Learning Curve Of Laparoscopic Pancreaticoduodenectomy Based On The Initial 112 Patients

Objective To analyze the learning curve of laparoscopic pancreaticoduodenectomy(LPD)and explore its inherent rule,so as to provide reference for clinical doctors to perform it step by step.Methods The clinical data of 112 cases of total laparoscopic pancreaticoduodenectomy(TLPD)performed by a single surgeon in the same surgical team in the third affiliated hospital of Soochow University from December 2015 to February 2018 were reviewed and analyzed retrospectively.The learning curve was divided into three phases by using the method of accumulative sum(CUSUM)analysis and the method of risk-adjusted accumulative sum(RA-CUSUM)analysis to explore and analyze the changes of relevant perioperative data and pathological features,and further analyze the independent risk factors of "surgical failure".Results The learning curve of LPD can be divided into three phases:the first phase is the learning phase,including case 1 to case 45;the second phase is the ability enhancement phase,including case 46 to 76;the third phase is the maturity phase,including case 77 to 112.There was no statistical difference in the preoperative data of these three phases.The operation time,intraoperative blood loss,and time to start fluid were all decreased phase by phase through the learning curve,the proportion of pancreatic cancer and the number of lymph nodes harvested were increased through the learning curve,with statistical differences.There was no statistical difference in postoperative hospital stay,incidence of complications,proportion of clavien-dindo grade?3,30-day readmission,90-day mortality and the total cost of hospitalization in the three phases.Logistic regression analysis showed that age and intraoperative blood transfusion were independent risk factors for "surgical failure".However,there was no statistical difference in the incidence of "operation failure" among the elderly patients at the three stages,and the differences among the three phases were same whether in elderly patients or in all patients.Laparoscopic revascularization started in the 48th case,and has been followed by a more mature phase.Conclusion It is safe and feasible to skip hybrid LPD to develop TLPD directly on the premise of rich OPD experience and skilled endoscopy suture technology.In this study,46 cases of surgery are needed to pass the learning period of LPD,and you can go into maturity phase after 76 LPDs.Endoscopic revascularization is not a sign of absolute surgical maturity of LPD,on the contrary,it may have entered a plateau phase,at which the surgeon should not be blindly confident in the choice of the patient.It is safe to properly carry out LPD for elderly patients during the initial learning curve,but the elderly patients should be paid more attention in any phase of the learning curve.LPD in the initial learning curve will not bring additional financial burden to the patients.