors that are associated with a shorter learning curve and less associated morbidity have not been investigated from clinical data. The aim of this study was to investigate whether there is a relationship between hospital volume and the length of the learning curve and learning associated morbidity. Methods Prospectively collected data were retrospectively analyzed of all consecutive patients undergoing Ivor Lewis TMIE in expert centers in Sweden, Denmark and the Netherlands. The primary outcome parameter was anastomotic leakage requiring reoperation or reintervention. Learning curves were plotted using weighted moving average and CUSUM analysis was used to determine after how many cases the plateau was reached. Learning associated morbidity was calculated with area under the curve analysis. The length of the learning curve and learning associated morbidity were compared between hospitals < 50 procedures per year (normal volume) and hospitals performing > 50 procedures (high volume) per year. Results Nine centers participated and 906 patients were included. The mean number of Ivor Lewis TMIE performed per center per year was 41 (range 22–60). The overall length of the learning curve was 136 cases and this was 148 cases in the normal volume group versus 122 cases in the high volume group. Learning associated anastomotic leakage occurred in 10 patients (7.4% of all patients operated during the learning curve) and this was 13 patients (8.5%) in the normal volume group versus 6 patients (5.2%) in the high volume group. Conclusion Learning curves were shorter and learning associated morbidity was lower in centers with higher case volume. This is the first study demonstrating this effect from clinical data. Patient safety can be significantly compromised during surgical learning curves and probably, patient safety can be increased if surgeons learn technically challenging procedures in higher volume centers. Our data can guide the design of implementation programs for technically challenging procedures. This abstract was submitted on behalf of the esophagectomy learning curve collaborative group. Disclosure All authors have declared no conflicts of interest.

scholarly journals Severe intraoperative bleeding predicts the risk of perioperative blood transfusion after robot-assisted radical prostatectomy

2021 ◽  
Author(s):  
Antonio Benito Porcaro ◽  
Riccardo Rizzetto ◽  
Nelia Amigoni ◽  
Alessandro Tafuri ◽  
Aliasger Shakir ◽  
...  
Keyword(s):  
Radical Prostatectomy ◽  
Blood Transfusion ◽  
Blood Loss ◽  
Univariate Analysis ◽  
Operating Time ◽  
Primary Treatment ◽  
Intraoperative Blood Loss ◽  
Robot Assisted ◽  
Intraoperative Bleeding ◽  
Perioperative Blood Transfusion

AbstractTo evaluate potential factors associated with the risk of perioperative blood transfusion (PBT) with implications on length of hospital stay (LOHS) and major post-operative complications in patients who underwent robot-assisted radical prostatectomy (RARP) as a primary treatment for prostate cancer (PCa). In a period ranging from January 2013 to August 2019, 980 consecutive patients who underwent RARP were retrospectively evaluated. Clinical factors such as intraoperative blood loss were evaluated. The association of factors with the risk of PBT was investigated by statistical methods. Overall, PBT was necessary in 39 patients (4%) in whom four were intraoperatively. Positive surgical margins, operating time and intraoperative blood loss were associated with perioperative blood transfusion on univariate analysis. On multivariate analysis, the risk of PBT was predicted by intraoperative blood loss (odds ratio, OR 1.002; 95% CI 1.001–1.002; p < 0.0001), which was associated with prolonged operating time and elevated body mass index (BMI). PBT was associated with delayed LOHS and Clavien–Dindo complications > 2. In patients undergoing RARP as a primary treatment for PCa, the risk of PBT represented a rare event that was predicted by severe intraoperative bleeding, which was associated with increased BMI as well as with prolonged operating time. In patients who received a PBT, prolonged LOHS as well as an elevated risk of major Clavien–Dindo complications were seen.

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.

Applicability and Feasibility of Incorporating Minimally Invasive Esophagectomy at a High Volume Center

2010 ◽  
Vol 14 (8) ◽  
pp. 1201-1206 ◽  
Author(s):  
Brittany L. Willer ◽  
Sumeet K. Mittal ◽  
Stephanie G. Worrell ◽  
Seemal Mumtaz ◽  
Tommy H. Lee
Keyword(s):  
Minimally Invasive ◽  
Minimally Invasive Esophagectomy ◽  
High Volume ◽  
Invasive Esophagectomy ◽  
High Volume Center

784 TRANSHIATAL HERNIA: AN UNDERDIAGNOSED BUT OVER-TREATED COMPLICATION AFTER MINIMALLY INVASIVE ESOPHAGECTOMY

2021 ◽  
Vol 34 (Supplement_1) ◽  
Author(s):  
Toon Kuypers ◽  
Sanne Stuart ◽  
Ingrid Martijnse ◽  
Joos Heisterkamp ◽  
Robert Matthijsen
Keyword(s):  
Postoperative Complications ◽  
Minimally Invasive ◽  
Minimally Invasive Esophagectomy ◽  
High Volume ◽  
Invasive Esophagectomy ◽  
Absorbable Sutures ◽  
Asymptomatic Patients ◽  
Surgical Data ◽  
Life Threatening ◽  
High Volume Center

Abstract   Postoperative transhiatal hernia is a possible life-threatening complication following esophagectomy. The incidence and indications to treat remain open to debate with apparently an increase after minimally invasive esophagectomy (MIE). The aim of this study is to analyze a large series of patients after MIE in a single high-volume center with a transhiatal herniation after minimally invasive esophagectomy (THAMIE) and obtain new insights in this pathology. Methods We included all patients who underwent a MIE (Ivor Lewis and McKeown procedure) in our hospital between 2015 and 2020. Retrospective analysis of demographic, clinical and surgical data was performed. Outcomes of measure were incidence, initial clinical presentation, treatment of choice, postoperative complications and symptoms, herniation recurrence. Results In 341 MIE 25 (7.3%) patients were diagnosed with a THAMIE postoperatively. 4 patients (16.0%) were asymptomatic at the time of presentation. 5 patients (20%) were treated conservatively because of recurrent carcinoma. 20 patients received a laparoscopic reduction of the transhiatal hernia and cruraplasty (19 non-absorbable sutures, 1 mesh) regardless whether they were symptomatic or not. 25.0%(5/20) of the patients were operated in emergency settings and 5.0% (1/20) was converted to a laparotomy. Postoperatively 6 of the 18 symptomatic patients (33.3%) experienced no relief of symptoms and 40.0% (8/20) of the THAMIE recurred. 35% had serious postoperative complications (clavien-dindo IIIa or more) and mortality was 0.0%. Conclusion The incidence of 7.33% found in our data suggests that THAMIE is a common complication after MIE. We almost exclusively (95.0%) treated patients in a laparoscopic way. Due to the high percentage of morbidity (35.0% ≥ CD IIIa), recurrence (40.0%) and patients with unrelieved symptoms(33.3%) we recommend a conservative treatment for the asymptomatic patients, and further analysis of predictive symptoms associated with a THAMIE to evolve to a shared decision making algorithm for elective symptomatic patients.

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.

A Case-Control Study on the Therapeutic Effect of Mediastinoscope-Assisted and Thoracoscope-Assisted Esophagectomy

2020 ◽  
pp. 155335062095826
Author(s):  
Li Guo ◽  
Qian Zhao ◽  
Kairui Wang ◽  
Duowen Zhao ◽  
Xiaofeng Ye ◽  
...  
Keyword(s):  
Lymph Node ◽  
Blood Loss ◽  
Minimally Invasive Esophagectomy ◽  
Survival Rates ◽  
Operation Time ◽  
Transhiatal Esophagectomy ◽  
Intraoperative Blood Loss ◽  
Invasive Esophagectomy ◽  
Minimal Trauma ◽  
Medical University

Objective. To compare the clinical efficacies of mediastinoscope-assisted and thoracoscope-assisted esophagectomy. Materials and Methods. Seventy-six patients with esophageal cancer who underwent minimally invasive esophagectomy at the General Hospital of Ningxia Medical University between June 2015 and January 2019 were retrospectively evaluated. Among them, 28 patients underwent mediastinoscope-assisted transhiatal esophagectomy (MATHE), and 48 received thoracoscope-assisted transthoracic esophagectomy (TATTE). The perioperative clinical data and follow-up data of the 2 groups were compared. Results. All operations were successful in both groups. MATHE was favorable in terms of operation time, intraoperative blood loss, drainage volume 3 days after surgery, postoperative hospital stay, and hypoproteinemia ( P < .05). Lymph node dissections were less than those in the TATTE ( P < .05). No significant differences in long-term postoperative complications and survival rate were found between the 2 groups ( P > .05). Conclusion. MATHE has the advantages of minimal trauma, shorter operation time, less intraoperative blood loss, and faster recovery. More adequate tumor clearance in terms of lymph node dissection can be achieved with TATTE. However, the comparison of survival rates between the 2 groups is similar.

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