腹腔镜袖状胃切除术学习曲线与手术时间的影响因素分析

Learning curve analysis and influencing factors of operation time of laparoscopic sleeve gastrectomy

目的探讨影响行腹腔镜袖状胃切除术手术时间的相关因素,分析肌少症和非肌少症性肥胖患者的手术学习曲线。方法采用回顾性队列研究方法。收集2018年1月至2022年6月福建医科大学附属协和医院收治的240例行腹腔镜袖状胃切除术肥胖症患者的临床资料;男52例,女188例;年龄为(30±8)岁。患者均施行减重手术,术前和术后获取患者第3腰椎椎体水平的轴位CT扫描图像,准确分割肌肉和脂肪。观察指标:(1)治疗和随访情况。(2)腹腔镜袖状胃切除术手术时间的影响因素分析。(3)学习曲线CUSUM分析结果。(4)学习初始阶段和熟练阶段患者临床资料比较。正态分布的计量资料以x±s表示,组间比较采用t检验。偏态分布的计量资料以M(IQR)表示,组间比较采用非参数检验。计数资料以绝对数表示,组间比较采用χ^(2)检验。单因素和多因素分析采用Logistic回归模型。计算CUSUM,并对其进行拟合。结果(1)治疗和随访情况。240例患者中,肌少症性肥胖97例,非肌少症性肥胖143例。240例患者均顺利施行腹腔镜袖状胃切除术,手术时间为(108±23)min,无中转开放手术,无围手术期死亡,均获得术后6个月随访。(2)腹腔镜袖状胃切除术手术时间的影响因素分析。多因素分析结果显示:肌少症性肥胖是影响行腹腔镜袖状胃切除术手术时间的独立因素(优势比=2.207,95%可信区间为1.207~4.038,P<0.05)。(3)学习曲线CUSUM分析结果。对肌少症性肥胖与非肌少症性肥胖患者的手术时间进行CUSUM学习曲线拟合,其中肌少症性肥胖患者CUSUM最佳拟合方程为y=-4E-08x6+1E-05x5-0.0011x4+0.0631x3-1.89x2+28.126x-48.671(x为手术例数),拟合优度决定系数R2为0.833;非肌少症性肥胖患者CUSUM最佳拟合方程为y=3E-09x6-1E-06x5+0.0002x4-0.0109x3+0.0638x2+12.053x-65.025(x为手术例数),拟合优度决定系数R2为0.716。依据累积和曲线变化趋势,肌少症性肥胖与非肌少症性肥胖患者拟合曲线分别在手术例数累积至第81例和36例时达到峰值,可分别将学习曲线划分为学习初始阶段和熟练阶段。(4)学习初始阶段和熟练阶段患者临床资料比较。①97例肌少症性肥胖患者中,行腹腔镜袖状胃切除术学习曲线初始阶段和成熟阶段分别为81例和16例,两者手术时间和术后住院时间分别为(119±23)min和(106±21)min、(5.9±2.3)d和(4.7±0.5)d,两者上述指标比较,差异均有统计学意义(t=2.074,2.147,P<0.05)。②143例非肌少症性肥胖患者中,行腹腔镜袖状胃切除术学习曲线初始阶段和成熟阶段分别为36例和107例,两者性别(女)、身高、术前体质量、脱脂质量、手术时间、术后住院时间、术后6个月体质量、术后6个月体质量指数、术后6个月多余体质量减少百分比、术后6个月多余体质量减少百分比>100%、术后6个月多余体质量指数分别为20例和87例、(170±10)cm和(164±8)cm、(110±25)kg和(99±20)kg、(57±12)kg和(52±12)kg、(108±22)min和(100±19)min、(6.1±1.6)d和(4.7±1.1)d、(80±16)kg和(71±16)kg、(27.63±4.22)kg/m^(2)和(25.89±4.48)kg/m^(2)、83%±35%和103%±42%、9例和48例、1.99(6.03)kg/m^(2)和0.31(5.82)kg/m^(2);两者上述指标比较,差异均有统计学意义(χ^(2)=9.484,t=3.266、2.424、2.141、2.137、5.821、2.740、1.993、-2.524,χ^(2)=4.432,Z=-2.300,P<0.05)。结论肌少症性肥胖是影响行腹腔镜袖状胃切除术手术时间的独立因素;肌少症性肥胖和非肌少症性肥胖度过腹腔镜袖状胃切除术的学习曲线分别需要81例和36例。

Objective To investigate the influencing factors of operation time for laparos-copic sleeve gastrectomy(LSG)and analyze the learning curve of LSG in sarcopenic obesity(SO)and non-sarcopenic obesity(NSO).Methods The retrospective cohort study was conducted.The clinical data of 240 obesity patients who underwent LSG in the Fujian Medical University Union Hospital from January 2018 to June 2022 were collected.There were 52 males and 188 females,aged(30±8)years.Patients underwent L3 vertebral body horizontal axial computer tomography(CT)scanning before and after receiving LSG to accurately segment muscles and fats.Observation indicators:(1)treatment and follow-up;(2)influencing factors of operation time for LSG;(3)cumulative sum(CUSUM)of learning curve;(4)comparison of clinical data between patients in the initial and profi-cient stages.Measurement data with normal distribution were represent as Mean±SD,and comparison between groups was conducted using the t test.Measurement data with skewed distribution were represented as M(IQR),and comparison between groups was conducted using the non-parameter test.Count data were described as absolute numbers,and comparison between groups was conducted using the chi-square test.Univariate and multivariate analyses were conducted using the Logistic regression model.The CUSUM of learning curve was calculated and the fitting process was conducted on scatter plot of learning curves.Results(1)Treatment and follow-up.Of the 240 patients,there were 97 cases of SO and 143 cases of NSO.All 240 patients underwent LSG successfully,without conversion to open surgery.The operation time of 240 patients was(108±23)minutes.None of patient died during the perioperative period and all patients underwent follow-up during the postoperative 6 months.(2)Influencing factors of operation time for LSG.Results of multivariate analysis showed that SO was an independent factor influencing operation time for LSG(odds ratio=2.207,95%confidence interval as 1.207-4.038,P<0.05).(3)CUSUM of learning curve.Results of CUSUM of operation time in patients of SO and NSO showed that the best fit equation of patients of SO was y=-4E-08x6+1E-05x5-0.0011x4+0.0631x3-1.89x2+28.126x-48.671(x means the number of surgical cases),with goodness-of-fit R2 as 0.833,and the best fit equation of patients of NSO was y=3E-09x6-1E-06x5+0.0002x4-0.0109x3+0.0638x2+12.053x-65.025(x means the number of surgical cases),with goodness-of-fit R2 as 0.716.Based on the trend of CUSUM of learning curve of operation time,the peak value of number of surgical cases in patients of SO and NSO was 81 and 36,respec-tively,which was used to divide the learning curve as two stages of the initial stage and the proficient stage.(4)Comparison of clinical data between patients in the initial and proficient stages.①Of the 97 patients of SO,there were 81 cases and 16 cases in the initial stage and the proficient stage of LSG,with the operation time,postoperative duration of hospital stay as(119±23)minutes,(5.9±2.3)days and(106±21)minutes,(4.7±0.5)days,showing significant differences between them(t=2.074,2.147,P<0.05).②Of the 143 patients of NSO,there were 36 cases and 107 cases in the initial stage and the proficient stage of LSG,with gender(female),height,preoperative body mass,defatted body mass,operation time,postoperative duration of hospital stay,body mass at postoperative 6 month,body mass index(BMI)at postoperative 6 month,percentage of excess weight loss(EWL%)at postoperative 6 month,cases with EWL%>100%at postoperative 6 month,excess BMI at post-operative 6 month as 20,(170±10)cm,(110±25)kg,(57±12)kg,(108±22)minutes,(6.1±1.6)days,(80±16)kg,(27.63±4.22)kg/m^(2),83%±35%,9,1.99(6.03)kg/m^(2)and 87,(164±8)cm,(99±20)kg,(52±12)kg,(100±19)minutes,(4.7±1.1)days,(71±16)kg,(25.89±4.48)kg/m^(2),103%±42%,48,0.31(5.82)kg/m^(2),showing significant differences between them(χ^(2)=9.484,t=3.266,2.424,2.141,2.137,5.821,2.740,1.993,-2.524,χ^(2)=4.432,Z=-2.300,P<0.05).Conclusions SO is an independent factor influencing operation time for LSG.It is suggested that the surgeons need to finish 81 cases and 36 cases master LSG in patients of SO and NSO.