腹腔镜胰十二指肠切除术的学习曲线

Analysis of learning curve for laparoscopic pancreaticoduodenectomy

目的 :为了进一步推广腹腔镜胰十二指肠切除术,拟分析手术次序与手术质量的关系,探讨其学习曲线。方法:回顾性分析本团队自2012年9月至2015年7月施行的120例腹腔镜胰十二指肠切除术病人的临床资料。其中111例行完全腹腔镜胰十二指肠切除术,另9例行腹腔镜辅助胰十二指肠切除术。根据手术先后顺序将病人按每30例一组,依次分为A、B、C、D 4组,对其手术相关指标和术后恢复情况进行比较分析。结果:平均手术时间(359.8±57.6)min,平均术中出血量(169.7±152.6)m L。42例(35.0%)术后出现并发症,无围手术期死亡。术后平均住院时间(17.0±9.8)d。随着手术经验的积累,手术时间从A组的(370.2±52.8)min降至D组的(342.0±73.1)min。胰肠吻合及胆肠吻合耗时均有减少趋势,分别从(55.0±8.7)min、(39.8±11.7)min减少至(43.6±7.6)min、(27.7±11.8)min。同时,临床疗效有稳步提升的趋势,除D组外,术中出血量、并发症发生率、术后住院时间分别从A组的(219.3±147.9)m L、43.3%、(18.7±10.0)d降至C组的(140.1±73.6)m L、23.3%、(14.4±6.2)d。结论:在腹腔镜技术成熟的中心,腹腔镜胰十二指肠切除术安全可行,可常规开展。随着术者手术经验的积累,30例以后,手术时间可逐步缩短,临床疗效稳步提升。

Objective To analyze the clinical outcomes of different period of learning curve of the laparoscopic pan-creaticoduodenectomy （ LPD ） to improve technique aspects of the procedure . Methods The data of 120 patients who underwent LPD at our institutions between September 2012 and July 2015 were reviewed retrospectively. There were 111 patients who underwent totally LPD and 9 patients underwent laparoscopic assisted pancreaticoduodenectomy. All the patients were divided into 4 groups in order with each 30 patients （1st-30th）, （31st-60th）, （61st-90th） and （91st-120th） in group A, B, C and D respectively. The overall clinical outcomes and changes during different learning period were ana-lyzed. Results The mean operative time was （359.8±57.6） min and mean blood loss （169.7±152.6） mL. Forty-two （35.0%） cases suffered postoperative complications without mortality. The average length of hospital stay （LOS） was （17.0 ±9.8） d. With accumulating experience of the surgery, the mean operative time tended to decrease from （370.2±52.8） min in group A to （342.0±73.1） min in group D. Moreover, mean operative time of pancreatojejunostomy and choledochojejunostomy also tended to decrease from （55.0±8.7） min, （39.8±11.7） min in group A to （43.6±7.6） min, （27.7±11.8） min in group D respectively. Meanwhile, the clinical results tended to get better with lower mean blood loss, less morbidity and shorter LOS from （219.3±147.9） mL, 43.3%, （18.7±10.0） d in group A to （140.1±73.6） mL, 23.3%, （14.4±6.2）d in group C re-spectively except for group D. Conclusions The LPD procedure is feasible and safe in technically developed center and could be routine practice. Clinical outcomes would be improved with accumulating experience after 30 cases of opera-tions, which represents the overcoming of learning curve.