低位直肠癌肛提肌外腹会阴联合切除术学习曲线研究

Analysis of the learning curve for extralevator abdominoperineal excision for low rectal cancer:Lessons from a single center`s experience

目的探讨直肠癌肛提肌外腹会阴联合切除术(ELAPE)的学习曲线。方法回顾性分析北京大学人民医院胃肠外科2012年6月至2014年10月接受ELAPE的55例直肠癌病人的临床资料,运用累积和控制图找出熟练掌握ELAPE所需要的例数,然后比较学习期和熟练期病人的手术效果。结果累积和控制分析显示熟练掌握ELAPE所需手术例数节点为30例。熟练期(30例)较学习期(25例)手术时间[(246.6±51.1)min vs.(286.3±43.2)min]、术中出血[(146.9±76.0)m L vs.(215.7±162.9)m L]和术后进食时间[(6.0±1.0)d vs.(7.0±2.0)d]均显著减少(P<0.05)。两组术后住院时间[(19.0±8.0)d vs.(18.0±9.0)d]、淋巴结检出总数[(17.0±6.0)枚vs.(17.0±9.0)枚]、手术相关并发症发生率(24.0%vs.40.0%)、环周切缘阳性率(4.0%vs.3.3%)、术中穿孔发生率(0 vs.6.7%)、手术标本质量差异无统计学意义(P>0.05)。结论直肠癌ELAPE的学习曲线约为30例,即可达到较熟练程度。

Objective To evaluate the learning curve of extralevator abdominoperineal excision （ELAPE） for rectal cancer. Methods The clinical data of 55 patients with rectal cancer performed ELAPE at Peking University People＇s Hospital between June 2012 and October 2014 were analyzed retrospectively. A cumulative sum （CSCUM） analysis was used to derive the learning curve. The differences between the learning phase and the proficient phase in surgical effects were analyzed retrospectively. Results The cumulative sum analysis revealed the degree of proficiency increased after 30 cases. Compared with learning phase （30 cases） , the operative time [ （246.6 ± 51.1 ） rain vs. （ 286.3 ± 43.2） mini, intraoperative blood loss[（ 146.9±76.0） mL vs. （215.7 ± 162.9） mL], postoperative dieting time [（6± 1 ） d vs. （7 ±2） d] in proficient phase （25 cases） decreased significantly respectively （P〈0.05）. The hospital stay [（19±8）d vs. （18±9） d], lymph nodes harvest [（17 ± 6）vs. （17 ±9）], operation-related complications incidence （24.0% vs. 40.0%）, positive circumferential resection margin （4.0% vs.3.3%）, intraoperative perforation incidence （0 vs. 6.7%） and the quality of specimens had no any statistical significance （P〉0.05）. Conclusion The learning process for ELAPE has a greater effect on the first 30 cases.