Evaluation of the learning curve of transanal total mesorectal excision: single-centre experience

Abstract

Introduction: Transanal total mesorectal excision (TaTME) has been recently proposed to overcome the difficulties of the standard TME approach, allowing better visualization and dissection of the mesorectal fascia. Although TaTME seems very promising, the evidence and body of knowledge on achieving proficiency in performing it are still sparse. Aim: To evaluate the learning curve of TaTME based on a single centre's experience. Material and methods: Consecutive patients undergoing TaTME since 2014 in a tertiary referral department were included in the study. All procedures were performed by one experienced surgeon. CUSUM curve analyses were performed to evaluate learning curves. Results: Sixty-six patients underwent TaTME. After analysis of postoperative morbidity rate, intraoperative adverse effects and operative time, we estimated that 40 cases are needed to achieve TaTME proficiency. Subsequently, patients were divided into two groups: before (40 patients) and after overcoming the learning curve (26 patients). Group 1 had higher readmission (p = 0.041) and complication rates (p = 0.019). There were no statistically significant differences in terms of intraoperative adverse effects, length of stay or pathological quality of the specimen. Conclusions: Transanal total mesorectal excision is a promising yet technically demanding procedure and requires at least 40 cases to complete the learning curve. More data are needed to introduce it as a standard procedure for low rectal cancer treatment.

The learning curve of transanal total mesorectal excision for rectal cancer is associated with local recurrence: results from a multicentre external audit

“…Multiple groups have assessed the learning curve by CUSUM analysis to be around 40-50 procedures [6][7][8][9]35]. Therefore, the chosen cut-off of 40 cases, next to the first cut-off at 10 procedures to serve as reference from the previous audit of 12 centres was considered appropriate.…”

“…Given the current debate on the safety of TaTME with respect to (multifocal) local recurrence postponing the publication of our current results was considered unethical. Multiple groups have assessed the learning curve by CUSUM analysis to be around 40–50 procedures [ 6 , 7 , 8 , 9 , 35 ]. Therefore, the chosen cut‐off of 40 cases, next to the first cut‐off at 10 procedures to serve as reference from the previous audit of 12 centres was considered appropriate.…”

Assessment of training and selected factors on speed and quality of performing different tasks on the endoscopic simulator

“…On the other hand, we think that, based on the learning curve in our research, results of a randomised controlled trial that show how laparoscopic surgical skills are significantly improved by use of a portable laparoscopic simulator [ 29 ] and other studies proving that warm-up sessions before operations cause improvement of performance [ 30 , 31 ] training on the box trainers and/or laparoscopic simulators may be widely and effectively used in many different aspects. As other researchers discovered, many attempts are required in different surgery cases to stabilize the learning curve [ 32 ]. That is why targeted training sessions are required to obtain sufficient proficiency.…”

Laparoscopic vs. open liver resections of posterolateral liver segments – a systematic review and meta-analysis

“…There is no consensus as to whether the laparoscopic technique decreases blood loss or not. Complex laparoscopic procedures have a steep learning curve, causing worse short-term outcomes at the beginning [ 28 , 29 ]. In our study, there were no differences between the groups.…”