腹腔镜前列腺切除术的学习曲线累积较慢


  April 2, 2009 — 根除性前列腺切除术后,复发风险与执刀医师的经验有强烈关联。不论开腹或者腹腔镜手术皆是如此。不过,研究者报告指出,腹腔镜根除性前列腺切除术的手术学习曲线(藉由增加医师经验而改善手术结果)比开腹手术累积来得慢。
  
  在线登载于4月1日Lancet Oncology期刊的研究指出,曾经有开腹根除性前列腺切除术经验的医师,结果显然比那些初次接触手术即为腹腔镜方式的医师差(风险差异为12·3%; 95%信心区间[CI]为8·8–15·7)。
  
  主要作者、副主治医师、研究方法论学者、纽约市Sloan-Kettering纪念癌症中心的Andrew Vickers博士表示,有些医师从未跟上学习曲线,这得纳入考量。如果他们每年只有进行少数几次根除性前列腺切除术,他们将很难跟上学习曲线。适当治疗前列腺癌需要许多手术经验。
  
  Vickers博士指出,之前的开腹根除性前列腺切除术经验反而让学习结果较差、且成为进行腹腔镜手术的一个风险因素,这有点令人惊讶。他在受访时表示,其中的一个可能是从腹腔镜所看到的视野不同,这需要医师从开放术野转换调适。
  
  如果这些结果获得再现,这些发现将对外科实务有重要影响,因为他们认为医师不需要在缺乏令人信服的理由下,在两种术式之间转换。
  
  【复发随经验降低】
  在之前的研究中,Vickers博士等人发现,经验丰富医师治疗的前列腺癌病患,无癌症存活比经验少之医师的病患多5年(J Natl Cancer Inst. 2007;99:1171–1177)。有10次以上手术经验医师的病患,术后5年复发风险为17.9%,手术经验有250次医师的病患,此复发风险只有10.7%。
  
  研究者在目前的研究中指出,随著执刀医师经验增加,腹腔镜根除性前列腺切除术后的癌症复发可能性减少,不过腹腔镜手术结果之改善似乎比开腹手术慢。
  
  研究者进行回溯多中心世代研究,对象为于1998年1月至2007年6月间,以腹腔镜治疗的4,702名前列腺癌病患。他们使用多变项模式评估每次手术时的医师手术经验与前列腺癌复发之间的关联,并根据已知的预测因子校正。
  
  总共有402件生化复发,5年无复发可能性为82% (95% CI, 80–84),平均追踪1.7年。
  
  【5 年复发风险*】

进行过之腹腔镜手术经验次术 , n

复发风险

10

17%

250

16%

750

9%


  *案例混合校正
  
  他们的分析显示,医师必须进行过将近750件腹腔镜手术,才可以达到和进行过250次传统手术的医师一样的疾病复发率。
  
  【需要更多资料】
  根据作者表示,对此可能有一些解释。其一为,腹腔镜根除式前列腺切除术本就比较难学。其二,除了增加个别医师的经验之外,腹腔镜学习曲线反映出专业调整而非技术。开腹根除性前列腺切除相对上是比较成熟的技术,而腹腔镜是最近才发展的手术技术。
  
  Vickers博士表示,我们的资料引起一些重要问题。医师一般会在两种技术之间变换,但是我们的资料显示,这有危险。医界必须决定医师是否须转换技术。
  
  他指出,我们也报告,有经验和无经验医师之间的复发率差异有8%。有经验的医师有比较低的复发率,所以我们需要了解之间的差异。
  
  国家癌症研究中心、Allbritton基因会以及David J. Koch基金会赞助本研究。研究者宣告没有相关财务关系。
  
  Lancet Oncol. 于印刷前在线登载于2009年4月1日。
  

Learning Curve Accrues More Slowly for Laparoscopic Prostatectomy

By Roxanne Nelson
Medscape Medical News

April 2, 2009 — After a radical prostatectomy, the risk for recurrence is strongly affected by the experience of the operating surgeon. This is true for both open and laparoscopic procedures. However, researchers report that the learning curve for surgery — improvement in surgical outcomes with increasing surgeon experience — appears to accrue more slowly for laparoscopic radical prostatectomy than for open surgery.

The authors of a study published online April 1 in the Lancet Oncology note that surgeons with previous experience in open radical prostatectomy had significantly poorer results than those whose first operation was laparoscopic (risk difference, 12·3%; 95% confidence interval [CI], 8·8–15·7).

"Some clinicians are never going to get up on the learning curve, and that needs to be taken into consideration," said lead author Andrew Vickers, PhD, associate attending research methodologist at Memorial Sloan-Kettering Cancer Center, in New York City. "If they are only doing a handful of radical prostatectomies a year, then they are going to have a hard time getting up on the learning curve. A great deal of surgical experience is required to treat prostate cancer optimally."

A great deal of surgical experience is required to treat prostate cancer optimally.

Dr. Vickers pointed out that it was somewhat surprising that previous open radical prostatectomy experience would lead to poorer outcomes, and that it was a risk factor when it came to performing laparoscopic procedures. "One explanation for this may be that the anatomy looks different when viewed through a laparoscope," he said in an interview. "It may take surgeons a while to adjust from open surgeries."

If the data are replicated, these findings may have important implications for surgical practice, because they suggest that surgeons should not switch back and forth between techniques without a compelling reason to do so, he explained.

Recurrences Decrease With Experience

In a previous study, Dr. Vickers and colleagues found that prostate cancer patients treated by highly experienced surgeons were far more likely to be cancer-free 5 years after surgery than patients treated by surgeons with less experience (J Natl Cancer Inst. 2007;99:1171–1177). The risk for recurrence 5 years after surgery was 17.9% for patients treated by surgeons who had performed 10 previous operations and 10.7% for those treated by surgeons who had performed 250 previous surgeries.

The probability of cancer recurrence after laparoscopic radical prostatectomy declined as the experience of the operating surgeon increased, the researchers note in the current study, but surgical outcome seemed to improve more slowly for laparoscopic than for open surgery.

The researcher conducted a retrospective multicenter cohort study of 4702 patients with prostate cancer treated laparoscopically between January 1998 and June 2007. They used multivariable models to assess the association between surgeon experience at the time of each surgery and prostate cancer recurrence, adjusted for established predictors.

There were a total of 402 biochemical recurrences, with a 5-year recurrence-free probability of 82% (95% CI, 80–84), with a median follow-up of 1.7 years.

Risk for Recurrence at 5 Years*
Previous Laparoscopic Procedures Performed, n Risk for Recurrence
10 17%
250 16%
750 9%
*Model adjusted for case mix

Their analysis showed that surgeons had to perform approximately 750 laparoscopic surgeries before they achieved the same low level of disease recurrence as other surgeons achieved after 250 traditional operations.

More Data Needed

According to the authors, there are a number of possible explanations for this observation. One is that laparoscopic radical prostatectomy may be inherently more difficult to learn. Another reason is that in addition to increasing experience of an individual surgeon, the laparoscopic learning curve may reflect profession-wide modifications to the technique. Open radical prostatectomy is a relatively mature procedure, they write, whereas laparoscopy is a much more recently developed surgical technique.

"Our data raise some important questions," said Dr. Vickers. "Surgeons commonly switch between techniques, but our data showed that a danger was associated with that. The surgical community needs to decide whether or not surgeons should switch techniques."

"We also report an 8% difference in recurrence rates between experienced and inexperienced surgeons," he added. "Experienced surgeons have lower recurrence rates, so we need to learn what they are doing differently."

The study was funded by the National Cancer Institute, the Allbritton Fund, and the David J. Koch Foundation. The researchers have disclosed no relevant financial relationships.

Lancet Oncol. Published online before print April 1, 2009.

    
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