True Learning Curve Research Articles

Anterior approaches in acetabular fractures: a true learning curve analysis.

Today, acetabular surgeons in training have to learn ilioinguinal and anterior intrapelvic approaches (AIP). The aim of this study was to describe the 5-years learning curve of a surgeon. Objective was to assess clinical and radiological results; and to assess factors which could influence this learning curve. Between November 2015 and May 2020, patients with an acetabular fracture operated by the surgeon during the 5-years learning curve with an anterior approach were included in this single-center retrospective study based on a prospective database. Epidemiological, operative, clinical, radiological and complications data's were collected. To assess learning-curve effect the series was divided into two groups: first 2.5-years and last 2-years. Subgroup analysis were performed according to the surgical approach, to the reduction quality and the prognostic factors. In total, 46 patients were included, 23 in period 1 and 23 in period 2. 16 patients (35%) had ilioinguinal approach and 30 patients (65%) had modified Stoppa-Cole approach. At mean follow-up of 24 months, 38 patients (83%) were reviewed. Anatomical reduction (< 1 mm) was achieved in 28 patients (60.9%) with a 9% rate of perioperative complications and 37% rate of post-operative complications. In conclusion, this study gives a realistic overview of the learning curve of anterior approaches in acetabular fractures surgery. Our results should encourage surgeons, while keeping in mind how much this surgery can be challenging, with high rate of complications and difficulty to obtain a systematic anatomical reduction.

Paper 07: The True Learning Curve in Hip Arthroscopy According to Patient-Reported Outcomes

Objectives: Arthroscopic correction of FAI is a powerful way to improve pain and function in athletes and patients. Surgeons learning hip arthroscopy experience a learning curve while gaining competence. The objective of the present study was to evaluate the learning curve in hip arthroscopy for FAI according to improvements in patient-reported outcome instruments. Methods: A retrospective review was performed of a single surgeon’s first 1000 hip arthroscopy cases during their first 4 years in practice. Arthroscopy cases that occurred concurrently with PAO or femoral osteotomy (n=360) were excluded. Convenience samples (n=50) were taken from each year in practice. Pre-operative and post-operative HOOS- Pain and HOOS-physical function scores were obtained. Linear trends were assessed, and cutoffs for MCID for HOOS (10 points) were surveyed across time. Students t tests were used for continuous variables and chi squared tests were used for categorical variables and significance was set to p&lt;0.05. Results: During the first 250 cases, a sample of patients was obtained (n=50), and 11/50 did not meet MCID (22%) for HOOS Pain at 1-year follow-up. A convenience sample of cases subsequent to this from cases 251-1000 (n=100) 11/100 after that did not meet MCID (11.0%, p&lt;0.05). The mean 1-year postop HOOS Pain score for year 1 was 82.77, year 2 was 90.56, year 3 was 89.34 and year 4 was 93.48 (P&lt;0.05). Delta HOOS Pain of PS did not change over time, p&gt;0.05). For both HOOS Pain and Physical Function subscales, 1-year postop scores continued to improve over the 4-year 1000-case study period (graph). Conclusions: According to the HOOS validated patient reported outcome instrument, the learning curve for significant benefits in hip arthroscopy is between 130-250 cases. Many patients (almost 80%) saw significant clinical benefit during the learning curve, however the quality of outcome was significantly improved after 250 cases. 1-year post-op PROs appear to continually improve even after cases 750-1000

The learning curve for anatomic and reverse total shoulder arthroplasty: a systematic review

Despite the rising incidence of anatomic total shoulder arthroplasty (ATSA) and reverse total shoulder arthroplasty (RTSA) among surgeons, little is known about the learning curve associated with these procedures. The purpose of this systematic review was to (1) identify the learning curves associated with ATSA and RTSA, (2) evaluate the effect of the learning curves on clinical outcomes, and (3) determine the number of cases needed to achieve proficiency. Four online databases [PubMed (NLM), MEDLINE (OVID), Cochrane Library (Wiley), and Scopus (Elsevier)] were systematically searched and screened according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. The search included results from the inception of each database to May 18, 2022. Data regarding study characteristics, patient demographics, learning curve analyses, patient reported outcome measures, range of motion, complication rates, and reoperationrates were collected. A quality assessment for each article was performed according to the Methodological Index for Nonrandomized Studies criteria. A total of 13 studies of fair to good quality were included for analysis (one of level II evidence, five of level III, and seven of level IV) with the majority originating from the United States [n= 8, 61.5%]. Overall, there were a total of 3381 cases (1861 RTSA and 1520 ATSA), with a mean patient age of 72.6years [range: 45-92 years]. From the studies analyzed in this systematic review, for RTSA, the approximate average number of cases surgeons need to perform to move to an acceptable position on the RTSA learning curve is 25 cases. For ATSA, a wider range of 16-86 cases was derived as only two studies reported on ATSA. Progression along the learning curve for RTSA and ATSA results in decreased operative times, improved patient-reported outcomes, and fewer complications. However, a true learning curve is difficult to quantify given the heterogeneity of reported outcome measures, individual surgeon experience at the time of data collection, and statistical analyses used across studies.

Cumulative sum analysis for the learning curve of minimally invasive mitral valve repair.

Minimally invasive mitral valve repair, recently, has become an alternative procedure to conventional mitral valve surgery, given its clinical benefits. Understanding the learning curve of a new procedure is important prior to its introduction. This study aimed to evaluate the learning curve for minimally invasive mitral valve repair and safety during the start-up period. The first 100 consecutive patients who underwent isolated minimally invasive mitral valve repair for mitral valve regurgitation were evaluated. The procedure was performed by a single surgeon at a single institution. Calculated cumulative sum analysis and cubic spline curve analysis were performed to evaluate the learning curves for the total procedure (TP), extracorporeal circulation (ECC), and aortic cross-clamping (ACC) times. ACC time was affected by the complexity of individual mitral valve repair; therefore, we analyzed the TP minus ACC (TP-ACC) time as a true learning curve by subtracting the ACC time from the TP time to exclude the difference of the complexity. Additionally, the operative outcome was assessed. Overall, the average TP, ECC, ACC, TP-ACC times were 211 ± 41, 133 ± 35, 108 ± 31, and 104 ± 4.9min, respectively. All cubic spline curves depicted a decreasing trend, and improvements in TP, ECC, and ACC times were observed after 56 cases, while those of the TP-ACC time were observed after 68 cases. None of the patients experienced hospital mortality, reoperation for bleeding, respiratory failure, cerebral infarction with a disability, or recurrence of mitral valve regurgitation. Acute renal failure occurred in one patient. In conclusion, minimally invasive mitral valve repair can be introduced safely and provide a favorable outcome. However, a learning curve exists for the operative time factors. Approximately 60 operations are required to achieve a consistent operative time.

The learning curve for the direct anterior total hip arthroplasty: a systematic review.

The direct anterior approach (DAA) for total hip arthroplasty (THA) is a muscle-sparing approach thought to have less post-operative pain and quicker recovery, with similar functional outcomes to other approaches. However, it is technically challenging and transitioning surgeons may experience increased complication rates. The purpose of this systematic review is to identify reported learning curves associated with the DAA. Three databases (MEDLINE, Embase, and Web of Science) were searched using terms including "total hip arthroplasty," "direct anterior approach," and "learning curve." Study characteristics, patient demographics, learning curve analyses, and complications were abstracted. Twenty-one studies met inclusion criteria, with a total of 9738 patients (60% female), an average age of 63.7 years (range: 13-94), body mass index of 27.0 kg/m2 (range: 16.8-58.9), and follow-up of 19 months (range: 1.5-100). There were five retrospective cohort studies and 13 case series representing fair methodological quality. Six studies depicted a true learning curve, with mean operative time of 156.59 ± 41.71 minutes for the first case, 93.18 ± 14.68 minutes by case 30, and 80.45 ± 12.28 minutes by case 100. Mean complication rate was 20.8 ± 12.7% in early groups and decreased to 7.6 ± 7.1% in late groups. This review demonstrated a substantial learning curve associated with the DAA to THA. Operative time plateaued after approximately 100 cases. Complication rates decreased substantially from early to late groups.

Assessment of Advanced Perioperative Outcomes to Identify the True Learning Curve of Robotic-assisted Partial Nephrectomy

ObjectivesTo evaluate the learning curve of robotic-assisted partial nephrectomy as it pertains to operative time (OT) and advanced perioperative variables such as achievement of trifecta, postoperative complications, 30-day readmission rates (RR), warm ischemia time (WIT), and functional volume loss (FVL). MethodsWe evaluated 418 consecutive robotic-assisted partial nephrectomy performed by a single surgeon between February 2008 and April 2019. Multivariable log-log regression models were used to evaluate the associations between case number and continuous outcomes (OT, WIT, and FVL). Multivariable logistic regression models were used to evaluate the association of case number with dichotomous outcomes (trifecta, postoperative complications, RR). ResultsAmong the 406 eligible patients included in the study, 252 (62.1%) were male, median age was 63 years (range, 22-84), and median body mass index was 29 kg/m2 (interquartile range 26-33). Surgeon experience was associated with shorter OT (−2.5% per 50% increase in case number; 95% confidence interval; P <.001) and plateaus around 77 cases performed. There was slight improvement with trifecta (odds ratio [per 50% increase in cases] = 1.08; 95% confidence interval) and the plateau was also at 77 cases, however, this was not statistically significant (P = .086). We did not find statistically significant associations of surgeon experience with FVL (P = .77), postoperative complications (P = .74), WIT (P = .73), or 30-day RR (P = .33). ConclusionThere does not appear to be a relationship between surgical experience and grade 3 or higher postoperative complications, 30-day RR, WIT, or FVL. Trifecta outcomes and maximum OT performance appear to be optimized at approximately 77 cases.

Surgical learning curve for robotic multiplex partial nephrectomy: The National Cancer Institute Experience.

660 Background: Multiplex partial nephrectomy (MPN) remains the standard of care for hereditary and bilateral kidney tumors. Our institution is an international referral center for the management of hereditary renal cell carcinoma, and therefore has considerable experience with MPN. The objective of this study was to evaluate surgical learning curve for MPN among multiple surgeons at a single institution over an 11-year period. Methods: Retrospective review of a prospectively maintained registry of patients who underwent MPN from 2007-present. The first 100 consecutive surgeries of 3 NIH fellowship trained Urologic Oncologists were identified and evaluated in quartiles. Surgical outcome measures including operative duration (OD), estimated blood loss (EBL), number of tumors resected, and complication rate were chosen as surrogate markers of learning curve. Differences in individual surgeon outcomes were evaluated and variables including re-do surgery and surgical approach were considered. Significant differences found among quartiles or among surgeon were evaluated with multivariate logistic regression analysis. Results: A total of 300 MPN's were identified. In the quartile analysis, there were no significant differences in OD, EBL, numbers of tumors resected or rates of complication. Among surgeon factors, there were differences in surgical approach and EBL (table). In a multivariate analysis of factors associated with EBL, open approach (95%CI 245-831), p &lt; 0.0001) and number of tumors (95%CI 43-82), p &lt; 0.0001) were independently associated. No factors were associated increased rate of complication. Conclusions: As surgeons progressed through their first 100 operations, no true learning curve was appreciated, with similar outcomes in each quartile. Among surgeon factors, open surgical approach appears to drive difference in EBL.[Table: see text]

True learning curve of laparoscopic spleen-preserving distal pancreatectomy with splenic vessel preservation

Laparoscopic distal pancreatectomy (LDP) is generally the treatment of choice for diseases of the pancreatic body and tail. Most surgeons prefer the spleen- and splenic vessel-preserving technique (SPVP-LDP) in benign/borderline pancreatic disease because complications of splenic infarction and gastric varices can arise after Warshaw technique. This study was aimed to determine the true learning curve of the SPVP-LDP procedure not LDP including Warshaw technique. Data were collected retrospectively from all patients who underwent a LDP between June 2007 and April 2017 at Gangnam Severance Hospital. We used cumulative sum control chart (CUSUM) analysis to assess the learning curve for the SPVP-LDP technique. Eight-three patients were performed LDP and we excluded patients who underwent robotic approach (N = 10) and open conversion DP (N = 8). Patients who underwent SPVP-LDP procedures were categorized into Group 1 (primary end-point). Those who underwent LDP procedures with splenectomy and the Warshaw technique were categorized into Group 2. We found that the 16th case was the cutoff point and the mean length of hospital stay was 13.0 days in the first period and 8.7 days in the second period (p = < 0.001). These results indicated that the frequency of SPVP-LDPs had increased and that technological progress had been made over time. The true learning curve for SPVP-LDP was indicated as 16 cases in a group of surgeons with no experience of laparoscopic pancreatic surgery.

True learning curve of laparoscopic spleen-preserving distal pancreatectomy with splenic vessel preservation.

Laparoscopic distal pancreatectomy (LDP) is generally the treatment of choice for diseases of the pancreatic body and tail. Most surgeons prefer the spleen- and splenic vessel-preserving technique (SPVP-LDP) in benign/borderline pancreatic disease because complications of splenic infarction and gastric varices can arise after Warshaw technique. This study was aimed to determine the true learning curve of the SPVP-LDP procedure not LDP including Warshaw technique. Data were collected retrospectively from all patients who underwent a LDP between June 2007 and April 2017at Gangnam Severance Hospital. We used cumulative sum control chart (CUSUM) analysis to assess the learning curve for the SPVP-LDP technique. Eight-three patients were performed LDP and we excluded patients who underwent robotic approach (N = 10) and open conversion DP (N = 8). Patients who underwent SPVP-LDP procedures were categorized into Group 1 (primary end-point). Those who underwent LDP procedures with splenectomy and the Warshaw technique were categorized into Group 2. We found that the 16th case was the cutoff point and the mean length of hospital stay was 13.0 days in the first period and 8.7 days in the second period (p = < 0.001). These results indicated that the frequency of SPVP-LDPs had increased and that technological progress had been made over time. The true learning curve for SPVP-LDP was indicated as 16 cases in a group of surgeons with no experience of laparoscopic pancreatic surgery.

Mastery in Bariatric Surgery: The Long-term Surgeon Learning Curve of Roux-en-Y Gastric Bypass.

To determine the effect of cumulative volume on all-cause morbidity and operative time. Gastric bypass is an important public health procedure, but it is difficult to master with little data about how surgeon cumulative volume affects outcomes longitudinally. This was a longitudinal study of 29 surgeons during the first 6 years of performing bariatric surgery in a high-volume, regionalized center of excellence system. Cumulative volume was determined using date and time of the procedure. Cumulative volume was analyzed in blocks of 75 cases. The main outcome of interest was all-cause morbidity during the index admission and the secondary outcome was operative time. Overall, 11,684 gastric bypasses were performed by 29 surgeons at 9 centers of excellence. The overall morbidity rate was 10.1% and short-term outcomes were related significantly to cumulative volume. Perioperative risk plateaued after approximately 500 cases and was lowest for surgeons who had completed more than 600 cases (odds ratio 0.53 95% confidence interval 0.26-0.96 P = 0.04) compared to the first 75 cases. Operative time also stabilized after approximately 500 cases, with an operative time 44.7 minutes faster than surgeons in their first 75 cases (95% confidence interval 37.0-52.4 min P < 0.001). The present study demonstrated the clear, substantial influence of surgeon cumulative volume on improved perioperative outcomes and operative time. This finding emphasizes role of the individual surgeon in perioperative outcomes and that the true learning curve needed to master a complex surgical procedure such as gastric bypass is longer than previously thought, in this case requiring approximately 500 cases to plateau.

Learning curve of sutureless transconjunctival 20-gauge vitrectomy.

BackgroundTo report the learning curve of transition from 20-gauge (20 G) conventional vitrectomy to a 20 G sutureless vitrectomy technique.Materials and methodsThis is a retrospective descriptive case study of 32 eyes from 32 consecutive patients who underwent sutureless 20 G pars plana vitrectomy. A 20 G microvitreoretinal blade was introduced, beveled transconjunctivally, slowly, parallel with the limbus, creating a conjunctivoscleral tunnel incision. Study participants were divided into three groups, and surgical time, induced astigmatism, and complications were compared.ResultsOf 32 consecutive patients, there was no significant difference in induced astigmatism or maneuvering between the early learning curve and other groups. The true learning curve was the first three patients. There were three cases where suturing the sclerotomy was necessary: one port in each case, three of 32 cases (9.3%), or three of 96 ports (2.9%).ConclusionThere were no significant difficulties in surgical maneuvers while performing 20 g sutureless vitrectomy.

Circulation : Clinical Summaries

<i>Circulation</i> : Clinical Summaries

Learning Minimally Invasive Mitral Valve Surgery

Background— Learning curves are vigorously discussed and viewed as a negative aspect of adopting new procedures. However, very few publications have methodically examined learning curves in cardiac surgery, which could lead to a better understanding and a more meaningful discussion of their consequences. The purpose of this study was to assess the learning process involved in the performance of minimally invasive surgery of the mitral valve using data from a large, single-center experience. Methods and Results— All mitral (including tricuspid, or atrial fibrillation ablation) operations performed over a 17-year period through a right lateral mini-thoracotomy with peripheral cannulation for cardiopulmonary bypass (n=3907) were analyzed. Data were obtained from a prospective database. Individual learning curves for operation time and complication rates (using sequential probability cumulative sum failure analysis) and average results were calculated. A total of 3895 operations by 17 surgeons performing their first minimally invasive surgery of the mitral valve operation at our institution could be evaluated. The typical number of operations to overcome the learning curve was between 75 and 125. Furthermore, &gt;1 such operation per week was necessary to maintain good results. Individual learning curves varied markedly, proving the need for good monitoring or mentoring in the initial phase. Conclusions— A true learning curve exists for minimally invasive surgery of the mitral valve. Although the number of operations required to overcome the learning curve is substantial, marked variation exists between individual surgeons. Such information could be very helpful in structuring future training and maintenance of competence programs for this kind of surgery.

Predictive factors of failure in management of ectopic pregnancy with single-dose methotrexate: a general population-based analysis from the Auvergne Register, France

In a general population setting, the existence of a learning curve for treatment of ectopic pregnancy with single-dose methotrexate has been demonstrated, because a significant decrease in failure rate can be achieved over time. Despite this finding, the risk of single-dose methotrexate failure increases significantly in patients with initial hCG levels>1,300 IU/L and/or in women who report having ever used combined oral contraception before pregnancy.

Extraperitoneal Laparoscopic Radical Prostatectomy: Clinical Experience and Learning Curve with 103 Cases

To estimate the early operative results and learning curve of extraperitoneal laparoscopic radical prostatectomy in 103 patients. Between March 2006 and January 2009, 103 patients with clinically organ-confined prostate cancer who underwent laparoscopic radical prostatectomy were enrolled in this study. Surgical morbidity and the oncologic and functional results of the groups were compared to evaluate the learning curve. The patients' mean age was 63.3±8.1 years, and their mean serum PSA was 14.1±7.6 ng/ml. The mean operating time and hospital stay were 265±83 minutes and 10.6±3.6 days, respectively. The mean postoperative period of an indwelling Foley catheter was 13.8±2.7 days. The positive surgical margin rate was 26.2%. After a mean follow-up of 15.5±9.4 months, a PSA relapse was observed in 3 (8.6%) patients in the first period. Continence and sufficient erection rates were about 80% and 45% after 6 months, respectively. Analysis of the learning curve revealed differences in the operating time, estimated blood loss, and complication rate but showed no influence on hospital days, indwelling Foley catheter days, or positive surgical margin rate. Although laparoscopic radical prostatectomy requires significant expertise with a learning curve, morbidity is low and the oncologic continence results were promising. Extraperitoneal laparoscopic radical prostatectomy could be considered as the first safe treatment for patients with organ-confined prostate cancer. The learning curve for extraperitoneal laparoscopic radical prostatectomy seemed to show no complete plateau in this study. It depended not only on technical skills, but also on self-perceived skills. Standardized expectations and operative outcomes could help to define the true learning curve for extraperitoneal laparoscopic radical prostatectomy.

Laparoscopic Radical Prostatectomy: the Learning Curve of the Initial 150 Cases

Purpose: We evaluated the early results and the learning curve of laparoscopic radical prostatectomy in the first 150 patients. Materials and Methods: Between July 2001 and March 2007, 150 consecutive patients with clinically organ-confined prostate cancer underwent laparoscopic radical prostatectomy. For evaluation of the learning curve, morbidity, oncologic, and functional results of the first 50 (group 1) and last 50 (group 3) procedures were compared. Results: The mean operating time and hospital stay was 289±66 minutes and 6.3±2.9 days, respectively. The median postoperative period of an indwelling Foley catheter was 5 days (range, 3-46 days). The intraoperative complication rate, including transfusion, was 15.3%. A positive surgical margin rate was 37.3%. After a mean follow-up of 33.5 months, a PSA relapse was observed in 39 (33.6%) patients. The continence rate was 77.1, 92.2, and 93.7% at 1, 6, and 12 months. Analysis of the learning curve revealed significant differences in the operating time, hospital stay, intraoperative complication rate, and indwelling Foley catheter days, whereas the postoperative complication rate, mean estimated blood loss, positive surgical margin rate, and continence rate 6 months postoperatively showed no influence. Conclusions: Although laparoscopic radical prostatectomy requires significant expertise with a learning curve, the morbidity is low and the oncologic continence result was promising. The learning curve for laparoscopic radical prostatectomy depends not only on the technical skills, but also on the self-perceived definition. It is likely that no complete plateau of the learning curve exists for any article. Standardized expectations and reporting of outcomes could help to better define the true learning curve for laparoscopic radical prostatectomy. (Korean J Urol 2008;49:879-885) 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏

Follow-up results and learning curve in laparoscopic gastrofundoplications

To analyze the postoperative results and the learning curve of laparoscopic gastrofundoplications by postoperative clinical monitoring of consequences and self-evaluation of complaints 12 months after surgery. One hundred patients (58 female and 42 male) were operated at the Department of Surgery, Hospital of Kaunas University of Medicine, from April 1998 to January 2001 because of hiatal hernias, complicated with gastroesophageal reflux (in 59 cases sliding axial non-fixed, in 38 cases sliding axial fixed, and in 3 cases paraesophageal hernias were found). 89 Nissen and 11 Toupet fundoplications were performed. Patients were distributed into five groups (20 patients in each). Operation time, number of postoperative complications, postoperative hospital stay were analyzed. The mean operation time was 198 min in the 1 st group, 105 min in the 2 nd group, 110 min in the 3 rd group, 124 min in the 4 th group and 120 min in the 5 th group. Conversion to laparotomy was necessary in two cases (the 1 st and the 2 nd groups). The number of postoperative complications decreased from 5 in the 1 st group to 2 in the 2 nd group, and to 1 in the 3 rd and 4 th groups; no complications were noted in the 5 th group. According patient's opinion, successful results were received in 87 %. Laparoscopy is a good approach for surgical management of hiatal hernias complicated with gastroesophageal reflux, but laparoscopic gastrofundoplication needs advanced skills to be performed safely. The learning curve in terms of operation time covered initial 20 procedures and remained stable afterwards, the number of postoperative complications decreased after initial 20 operations, but dangerous complications occurred until the 60 th procedure. Other conventional elective surgical procedures of medium extent can be successfully performed simultaneously with laparoscopic fundoplication without affecting the outcome. The true learning curve of laparoscopic fundoplication can be drawn by careful follow-up and analysis of long-term postoperative results; this enables to improve operative techniques.