Learning Curve Of The Application Of Huang’s Three-step Maneuver In A Laparoscopic Spleen-preserving Splenic Hilar Lymphadenectomy For Advanced Gastric Cancer

Objective To investigate the learning curve of the application of Huang’s three-step maneuver, which was summarized and proposed by our center for the treatment of advanced upper gastric cancer.Methods From April 2012 to March 2013, 130 consecutive patients who underwent a laparoscopic spleen-preserving splenic hilar lymphadenectomy(LSPL) by a single surgeon who performed Huang’s three-step maneuver were retrospectively analyzed.The step was divided into three parts.The first step involved the dissection of LNs in the inferior pole region of the spleen, the second step involved the dissection of the lymph nodes in the region of the Sp A trunk, and the third step involved the dissection of LNs in the superior pole region of the spleen.The learning curve was analyzed based on the moving average(MA) method and the cumulative sum method(CUSUM). Surgical outcomes, short-term outcomes and follow-up results before and after learning curve were contrastively analyzed. A stepwise multivariate logistic regression was used for a multivariable analysis to determine the factors that affect the operative time using Huang’s three-step maneuver.Results Based on the CUSUM, the learning curve for Huang’s three-step maneuver was divided into phase 1(cases 1-40) and phase 2(cases 41-130). The dissection time(DT)(P< 0.001), blood loss(BL)(P< 0.001) and number of vessels injured in phase2 were significantly less than those in phase 1. There were no significant differences in the clinicopathological characteristics, short-term outcomes or major postoperative complications between the learning curve phases. Univariate and multivariate analyses revealed that body mass index(BMI), short gastric vessels(SGVs), splenic hilar artery(Sp A) type and learning curve phase were significantly associated with DT. In the entire group, 124 patients were followed for a median time of 23.0 months(range, 3 to 30months). There was no significant difference in the survival curve between phases.Conclusion Beginner spent the learning curve after 40 cases LSPL.AUGC patients with a BMI less than 25 kg/m2, a small number of SGVs and a concentrated type of Sp A are ideal candidates for surgeons who are in phase 1 of the learning curve.