Author reply to the letter to the editor “Surgeon’s volume and lymph nodes number in assessing colorectal cancer surgery and multimodal treatment quality”

Abstract

We thank Dr. Hottenrott for interest in our paper. We absolutely agree that the surgeon plays a central role in the operative and oncological safety during laparoscopic colorectal cancer surgery. Several studies have shown the learning curve for laparoscopic colorectal surgery [1–5]. Most of the studies have reported that the learning curve shows a ‘‘plateau’’ reaching adequate experience at some number of cases and suggest a certain number of cases to achieve a ‘‘plateau.’’ To date, however, there have not been a sufficient number of studies on the oncological learning curve. Therefore, the number of cases required to achieve sufficient experience continues to be debated. In the April issue of Surgical Endoscopy, we addressed the changes in the personal learning curve for laparoscopic colorectal cancer surgery with the accumulation of experience, and its impact on the oncological and surgical outcomes. As we mentioned in our study, the learning curve for laparoscopic colorectal resection showed a gradual change over all time periods. Although, our study did not address the role of the surgeon’s volume of cases on safety and effectiveness of the laparoscopic procedure, the volume of cases that a surgeon treats changes as the level of experience increases. Similar to open surgery, the surgeon’s volume of cases is associated with the safety and effectiveness of laparoscopic surgery and perhaps more important in cases of rectal cancer surgery. For rectal cancer surgery, the surgeon’s proficiency was one of the determining factors associated with the oncological outcomes. Analysis of the surgeon’s volume and its influence on surgical outcomes is important and a necessary feature of training for laparoscopic colorectal surgery [6, 7]. In addition, the ‘‘long-term progression’’ of surgery also is important to consider; we found that the retrieved lymph node number was decreased and anastomotic leakage was increased after accumulation of a sufficient number of cases to achieve sufficient learning experience for the procedure. Therefore, some skills may appear to have improved outcomes while others may be associated with poorer outcomes due to, in part, the expansion of the indications for the surgery. Therefore, as surgical indications are extended so too is the learning curve for the procedure.