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. 2023 Sep 1;158(9):927-933.
doi: 10.1001/jamasurg.2023.2279.

Learning Curves of Minimally Invasive Distal Pancreatectomy in Experienced Pancreatic Centers

Sanne Lof  1   2   3 , Linda Claassen  4 , Gerjon Hannink  5 , Bilal Al-Sarireh  6 , Bergthor Björnsson  7 , Ugo Boggi  8 , Fernando Burdio  9 , Giovanni Butturini  10 , Giovanni Capretti  11 , Riccardo Casadei  12 , Safi Dokmak  13 , Bjørn Edwin  14 , Alessandro Esposito  15 , Jean M Fabre  16 , Giovanni Ferrari  17 , Asmund A Fretland  14 , Fadhel S Ftériche  13 , Giuseppe K Fusai  18 , Alessandro Giardino  10 , Bas Groot Koerkamp  19 , Mathieu D'Hondt  20 , Asif Jah  21 , Sivesh K Kamarajah  22 , Emanuele F Kauffmann  8 , Tobias Keck  23 , Stijn van Laarhoven  21 , Alberto Manzoni  3 , Marco V Marino  24 , Ravi Marudanayagam  25 , Izaak Q Molenaar  26 , Patrick Pessaux  27 , Edoardo Rosso  28 , Roberto Salvia  15 , Zahir Soonawalla  29 , Regis Souche  16 , Steven White  22 , Frans van Workum  30 , Alessandro Zerbi  11 , Camiel Rosman  4 , Martijn W J Stommel  4 , Mohammed Abu Hilal  3   31 , Marc G Besselink  1   2 ; European Consortium on Minimally Invasive Pancreatic Surgery (E-MIPS)
Collaborators, Affiliations

Learning Curves of Minimally Invasive Distal Pancreatectomy in Experienced Pancreatic Centers

Sanne Lof et al. JAMA Surg. .

Abstract

Importance: Understanding the learning curve of a new complex surgical technique helps to reduce potential patient harm. Current series on the learning curve of minimally invasive distal pancreatectomy (MIDP) are mostly small, single-center series, thus providing limited data.

Objective: To evaluate the length of pooled learning curves of MIDP in experienced centers.

Design, setting, and participants: This international, multicenter, retrospective cohort study included MIDP procedures performed from January 1, 2006, through June 30, 2019, in 26 European centers from 8 countries that each performed more than 15 distal pancreatectomies annually, with an overall experience exceeding 50 MIDP procedures. Consecutive patients who underwent elective laparoscopic or robotic distal pancreatectomy for all indications were included. Data were analyzed between September 1, 2021, and May 1, 2022.

Exposures: The learning curve for MIDP was estimated by pooling data from all centers.

Main outcomes and measures: The learning curve was assessed for the primary textbook outcome (TBO), which is a composite measure that reflects optimal outcome, and for surgical mastery. Generalized additive models and a 2-piece linear model with a break point were used to estimate the learning curve length of MIDP. Case mix-expected probabilities were plotted and compared with observed outcomes to assess the association of changing case mix with outcomes. The learning curve also was assessed for the secondary outcomes of operation time, intraoperative blood loss, conversion to open rate, and postoperative pancreatic fistula grade B/C.

Results: From a total of 2610 MIDP procedures, the learning curve analysis was conducted on 2041 procedures (mean [SD] patient age, 58 [15.3] years; among 2040 with reported sex, 1249 were female [61.2%] and 791 male [38.8%]). The 2-piece model showed an increase and eventually a break point for TBO at 85 procedures (95% CI, 13-157 procedures), with a plateau TBO rate at 70%. The learning-associated loss of TBO rate was estimated at 3.3%. For conversion, a break point was estimated at 40 procedures (95% CI, 11-68 procedures); for operation time, at 56 procedures (95% CI, 35-77 procedures); and for intraoperative blood loss, at 71 procedures (95% CI, 28-114 procedures). For postoperative pancreatic fistula, no break point could be estimated.

Conclusion and relevance: In experienced international centers, the learning curve length of MIDP for TBO was considerable with 85 procedures. These findings suggest that although learning curves for conversion, operation time, and intraoperative blood loss are completed earlier, extensive experience may be needed to master the learning curve of MIDP.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Fretland reported receiving speaker fees from Olympus and Bayer and institutional support from Siemens outside the submitted work. Dr van Workum reported receiving an investigator-initiated study grant from Johnson & Johnson for a video assessment tool for minimally invasive esophagectomy during the conduct of the study. Prof Besselink reported receiving investigator-initiated study grants from Intuitive Surgical, Ethicon, and Medtronic outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Learning Curve of Minimally Invasive Distal Pancreatectomy for Textbook Outcome
The solid blue line represents the generalized additive model (pooled incidence) with a 95% CI (shaded area). The dotted orange line represents the predicted outcomes based on case mix (shaded area indicates 95% CI). The light blue dashed line is the 2-piece model. The first phase is the linear ascending section, the second phase is the plateau phase, which starts after the break point. The break point represents the length of the learning curve.
Figure 2.
Figure 2.. Learning Curve of Minimally Invasive Distal Pancreatectomy for Postoperative Pancreatic Fistula Grade B/C
The solid blue line represents the generalized additive model (pooled incidence) with a 95% CI (shaded area). The dotted orange line represents the predicted outcomes based on case mix (shaded area indicates 95% CI). The light blue dashed line is the 2-piece model. The first phase is the linear descending section; there is no second phase since a plateau was not reached within 100 procedures.
Figure 3.
Figure 3.. Learning Curve of Minimally Invasive Distal Pancreatectomy for Operation Time
The solid blue line represents the generalized additive model (pooled incidence) with a 95% CI (shaded area). The dotted orange line represents the predicted outcomes based on case mix (shaded area indicates 95% CI). The light blue dashed line is the 2-piece model. The first phase is the linear descending section, and the second phase is the plateau phase, which starts after the break point. The break point represents the length of the learning curve.
Figure 4.
Figure 4.. Learning Curve of Minimally Invasive Distal Pancreatectomy for Intraoperative Blood Loss
The solid blue line represents the generalized additive model (pooled incidence) with a 95% CI (shaded area). The dotted orange line represents the predicted outcomes based on case mix (shaded area indicates 95% CI). The light blue dashed line is the 2-piece model. The first phase is the linear descending section. The second phase is the plateau phase, which starts after the break point. The break point represents the length of the learning curve.
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References

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