Learning Curve to Lymph Node Resection in Minimally Invasive Esophagectomy for Cancer

Abstract

<jats:sec><jats:title>Objective</jats:title><jats:p> Minimally invasive esophagectomy (MIE) is a safe alternative to open approaches, yet the impact of the minimally invasive approach on oncologic efficacy is unclear. The objectives of the current study were to compare lymph node yields and surgical margins during a single-surgeon series to examine the learning curve to oncologic aspects of MIE. </jats:p></jats:sec><jats:sec><jats:title>Methods</jats:title><jats:p> A retrospective review of a prospectively maintained institutional database was performed. The sequential MIE experience for esophageal cancer was subcategorized into terciles (first 25 MIEs as early, next 24 as middle, and most recent 24 as later). </jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p> Seventy-three patients underwent MIE for cancer between 2008 and 2013. Complete resections (R0) were performed in 71 cases (93%), and there were no significant differences in the number of complete resections with negative margins during the MIE experience ( P = 0.54). The number of lymph nodes harvested during MIE increased significantly with progressive experience, with a mean of 22, 29, and 28 nodes recovered in the early, middle, and late subgroups, respectively ( P = 0.038). On multivariate analysis, only increasing surgeon experience (1.4-fold increase in nodal yield for the latter two thirds relative to the first third, P = 0.0011) and histology of high-grade dysplasia (0.54-fold decrease in nodal yield relative to adenocarcinoma or squamous cell carcinoma, P = 0.025) were significant predictors of lymph node yield. </jats:p></jats:sec><jats:sec><jats:title>Conclusions</jats:title><jats:p> The ability to execute a complete lymphadenectomy during MIE is affected by surgeon experience and improves over time, plateauing after the first 25 cases. </jats:p></jats:sec>

Learning curve for minimally invasive oesophagectomy of oesophageal cancer and survival analysis

“…Dhamija et al [ 11 ] reported the learning curve for lymph node resection in MIE for oesophageal cancer and suggested that the ability to dissect lymph nodes completely during MIE was affected by the surgeons’ experience, which may accumulate over time. A significant increase in experience was achieved after the first 25 cases in their study.…”

“…The minimally invasive approach is performed via a distinct view of the surgical anatomy, and specialised surgical schemes and skills are required. Although learning curves and other parameters for lymph node dissection were reported over the past few years [ 11 – 14 ], systematic analyses of these learning curves, the clinical indexes and survival outcomes using a large number of cases or long monitoring times remain limited. From July 2010 to August 2016, 214 patients underwent MIE for oesophageal cancer and were followed up.…”

Recurrent laryngeal nerve lymph node dissection in minimally invasive esophagectomy

“…However, researches support that surgeons could get the same lymphadenectomy results in MIE as open surgery (10). Technical development is a key element in RLN lymph node dissection (11). Good exposure of surgical area is the first thing to do in lymph node dissection.…”

“…Obvious learning curve could be observed in MIE. Reports mentioned that the ability to execute a complete lymphadenectomy during MIE might require the operation of 25-40 cases (11,12 Assistant is also important during the RLN lymph node dissection. With a grasping forcep, assistant help expose the surgical area and free one hand of the operator.…”

Learning Curve for Minimally Invasive Oesophagectomy of Esophageal Cancer and contrast with Open Oesophagectomy

“…The minimally invasive approach is performed via a distinct view of the surgical anatomy, and specialized surgical schemes and skills are required. Although learning curves and other parameters for lymph node dissection have been reported over the past few years [17][18][19][20] , systematic analyses of these learning curves, as well as the clinical indexes and survival outcomes, with more than 200 cases or long monitoring times, are still limited. From July 2010 to August 2016, 214 patients underwent MIE for oesophageal cancer and were followed up.…”