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Colorectal surgeons’ learning curve of transanal endoscopic microsurgery

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Abstract

Background

Transanal endoscopic microsurgery (TEM) is a technically demanding key technique in minimally invasive rectal surgery. We investigated the learning curve of colorectal surgeons commencing with TEM.

Methods

All TEM procedures of four colorectal surgeons were analyzed. Procedures were ranked chronologically per surgeon. Outcomes included conversion, postoperative complications, procedure time, and recurrence. Backward multivariable regression analysis identified learning curve effects and other predictors.

Results

Four surgeons resected 693 rectal lesions [69.9 % adenoma/25.5 % carcinoma; median size 20 cm2; interquartile range (IQR) 11–35; 7 ± 4 cm ab ano]. A total of 555 resections (80.1 %) were histopathologically radical (R0). Conversion (4.3 %) was influenced by a learning curve [odds ratio (OR) 0.991 per additional procedure; 95 % confidence interval (CI) 0.984–0.998] and by lesion size. Postoperative complications depended only on the individual surgeon and lesion size in benign lesions (10.4 % complications). A learning curve (OR 0.99; 95 % CI 0.988–0.998) and peritoneal entrance affected complications in malignant lesions (13.3 %). Procedure time [median 55 min (IQR 30–90)] was influenced by a learning curve [B −0.11 (95 % CI −0.14 to −0.09)], individual surgeon, single-piece resection, peritoneal entrance, lesion size, and rectal quadrant. Recurrence of benign lesions (4.5 %) depended on lesion size, R0 resection, and prior resection attempts. Recurrence of malignant lesions (8.9 %) depended on 3D stereoscopic view, lesion size, full-thickness resection, and length of follow-up. Recurrence-free survival of patients operated during the 36th through 80th procedure per surgeon was significantly shorter than in patients operated during procedures 1–35 and 81 onwards.

Conclusions

A surgical learning curve affected conversion rate, procedure time, and complication rate. It did not influence recurrence rates, possibly due to evolving patient populations. This first insight into the learning curve of TEM stresses the importance of quality monitoring and centralisation of care.

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Disclosures

Drs. Barendse, Bijnen, Consten, Hoff, Dekker, Fockens, Bemelman, and de Graaf, as well as Mr. Dijkgraaf and Miss Rolf have no conflict of interest or financial ties to disclose.

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Authors and Affiliations

  1. Department of Gastroenterology and Hepatology, Academic Medical Center, PO Box 22660, 1100 DD, Amsterdam, The Netherlands

    Renée M. Barendse, Ursula R. Rolf, Evelien Dekker & Paul Fockens

  2. Clinical Research Unit, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands

    Marcel G. Dijkgraaf

  3. Department of Surgery, Medical Center Alkmaar, Alkmaar, The Netherlands

    Arnold B. Bijnen

  4. Department of Surgery, Meander Medical Center, Amersfoort, The Netherlands

    Esther C. J. Consten

  5. Department of Surgery, Medical Center Leeuwarden, Leeuwarden, The Netherlands

    Christiaan Hoff

  6. Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands

    Willem A. Bemelman

  7. Department of Surgery, IJsselland Hospital, Capelle aan den IJssel, The Netherlands

    Eelco J. R. de Graaf

Authors
  1. Renée M. Barendse
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  2. Marcel G. Dijkgraaf
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  3. Ursula R. Rolf
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  4. Arnold B. Bijnen
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  5. Esther C. J. Consten
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  6. Christiaan Hoff
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  7. Evelien Dekker
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  8. Paul Fockens
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  9. Willem A. Bemelman
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  10. Eelco J. R. de Graaf
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Correspondence to Renée M. Barendse.

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Barendse, R.M., Dijkgraaf, M.G., Rolf, U.R. et al. Colorectal surgeons’ learning curve of transanal endoscopic microsurgery. Surg Endosc 27, 3591–3602 (2013). https://doi.org/10.1007/s00464-013-2931-6

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  • DOI: https://doi.org/10.1007/s00464-013-2931-6

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