Characteristics of Learning Curve in Minimally-Invasive Ileal Pouch Anal Anastomosis in a Single Institution

Ahmet Rencuzogullari, MD, Luca Stocchi, MD, Meagan Costedio, MD, Emre Gorgun, MD, Hermann Kessler, MD, Feza H. Remzi, MD. Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic

INTRODUCTION: Previous work from our institution has characterized the learning curve for open ileal pouch-anal anastomosis (IPAA). The purpose of the present study was to assess the learning curve of minimally-invasive IPAA.

METHODS AND PROCEDURES: Learning curves on 372 cases of minimally-invasive IPAA by 20 surgeons (10 seniors vs. 10 juniors) during 2002- 2013, included in an institutional, prospectively maintained database were assessed for pelvis sepsis,other pouch-related complications (hemorrhage, anastomotic stricture or separation, pouch failure, fistula), operative times and conversion rates. Predicted outcome models were constructed using perioperative variables selected by stepwise logistic regression, using Akaike’s information criteria. Cumulative sums (CUSUM) of differences between observed and predicted outcomes were graphed over time to identity possible patterns demonstrating improvements for the institution, senior vs junior surgeons and busiest individual surgeons (surgeon A, 71 cases, and surgeon B, 54 cases)

RESULTS: Institutional outcomes significantly improved for pelvis sepsis rate (18.2% vs. 7.0%. CUSUM peak after 143 cases, p=0.001, Figure 1A) and other pouch-related complication rates  (32.9% vs. 12.4%, CUSUM peak after 155 cases, respectively, p<0.001,Figure 2A). Institutional total proctocolectomy mean operative times significantly decreased (307 min vs. 253 min, CUSUM peak after 84 cases, p<0.001), unlike completion proctectomy (p=0.093) or conversion rates (10% vs. 5.4%, p=0.235). Similar learning curves were identified among senior surgeons but not among junior surgeons (Figure 1B,1C, 2B, 2C). Learning curves were identified for both the 2 busiest individual surgeons for pelvic sepsis (peaks at 47 and 9 cases, p=0.045 and p=0.002), and other pouch complications (peak at 41 cases for both, p=0.002 and p=0.006), but only in one surgeon for operative times (CUSUM peak after 13 cases for both total proctocolectomy and completion proctectomy (p=0.002 and p=0.006)(Table)

CONCLUSION: Pouch complications are the most consistent and relevant learning curve endpoints in laparoscopic IPAA.




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