Evaluation of Learning Curve and Outcomes of Laparoscopic Sleeve Gastrectomy Based On 4-year Experience of a Single Surgeon.

Anna Novikova, MD, Diego R Camacho, MD. Montefiore Medical Center

Introduction: Laparoscopic sleeve gastrectomy (LSG) has rapidly become the bariatric procedure of choice due to success regarding outcomes of weight loss and addressing comorbidities. The objective of this study is to ascertain trends, outcomes and the learning curve, predicting the number of cases required for a surgeon to reach a mastery level, based on 4-year term.

Methods: A total of 250 consecutive patients who underwent LSG by a single surgeon, from January 2011 to December 2014, were the focus of our retrospective review. The cases were sorted chronologically into 4 groups, consistent with year, when the surgery was performed. Patient’s demographic, operative, postoperative characteristics and outcomes were prospectively assessed and analyzed. A cumulative sum (CUSUM) method was used to evaluate the learning curve . The one-way ANOVA test and pairwise Bonferroni comparison were used to assess the change of operative time over 4 time periods.

Results: Data of 250 patients was analyzed. Only 198 patients who underwent LSG were included (Excluded: 52 patients had LSG with concomitant procedure). Male to Female ration 1:6, mean age 44.83 ± 11.6 years, mean operative time 75.4 ± 29.3 min., mean postoperative day discharge 2.2 ± 0.85 days, mean preoperative BMI 44.9 ± 8.1, mean postoperative BMI 33.24 ± 7.01, mean %BMI reduction (over 1year follow-up period) 25 ± 9.7%. Intraoperative complications rate 0.5%, 30-day readmission rate 4.4%, 30-day mortality rate 0.5% (1 case due to GI bleeding). A significant number of patients reported resolution or improvement in comorbidities. The combined rates at 1-year follow-up were 48%, 41%, 30%, 24% and 28% for diabetes mellitus type 2, hypertension, hyperlipidemia obstructive sleep apnea and GERD respectively.

Overall there was a significant decline in OT (p < 0.01, as confirmed by one-way ANOVA). Pairwise comparison of OT in each year (using Bonferroni comparison) revealed a significant decline of OT from Year 2011 to 2012 (p value < 0.01), insignificant decline in OT from Year 2012 to 2013 (p = 0.38) and significant decline in OT from Year 2013 to 2014(p value < 0.01). A CUSUM analysis showed a decreasing trend, suggesting that more than 121 cases were needed to reach mastery level.

Conclusions: A continuous decrease in OT was observed over entire study period. Despite that more than 121 cases are needed to achive the mastery level in LSG , this doesn't impact mortality, morbidity levels nor 1-year postoperative outcomes in an experienced laparoscopic surgeon.