The learning curve in the use of trans-oral laser microsurgery for cancer treatment

Abstract

The authors from the University of Barcelona present their experience of using trans-oral laser micro-surgery (TOLMS) in the management of laryngeal and hypopharyngeal cancers over a 14-year period and extrapolate from analysis of the data [1], with surgeons graded by levels of experience addressing early and locally advanced tumours, as well as stage of disease and comment on patient outcome using analysis of number of surgeries per patient, rate of complications, rates of positive and negative tumour margins, rate if tumour relapse, type of surgical salvage procedure employed and disease-specific survival. The difference between the mean of surgical interventions was statistically significant, and the number of total laryngectomy employed as a salvage procedure was lower in the group of patients operated upon by more experienced surgeons. Tumour-free margins and tumour relapse were not influenced by experience. The number of overall complications and the disease-specific survival rates was significantly lower in the ‘‘expert’’ group. The authors do agree that the learning curve of TOLMS for glottis, supraglottic and hypopharyngeal lesions may be different, and suggest that further analysis with larger numbers in each sub-site is necessary. They also suggest that for TOLMS ‘‘beginners’’ that early teaching, confidence and analysis of competency should be gained with early tumours. Based on their results it is suggested that experience in the use of TOLMS should be gained in a levelled approach graduating from early tumours to intermediate and then advanced T stage disease. This paper is a first attempt to review a large series of treated patients and analyse the involvement of surgeons of differing experiences against a number of outcome measures. However, of the 5 surgeons work reported, all were ‘‘experienced’’ head and neck surgeons. The majority (80 %) had more than 15 years of surgical experience before commencing TOLMS, and the other surgeon was less than 7 years experienced. Thus, the surgeons in this report, while ‘‘new’’ to TOLMS had already got experience of micro-laryngoscopy and bimanual surgical excisions, identification of tumours and their margins prior to being introduced to TOLMS. This may not be universally equivalent when starting up a practice employing TOLMS for the management of laryngeal and hypopharyngeal cancers. The most important steps when considering introducing ‘‘new technologies’’ into surgery is to ensure that a ‘‘team approach’’ is agreed and developed—this naturally in cancer surgery will involve the surgeon, the anaesthetist and the histopathologist. The introduction of such new clinical interventions and surgical techniques may need to be approved by the local hospital clinical governance board, and comply with clinicians being able to demonstrate that they can meet externally set of standards on appropriate training, as in the UK NHS [2]. It is also important not to ignore that the data need to be collected prospectively, documentation of duration of surgery, hospital stay, complications, tumour status of resection margins achieved, ability to salvage close or positive margins, functional outcome—objective and subjective evaluation of voice and swallowing outcomes, as well as disease-specific survival. The ability of residents (training grade) to achieve TOLMS expertise is strongly influenced by the personal skills and P. Bradley (&) Department of Otorhinolaryngology Head and Neck Surgery, Nottingham University Hospitals, Queens Medical Centre Campus, Nottingham, UK e-mail: pjbradley@zoo.co.uk