Skip to main content

Advertisement

SpringerLink
Log in

The slope of the learning curve in 600 consecutive endoscopic transsphenoidal pituitary surgeries

  • Original Article - Pituitaries
  • Published:
Acta Neurochirurgica Aims and scope Submit manuscript

Abstract

Background

Endonasal endoscopic transsphenoidal surgery (EETS) for pituitary adenoma has become a mainstay of treatment over the last two decades and it is generally accepted that once this learning curve is achieved, a plateau is reached with little incremental improvement.

Objective

The objective of this study was to assess the slope of the learning curve over a long period of time for a variety of outcomes measures.

Methods

We examined outcomes and complications in a consecutive series of 600 EETS for pituitary adenoma grouped into quartiles based on date of surgery.

Results

GTR significantly increased across quartiles from 55 to 79% in the last quartile (p < 0.005). The rate of intraoperative CSF leak significantly decreased from 60% in the first quartile to 33% in the last quartile and the rate of lumbar drain placement from 28% in the first quartile to 6% in the last quartile (p < 0.005). Hormonal remission for secreting adenomas increased from 68% in the first quartile to 90% in the last quartile (p < 0.05). The rate of post-operative CSF leak trended lower (3% in first quartile to 0.7% in last two quartiles). The greatest improvement in outcome occurred between the first and second quartiles (19.9%), but persistent improvement occurred between the second and third (6.7%) and third and fourth quartiles (8.0%).

Conclusion

Although the slope of the learning curve is steeper earlier in a surgeon’s experience, the slope does not plateau and continues to increase even over more than a decade.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. Alhilali LM, Little AS, Yuen KCJ, Lee J, Ho TK, Fakhran S, White WL (2020) Early postoperative MRI and detection of residual adenoma after transsphenoidal pituitary surgery. J Neurosurg:1–10. https://doi.org/10.3171/2019.11.JNS191845

  2. Bokhari MB, Patel CB, Ramos-Valadez DI, Ragupathi M, Haas EM (2011) Learning curve for robotic-assisted laparoscopic colorectal surgery. Surg Endosc 25:855–860. https://doi.org/10.1007/s00464-010-1281-x

    Article  PubMed  Google Scholar 

  3. Bokhari AR, Davies MA, Diamond T (2013) Endoscopic transsphenoidal pituitary surgery: a single surgeon experience and the learning curve. Br J Neurosurg 27:44–49. https://doi.org/10.3109/02688697.2012.709554

    Article  PubMed  Google Scholar 

  4. Casanueva FF, Barkan AL, Buchfelder M, Klibanski A, Laws ER, Loeffler JS, Melmed S, Mortini P, Wass J, Giustina A, Pituitary Society EGoPT (2017) Criteria for the definition of Pituitary Tumor Centers of Excellence (PTCOE): a pituitary society statement. Pituitary 20:489–498. https://doi.org/10.1007/s11102-017-0838-2

    Article  PubMed  PubMed Central  Google Scholar 

  5. Cavallo LM, Somma T, Solari D, Iannuzzo G, Frio F, Baiano C, Cappabianca P (2019) Endoscopic endonasal transsphenoidal surgery: history and evolution. World Neurosurg 127:686–694. https://doi.org/10.1016/j.wneu.2019.03.048

    Article  PubMed  Google Scholar 

  6. Ciric I, Ragin A, Baumgartner C, Pierce D (1997) Complications of transsphenoidal surgery: results of a national survey, review of the literature, and personal experience. Neurosurgery 40:225–236; discussion 236-227. https://doi.org/10.1097/00006123-199702000-00001

    Article  CAS  PubMed  Google Scholar 

  7. Foo CC, Law WL (2016) The learning curve of robotic-assisted low rectal resection of a novice rectal surgeon. World J Surg 40:456–462. https://doi.org/10.1007/s00268-015-3251-x

    Article  PubMed  Google Scholar 

  8. Forbes N, Mohamed R, Raman M (2016) Learning curve for endoscopy training: is it all about numbers? Best Pract Res Clin Gastroenterol 30:349–356. https://doi.org/10.1016/j.bpg.2016.04.003

    Article  PubMed  Google Scholar 

  9. Hopper AN, Jamison MH, Lewis WG (2007) Learning curves in surgical practice. Postgrad Med J 83:777–779. https://doi.org/10.1136/pgmj.2007.057190

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  10. Jakimovski D, Bonci G, Attia M, Shao H, Hofstetter C, Tsiouris AJ, Anand VK, Schwartz TH (2014) Incidence and significance of intraoperative cerebrospinal fluid leak in endoscopic pituitary surgery using intrathecal fluorescein. World Neurosurg 82:e513–e523. https://doi.org/10.1016/j.wneu.2013.06.005

    Article  PubMed  Google Scholar 

  11. Jane JA Jr, Laws ER Jr (2001) The surgical management of pituitary adenomas in a series of 3,093 patients. J Am Coll Surg 193:651–659. https://doi.org/10.1016/s1072-7515(01)01101-2

    Article  PubMed  Google Scholar 

  12. Jimenez-Rodriguez RM, Diaz-Pavon JM, de la Portilla de Juan F, Prendes-Sillero E, Dussort HC, Padillo J (2013) Learning curve for robotic-assisted laparoscopic rectal cancer surgery. Int J Color Dis 28:815–821. https://doi.org/10.1007/s00384-012-1620-6

    Article  Google Scholar 

  13. Kanter AS, Dumont AS, Asthagiri AR, Oskouian RJ, Jane JA Jr, Laws ER Jr (2005) The transsphenoidal approach. A historical perspective. Neurosurg Focus 18:e6. https://doi.org/10.3171/foc.2005.18.4.7

    Article  PubMed  Google Scholar 

  14. Kassam AB, Prevedello DM, Carrau RL, Snyderman CH, Thomas A, Gardner P, Zanation A, Duz B, Stefko ST, Byers K, Horowitz MB (2011) Endoscopic endonasal skull base surgery: analysis of complications in the authors’ initial 800 patients. J Neurosurg 114:1544–1568. https://doi.org/10.3171/2010.10.JNS09406

    Article  PubMed  Google Scholar 

  15. Khan N, Abboudi H, Khan MS, Dasgupta P, Ahmed K (2014) Measuring the surgical ‘learning curve’: methods, variables and competency. BJU Int 113:504–508. https://doi.org/10.1111/bju.12197

    Article  PubMed  Google Scholar 

  16. Koc K, Anik I, Ozdamar D, Cabuk B, Keskin G, Ceylan S (2006) The learning curve in endoscopic pituitary surgery and our experience. Neurosurg Rev 29:298–305; discussion 305. https://doi.org/10.1007/s10143-006-0033-9

    Article  PubMed  Google Scholar 

  17. Kubat E, Hansen N, Nguyen H, Wren SM, Eisenberg D (2016) Urgent and elective robotic single-site cholecystectomy: analysis and learning curve of 150 consecutive cases. J Laparoendosc Adv Surg Tech A 26:185–191. https://doi.org/10.1089/lap.2015.0528

    Article  PubMed  Google Scholar 

  18. Leach P, Abou-Zeid AH, Kearney T, Davis J, Trainer PJ, Gnanalingham KK (2010) Endoscopic transsphenoidal pituitary surgery: evidence of an operative learning curve. Neurosurgery 67:1205–1212. https://doi.org/10.1227/NEU.0b013e3181ef25c5

    Article  PubMed  Google Scholar 

  19. Liu JK, Cohen-Gadol AA, Laws ER Jr, Cole CD, Kan P, Couldwell WT (2005) Harvey Cushing and Oskar Hirsch: early forefathers of modern transsphenoidal surgery. J Neurosurg 103:1096–1104. https://doi.org/10.3171/jns.2005.103.6.1096

    Article  PubMed  Google Scholar 

  20. Lofrese G, Vigo V, Rigante M, Grieco DL, Maresca M, Anile C, Mangiola A, De Bonis P (2018) Learning curve of endoscopic pituitary surgery: experience of a neurosurgery/ENT collaboration. J Clin Neurosci 47:299–303. https://doi.org/10.1016/j.jocn.2017.09.011

    Article  PubMed  Google Scholar 

  21. Oldfield EH, Vortmeyer AO (2006) Development of a histological pseudocapsule and its use as a surgical capsule in the excision of pituitary tumors. J Neurosurg 104:7–19. https://doi.org/10.3171/jns.2006.104.1.7

    Article  PubMed  Google Scholar 

  22. O'Malley BW Jr, Grady MS, Gabel BC, Cohen MA, Heuer GG, Pisapia J, Bohman LE, Leibowitz JM (2008) Comparison of endoscopic and microscopic removal of pituitary adenomas: single-surgeon experience and the learning curve. Neurosurg Focus 25:E10. https://doi.org/10.3171/FOC.2008.25.12.E10

    Article  PubMed  Google Scholar 

  23. Oomen M, Bakx R, Peeters B, Boersma D, Wijnen M, Heij H (2013) Laparoscopic pyloromyotomy, the tail of the learning curve. Surg Endosc 27:3705–3709. https://doi.org/10.1007/s00464-013-2951-2

    Article  PubMed  Google Scholar 

  24. Patel KS, Kazam J, Tsiouris AJ, Anand VK, Schwartz TH (2014) Utility of early postoperative high-resolution volumetric magnetic resonance imaging after transsphenoidal pituitary tumor surgery. World Neurosurg 82:777–780. https://doi.org/10.1016/j.wneu.2014.07.014

    Article  PubMed  PubMed Central  Google Scholar 

  25. Pernar LIM, Robertson FC, Tavakkoli A, Sheu EG, Brooks DC, Smink DS (2017) An appraisal of the learning curve in robotic general surgery. Surg Endosc 31:4583–4596. https://doi.org/10.1007/s00464-017-5520-2

    Article  PubMed  Google Scholar 

  26. Prevedello DM, Doglietto F, Jane JA Jr, Jagannathan J, Han J, Laws ER Jr (2007) History of endoscopic skull base surgery: its evolution and current reality. J Neurosurg 107:206–213. https://doi.org/10.3171/JNS-07/07/0206

    Article  PubMed  Google Scholar 

  27. Qureshi T, Chaus F, Fogg L, Dasgupta M, Straus D, Byrne RW (2016) Learning curve for the transsphenoidal endoscopic endonasal approach to pituitary tumors. Br J Neurosurg 30:637–642. https://doi.org/10.1080/02688697.2016.1199786

    Article  PubMed  Google Scholar 

  28. Schwartz TH, Morgenstern PF, Anand VK (2019) Lessons learned in the evolution of endoscopic skull base surgery. J Neurosurg 130:337–346. https://doi.org/10.3171/2018.10.JNS182154

    Article  PubMed  Google Scholar 

  29. Shakir M, Boone BA, Polanco PM, Zenati MS, Hogg ME, Tsung A, Choudry HA, Moser AJ, Bartlett DL, Zeh HJ, Zureikat AH (2015) The learning curve for robotic distal pancreatectomy: an analysis of outcomes of the first 100 consecutive cases at a high-volume pancreatic centre. HPB (Oxford) 17:580–586. https://doi.org/10.1111/hpb.12412

    Article  Google Scholar 

  30. Sng KK, Hara M, Shin JW, Yoo BE, Yang KS, Kim SH (2013) The multiphasic learning curve for robot-assisted rectal surgery. Surg Endosc 27:3297–3307. https://doi.org/10.1007/s00464-013-2909-4

    Article  PubMed  Google Scholar 

  31. Sonnenburg RE, White D, Ewend MG, Senior B (2004) The learning curve in minimally invasive pituitary surgery. Am J Rhinol 18:259–263

    Article  Google Scholar 

  32. Subramonian K, Muir G (2004) The ‘learning curve’ in surgery: what is it, how do we measure it and can we influence it? BJU Int 93:1173–1174. https://doi.org/10.1111/j.1464-410X.2004.04891.x

    Article  CAS  Google Scholar 

  33. Voitk AJ, Tsao SG, Ignatius S (2001) The tail of the learning curve for laparoscopic cholecystectomy. Am J Surg 182:250–253. https://doi.org/10.1016/s0002-9610(01)00699-7

    Article  CAS  PubMed  Google Scholar 

  34. Wright T (1936) Factors affecting the cost of airplanes. J Aeronaut Sci 3:136

    Article  Google Scholar 

  35. Yamaguchi T, Kinugasa Y, Shiomi A, Sato S, Yamakawa Y, Kagawa H, Tomioka H, Mori K (2015) Learning curve for robotic-assisted surgery for rectal cancer: use of the cumulative sum method. Surg Endosc 29:1679–1685. https://doi.org/10.1007/s00464-014-3855-5

    Article  PubMed  Google Scholar 

  36. Younus IGM, Uribe-Cardenas R, Morgenstern P, Kacker A, Tabaee A, Anand VK, Schwartz TH (2020) How long is the tail end of the learning curve? Results from 1000 consecutive endonasal endoscopic skull base cases following the initial 200 cases? J Neurosurg:1–11. https://doi.org/10.3171/2019.12.JNS192600

Download references

Author information

Authors and Affiliations

  1. Department of Neurosurgery, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY, USA

    Iyan Younus, Mina M. Gerges, Rafael Uribe-Cardenas, Peter Morgenstern & Theodore H. Schwartz

  2. Department of Otolaryngology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY, USA

    Ashutosh Kacker, Abtin Tabaee, Vijay K. Anand & Theodore H. Schwartz

  3. Department of Neuroscience, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY, USA

    Theodore H. Schwartz

  4. Departments of Neurosurgery, Otolaryngology and Neuroscience, Weill Cornell Medicine, New York-Presbyterian Hospital, 525 East 68th St. Box #99, New York, NY, USA

    Theodore H. Schwartz

Authors
  1. Iyan Younus
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Mina M. Gerges
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Rafael Uribe-Cardenas
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Peter Morgenstern
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Ashutosh Kacker
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Abtin Tabaee
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Vijay K. Anand
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Theodore H. Schwartz
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Theodore H. Schwartz.

Ethics declarations

For this type of study formal consent is not required.

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee (name of institute/committee) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical Collection on Pituitaries

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Younus, I., Gerges, M.M., Uribe-Cardenas, R. et al. The slope of the learning curve in 600 consecutive endoscopic transsphenoidal pituitary surgeries. Acta Neurochir 162, 2361–2370 (2020). https://doi.org/10.1007/s00701-020-04471-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00701-020-04471-x

Keywords

Search

Navigation