基于112例手术的腹腔镜胰十二指肠切除术学习曲线  

The learning curve of laparoscopic pancreaticoduodenectomy based on the initial 112 patients

作　　者：谭煜炜 汤天逾 张悦[1] 张丽伟[1] 祖广晨 安勇[1] 陈卫波[1] 邬迪[1] 孙冬林[1] 陈学敏[1] Tan Yuwei;Tang Tianyu;Zhang Yue;Zhang Liwei;Zu Guangchen;An Yong;Chen Weibo;Wu Di;Sun Donglin;Chen Xuemin(The Third Affiliated Hospital of Soochow University,Changzhou 213003,Jiangsu Province,China)

机构地区：[1]常州市第一人民医院苏州大学附属第三医院肝胆胰外科,常州213003

出　　处：《中华肝胆外科杂志》2019年第10期763-767,共5页Chinese Journal of Hepatobiliary Surgery

摘　　要：目的探讨和分析腹腔镜胰十二指肠切除术(LPD)的学习曲线,为术者循序渐进地开展该手术提供参考。方法回顾性分析常州市第一人民医院同一主刀医生从2015年12月至2018年2月连续开展的112例LPD患者的临床资料。利用累积和分析法(CUSUM)及风险调整累积和分析法(RA-CUSUM),将学习曲线分为3个阶段,分析相关围手术期及术后病理各项指标。结果曲线的第一阶段为学习期,包括1到45例手术操作;第二阶段为能力增强期,为46到76例手术操作;第三阶段为成熟期,为77到112例手术操作。患者3个阶段的手术时间[(448.4±75.0)min比(381.3±74.3)min比(336.2±52.1)min)],术中出血量[(373.3±250.1)ml比(332.3±211.6)ml比(265.3±253.2)ml]、进食流质时间[6.0(5.0,8.0)d比5.0(3.0,6.0)d比3.0(3.0±5.0)d]逐步减少,胰腺癌占比(11.1%比38.7%比44.4%)、清扫淋巴结数目[(10.0±7.0)个比(8.8±4.3)个比(13.3±6.2)个]增多,差异均有统计学意义(均P<0.05)。患者术后住院时间,术后胰瘘等并发症发生率三阶段比较差异无统计学意义(P>0.05)。术者第一例血管重建发生在第48例,属于能力增强期。结论经过46例LPD手术,术者可以基本度过LPD的学习阶段,手术操作超过76例可以到达成熟期。血管重建应当被看做度过学习期的标志,而不是到达成熟期的标志。此时,应提早预判学习过程中的"高原现象",适时做出调整。Objective To study the learning curve of laparoscopic pacreaticoduodenectomy (LPD) with a view to find an appropriate way to develop LPD step by step. Methods 112 consecutive patients who completely underwent LPD in a single surgery center at the First People’s Hospital of Changzhou from December 2015 to February 2018 were retrospectively reviewed. By using both the cumulative sum (CUSUM) and the risk-adjusted CUSUM (RA-CUSUM) methods to analyze the perioperative data of these patients, the learning curve of LPD was studied in a more scientific way. Results The learning curve could be divided into three phases: Phase 1, the initial period (the initial 45 patients);Phase 2, the enhancement period (the subsequent 31 patients);Phase 3, the maturation period (the remaining patients). For these 3 phases, the corresponding operative times were (448.4±75.0),(381.3±74.3), and (336.2±52.1) min, respectively (P<0.05). The intraoperative blood losses were (373.3±250.1),(332.3±211.6), and (265.3±253.2) ml, respectively (P<0.05). The times to oral intake were 6.0(5.0, 8.0), 5.0(3.0, 6.0), and 3.0(3.0, 5.0) days, respectively (P<0.05). The number of lymph nodes harvested were (10.0±7.0),(8.8±4.3), and (13.3±6.2), respectively (P<0.05). All these showed significant improvement through the 3 phases. On the other hand, the postoperative stays, the postoperative pancreatic fistula rates were also decreased. But these failed to reach statistical significance. Vascular reconstruction was carried out in the 48th patient in phase 2 of the study. Conclusions The initial phase of LPD passed after LPD for 46 patients, but the maturation phase occurred after LPD on 76 patients. Vascular reconstruction should be considered as passing through the learning phase rather than reaching the maturity phase. Adjustments made in the enhancement phase helped to get through the maturation phase earlier.

关 键 词：腹腔镜 胰十二指肠切除术 胰腺肿瘤 胆管肿瘤 学习曲线 治疗结果 

分 类 号：R65[医药卫生—外科学]