内镜下全层切除术治疗胃间质瘤的学习曲线及其影响因素

Learning curve of endoscopic full-thickness resection of gastric stromal tumor and its influencing factors

目的 研究内镜下全层切除术(EFTR)治疗胃间质瘤的学习曲线及其影响因素。方法 回顾性分析2018年6月至2022年1月苏州大学附属第一医院由同一名内镜医生从其第1例以EFTR方式治疗的50例胃间质瘤患者的临床资料。采用累积和分析法(CUSUM)拟合学习曲线,比较分析不同学习阶段患者的围手术期资料,并比较分析不同手术时间分组患者的围手术期指标。结果手术时间累积和拟合公式为CUSUM(n)=30.72+41.97n-1.502n2+0.013 08n3(n为病例序号),拟合模型检验P<0.05,拟合系数R2=0.966,拟合曲线在第18例时出现转折,以此将学习曲线分为学习阶段(1~18例)和掌握阶段(19~50例)。掌握阶段组(n=32)的手术时间短于学习阶段组(n=18),并发症发生率低于学习阶段组,差异有统计学意义(P<0.05)。学习阶段组和掌握阶段组患者的性别、年龄、肿瘤部位、肿瘤大小、浸润深度、美国麻醉医师协会(ASA)评分分级、肿瘤危险度分级、创面闭合方式、术后禁食时间、术后住院时间、中转外科发生率及R0切除发生率比较,差异均无统计学意义(P>0.05)。长时间组(n=25)患者的肿瘤大小、创面闭合方式、术者所处学习阶段与短时间组(n=25)比较,差异有统计学意义(P<0.05);短时间组和长时间组患者的年龄、性别、肿瘤部位、浸润深度、ASA评分分级比较,差异均无统计学意义(P>0.05)。结论 术者完成大约18例EFTR可跨越学习曲线。初学者应不断积累手术经验,合理选择病例及医疗器械,更快、更安全地度过EFTR学习曲线。

Objective To study the learning curve and influencing factors of endoscopic full-thickness resection(EFTR) in the treatment of gastric stromal tumors. Methods The clinical data of 50 patients with gastric stromal tumor treated by the same endoscopist from the first case of EFTR in the First Affiliated Hospital of Soochow University from June 2018 to January 2022 were retrospectively analyzed. The cumulative sum method(CUSUM) was used to fit the learning curve, and the perioperative data of patients at different learning stages were compared and analyzed, the perioperative data of patients in different learning stages were compared and analyzed, and the perioperative indexes of patients in different operation time groups were compared and analyzed. Results The operation time accumulation and fitting formula was CUSUM(n)=30.72+41.97n-1.502n~2+0.013 08n~3(n was the case number), the fitting model test P <0.05, the fitting coefficient R~2=0.966. The curve of fitting showed a turning point at the 18thcase, so the learning curve was divided into a learning stage(1-18 cases) and a mastering stage(19-50 cases). The operation time of the master stage group(n=32) was shorter than that of the learning stage group(n=18), and the complication rate was lower than that of the learning stage group, the differences were statistically significant(P<0.05). There were no statistically significant differences in gender, age, tumor site, tumor size, depth of invasion, American Society of Anaesthesiologists(ASA) grading, tumor risk grading, wound closure mode,postoperative fasting time, postoperative hospital stay, incidence of conversion to surgery and incidence of R0 resection between the learning stage group and the master stage group(P>0.05). There were statistically significant differences in tumor size, wound closure mode and surgical learning stage between the long-term group(n=25) and the short-term group(n=25)(P<0.05). There were no statistically significant differences in age, sex, tumor site, depth of invasion and ASA grading between the short-term group and the long-term group(P >0.05). Conclusion The operator completes approximately cases of 18 EFTR to cross the learning curve. Beginners should continue to accumulate surgical experience,select cases and medical devices reasonably, and pass the EFTR learning curve faster and more safely.