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Total laparoscopic pancreaticoduodenectomy in patients with periampullary tumors: a learning curve analysis

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Abstract

Background

With continued technical advances in surgical instruments and growing expertise, many surgeons have safely performed laparoscopic pylorus-preserving pancreaticoduodenectomies (LPDs) with good results, and the laparoscopic approach is being performed more frequently. However, this complex procedure requires a relatively long training period to ensure technical competence. The present study aimed to analyze the learning curve for LPD.

Methods

From September 2012 to May 2019, LPDs were performed for 171 patients at the Yonsei University Severance Hospital by a single surgeon. We retrospectively analyzed the demographic and surgical outcomes. The learning curve for LPD was evaluated using both the cumulative sum (CUSUM) and risk-adjusted CUSUM (RA-CUSUM) methods. All variables among the learning curve phases were compared.

Results

Based on the CUSUM and the RA-CUSUM analyses, the learning curve for LPD was grouped into three phases: phase I was the initial learning period (cases 1–40), phase II represented the technical competence period (cases 41–100), and phase III was regarded as the challenging period (cases 101–171).

Conclusions

According to the learning curve analysis, 40 cases are required to achieve technical competence in LPD and 100 cases are required to address highly challenging cases.

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References

  1. Whipple AO (1945) Pancreaticoduodenectomy for islet carcinoma: a five-year follow-up. Ann Surg 121(6):847–852

    Article  CAS  Google Scholar 

  2. Greenblatt DY, Kelly KJ, Rajamanickam V, Wan Y, Hanson T, Rettammel R, Winslow ER, Cho CS, Weber SM (2011) Preoperative factors predict perioperative morbidity and mortality after pancreaticoduodenectomy. Ann Surg Oncol 18(8):2126–2135

    Article  Google Scholar 

  3. Kendrick ML, van Hilst J, Boggi U, de Rooij T, Walsh RM, Zeh HJ, Hughes SJ, Nakamura Y, Vollmer CM, Kooby DA, Asbun HJ (2017) Minimally invasive pancreatoduodenectomy. HPB (Oxford) 19(3):215–224

    Article  Google Scholar 

  4. Gagner M, Pomp A (1994) Laparoscopic pylorus-preserving pancreatoduodenectomy. Surg Endosc 8(5):408–410

    Article  CAS  Google Scholar 

  5. Gagner M, Pomp A (1997) Laparoscopic pancreatic resection: is it worthwhile? J Gastrointest Surg 1(1):20–25 discussion 25-26

    Article  CAS  Google Scholar 

  6. Tran TB, Dua MM, Worhunsky DJ, Poultsides GA, Norton JA, Visser BC (2016) The first decade of laparoscopic pancreaticoduodenectomy in the United States: costs and outcomes using the nationwide inpatient sample. Surg Endosc 30(5):1778–1783

    Article  Google Scholar 

  7. Kang CM, Lee SH, Chung MJ, Hwang HK, Lee WJ (2015) Laparoscopic pancreatic reconstruction technique following laparoscopic pancreaticoduodenectomy. J Hepatobiliary Pancreat Sci 22(3):202–210

    Article  Google Scholar 

  8. Hogg ME, Besselink MG, Clavien PA, Fingerhut A, Jeyarajah DR, Kooby DA, Moser AJ, Pitt HA, Varban OA, Vollmer CM, Zeh HJ 3rd, Hansen P (2017) Training in minimally invasive pancreatic resections: a paradigm shift away from "see one, do one, teach one". HPB (Oxford) 19(3):234–245

    Article  Google Scholar 

  9. de Rooij T, van Hilst J, Topal B, Bosscha K, Brinkman DJ, Gerhards MF, de Hingh IH, Karsten TM, Lips DJ, Luyer MD, Marsman HA, van Rijssen LB, Steen MW, Busch OR, Festen S, Besselink MG (2019) Outcomes of a multicenter training program in laparoscopic pancreatoduodenectomy (LAELAPS-2). Ann Surg 269(2):344–350

    Article  Google Scholar 

  10. Navarro JG, Kang CM (2019) Pitfalls for laparoscopic pancreaticoduodenectomy: need for a stepwise approach. Ann Gastroenterol Surg 3(3):254–268

    Article  Google Scholar 

  11. Bassi C, Marchegiani G, Dervenis C, Sarr M, Abu Hilal M, Adham M, Allen P, Andersson R, Asbun HJ, Besselink MG, Conlon K, Del Chiaro M, Falconi M, Fernandez-Cruz L, Fernandez-Del Castillo C, Fingerhut A, Friess H, Gouma DJ, Hackert T, Izbicki J, Lillemoe KD, Neoptolemos JP, Olah A, Schulick R, Shrikhande SV, Takada T, Takaori K, Traverso W, Vollmer CR, Wolfgang CL, Yeo CJ, Salvia R, Buchler M, International Study Group on Pancreatic S (2017) The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 Years After. Surgery 161(3):584–591

    Article  Google Scholar 

  12. Wente MN, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, Izbicki JR, Neoptolemos JP, Padbury RT, Sarr MG, Traverso LW, Yeo CJ, Buchler MW (2007) Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS). Surgery 142(5):761–768

    Article  Google Scholar 

  13. Wente MN, Veit JA, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, Izbicki JR, Neoptolemos JP, Padbury RT, Sarr MG, Yeo CJ, Buchler MW (2007) Postpancreatectomy hemorrhage (PPH): an International Study Group of Pancreatic Surgery (ISGPS) definition. Surgery 142(1):20–25

    Article  Google Scholar 

  14. Han SH, Kang CM, Hwang HK, Yoon DS, Lee WJ (2019) The Yonsei experience of 104 laparoscopic pancreaticoduodenectomies: a propensity score-matched analysis with open pancreaticoduodenectomy. Surg Endosc 34:1658

    Article  Google Scholar 

  15. Biau DJ, Porcher R (2010) A method for monitoring a process from an out of control to an in control state: Application to the learning curve. Stat Med 29(18):1900–1909

    Article  Google Scholar 

  16. Kuroki T, Kitasato A, Adachi T, Tanaka T, Hirabaru M, Matsushima H, Soyama A, Hidaka M, Takatsuki M, Eguchi S (2014) Learning curve for laparoscopic pancreaticoduodenectomy: a single surgeon's experience with consecutive patients. Hepatogastroenterology 61(131):838–841

    PubMed  Google Scholar 

  17. Speicher PJ, Nussbaum DP, White RR, Zani S, Mosca PJ, Blazer DG 3rd, Clary BM, Pappas TN, Tyler DS, Perez A (2014) Defining the learning curve for team-based laparoscopic pancreaticoduodenectomy. Ann Surg Oncol 21(12):4014–4019

    Article  Google Scholar 

  18. Nagakawa Y, Nakamura Y, Honda G, Gotoh Y, Ohtsuka T, Ban D, Nakata K, Sahara Y, Velasquez V, Takaori K, Misawa T, Kuroki T, Kawai M, Morikawa T, Yamaue H, Tanabe M, Mou Y, Lee WJ, Shrikhande SV, Conrad C, Han HS, Tang CN, Palanivelu C, Kooby DA, Asbun HJ, Wakabayashi G, Tsuchida A, Takada T, Yamamoto M, Nakamura M (2018) Learning curve and surgical factors influencing the surgical outcomes during the initial experience with laparoscopic pancreaticoduodenectomy. J Hepatobiliary Pancreat Sci 25(11):498–507

    Article  Google Scholar 

  19. Song KB, Kim SC, Lee W, Hwang DW, Lee JH, Kwon J, Park Y, Lee SJ, Park G (2019) Laparoscopic pancreaticoduodenectomy for periampullary tumors: lessons learned from 500 consecutive patients in a single center. Surg Endosc 34:1343

    Article  Google Scholar 

  20. Torphy RJ, Friedman C, Halpern A, Chapman BC, Ahrendt SS, McCarter MM, Edil BH, Schulick RD, Gleisner A (2018) Comparing short-term and oncologic outcomes of minimally invasive versus open pancreaticoduodenectomy across low and high volume centers. Ann Surg 270:1147

    Article  Google Scholar 

  21. Ausania F, Landi F, Martinez-Perez A, Fondevila C (2019) A meta-analysis of randomized controlled trials comparing laparoscopic vs open pancreaticoduodenectomy. HPB (Oxford) 21(12):1613–1620

    Article  Google Scholar 

  22. Dokmak S, Fteriche FS, Aussilhou B, Bensafta Y, Levy P, Ruszniewski P, Belghiti J, Sauvanet A (2015) Laparoscopic pancreaticoduodenectomy should not be routine for resection of periampullary tumors. J Am Coll Surg 220(5):831–838

    Article  Google Scholar 

  23. van Hilst J, de Rooij T, Bosscha K, Brinkman DJ, van Dieren S, Dijkgraaf MG, Gerhards MF, de Hingh IH, Karsten TM, Lips DJ, Luyer MD, Busch OR, Festen S, Besselink MG (2019) Laparoscopic versus open pancreatoduodenectomy for pancreatic or periampullary tumours (LEOPARD-2): a multicentre, patient-blinded, randomised controlled phase 2/3 trial. Lancet Gastroenterol Hepatol 4(3):199–207

    Article  Google Scholar 

  24. Wang M, Meng L, Cai Y, Li Y, Wang X, Zhang Z, Peng B (2016) Learning curve for laparoscopic pancreaticoduodenectomy: a CUSUM analysis. J Gastrointest Surg 20(5):924–935

    Article  Google Scholar 

  25. Huebner M, Kendrick M, Reid-Lombardo KM, Que F, Therneau T, Qin R, Donohue J, Nagorney D, Farnell M, Sarr M (2012) Number of lymph nodes evaluated: prognostic value in pancreatic adenocarcinoma. J Gastrointest Surg 16(5):920–926

    Article  Google Scholar 

  26. Valsangkar NP, Bush DM, Michaelson JS, Ferrone CR, Wargo JA, Lillemoe KD, Fernandez-del Castillo C, Warshaw AL, Thayer SP (2013) N0/N1, PNL, or LNR? The effect of lymph node number on accurate survival prediction in pancreatic ductal adenocarcinoma. J Gastrointest Surg 17(2):257–266

    Article  Google Scholar 

  27. Choi M, Kang CM (2020) Developing an in vivo porcine model of duct-to-mucosa pancreaticojejunostomy (Yonsei-PJ(DTM)). Ann Gastroenterol Surg 4(2):180–184

    Article  Google Scholar 

  28. Kuroki T, Fujioka H (2019) Training for laparoscopic pancreaticoduodenectomy. Surg Today 49(2):103–107

    Article  Google Scholar 

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Acknowledgements

Munseok Choi acquired and analyzed the data and drafted the manuscript. Ho Kyoung Hwang and Woo Jung Lee revised the manuscript. Chang Moo Kang conceived and designed the study, revised, and gave final approval to the manuscript.

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Authors and Affiliations

  1. Division of Hepatobiliary and Pancreatic Surgery, Yonsei University College of Medicine, Seoul, Korea

    Munseok Choi, Ho Kyoung Hwang, Woo Jung Lee & Chang Moo Kang

  2. Department of Surgery, Yonsei University College of Medicine, Ludlow Faculty Research Building #201, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea

    Munseok Choi, Ho Kyoung Hwang, Woo Jung Lee & Chang Moo Kang

  3. Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, Korea

    Munseok Choi, Ho Kyoung Hwang, Woo Jung Lee & Chang Moo Kang

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  1. Munseok Choi
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Correspondence to Chang Moo Kang.

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Munseok Choi, Ho Kyoung Hwang, Woo Jung Lee, and Chang Moo Kang have no conflict of interest or financial ties to disclose.

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Choi, M., Hwang, H.K., Lee, W.J. et al. Total laparoscopic pancreaticoduodenectomy in patients with periampullary tumors: a learning curve analysis. Surg Endosc 35, 2636–2644 (2021). https://doi.org/10.1007/s00464-020-07684-4

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  • DOI: https://doi.org/10.1007/s00464-020-07684-4

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