Learning curves in minimally invasive esophagectomy

Abstract

Surgical innovation and pioneering are important for improving patient outcome, but can be associated with learning curves. Although learning curves in surgery are a recognized problem, the impact of surgical learning curves is increasing, due to increasing complexity of innovative surgical procedures, the rapid rate at which new interventions are implemented and a decrease in relative effectiveness of new interventions compared to old interventions. For minimally invasive esophagectomy (MIE), there is now robust evidence that implementation can lead to significant learning associated morbidity (morbidity during a learning curve, that could have been avoided if patients were operated by surgeons that have completed the learning curve). This article provides an overview of the evidence of the impact of learning curves after implementation of MIE. In addition, caveats for implementation and available evidence regarding factors that are important for safe implementation and safe pioneering of MIE are discussed.

Keywords: Learning curve; Minimally invasive esophagectomy; Pioneering; Proficiency gain curve; Safe implementation.

Figure 1

Scenarios in which the differences in the impact that learning curves can have on the effectiveness of an innovative intervention is described. A: Learning curves can be neglected in case of a short learning curve and large difference in relative effectiveness between the regular technique and the innovative technique. B: If the learning curve of an innovative technique is substantial and the difference in relative effectiveness is small, learning curves can have a large impact on when an innovative technique becomes effective.