经口腔前庭入路机器人甲状腺手术的学习曲线分析

A prospective study of learning curve of transoral robotic thyroidectomy

目的探讨经口腔前庭入路机器人甲状腺手术(transoral robotic thyroidectomy, TORT)的学习曲线。方法前瞻性收集并分析2020年4月至2021年11月期间,就诊于解放军联勤保障部队第九六〇医院行TORT的70例患者的临床数据。采用累积和分析法拟合学习曲线,根据累积和值分为学习阶段和熟练阶段,探讨两个阶段的临床数据资料。结果70例患者均顺利完成TORT,无中转开放手术,手术时间129~490 min,平均(223.82±72.05)min;随访时间1~20个月,平均(10.23±5.43)个月;均无复发转移。选择并收集70例中连续进行的50例行甲状腺腺叶切除(含中央区淋巴结清扫)患者的临床数据进行统计分析,手术时间148~262 min,平均(205.68±57.59)min。采用累积和分析法发现,23例为跨越学习曲线掌握TORT的最低手术例数;学习阶段手术时间148~380 min,平均(238.17±63.32)min;熟练阶段手术时间134~262 min,平均(178±32.57)min。学习阶段和熟练阶段患者的手术时间比较,差异有统计学意义(P<0.05);患者年龄、性别、肿瘤大小、中央区淋巴结清扫数、中央区淋巴结阳性数、术后拔管时间、并发症率比较,差异无统计学意义(P>0.05)。结论对于经验丰富的外科医师,严格选择合适患者后,TORT是安全、可行的,跨越TORT学习曲线需要累积的最低手术例数为23例。

Objective To investigate the learning curve of transoral robotic thyroidectomy.Methods From Apr. 2020 to Nov. 2021, the clinical data of 70 patients who had received transoral robotic thyroidectomy (TORT) at the 960th Hospital of PLA were gathered and studied prospectively. The cumulative sum analysis (CUSUM) was used to fit the learning curve. According to the CUSUM value, it was divided into learning stage and proficiency stage, and the clinical data of the two stages were analyzed.Results All the 70 patients successfully underwent TORT without conversion to open operation. The mean operation time was (223.82±72.05)min, 129- 490 min. There was no recurrence or metastasis after a mean follow-up time of (10.23±5.43)months, 1-20 months. The data of 50 consecutive cases of thyroidectomy (including central lymph node dissection) were selected and collected for statistical analysis. The mean operation time was (205.68 ± 57.59)min, 148-262 min. The lowest number of operations to master TORT and cross the learning curve was explored using CUSUM: the mean operation time in the learning stage was(238.17 ± 63.32)min, 148-380 min, and the mean operation time of proficiency stage was (178 ± 32.57) min, 134-262 min. There was significant difference in operation time between learning stage and proficiency stage(P<0.05);There was no significant difference in age, gender, tumor size, the number of dissect of lymph nodes, the number of lymph nodes positive in the central area, the extubation days after surgery, and the rate of complications between the two stages(P>0.05).Conclusions TORT is safe and feasible for expert surgeons who carefully choose appropriate patients. It′s a total of 23 operations that must be accumulated to cross the TORT learning curve.