Abstract
Background
This study was conducted to evaluate the leaning curve of D2 lymph node dissection for patients with gastric cancer in a high-volume center.
Methods
The authors prospectively reviewed the data of all patients who underwent total gastrectomy with D2 lymph node dissection during a 4-year period. Retrieved lymph node number was used as a surrogate marker of oncological outcome. The retrieved lymph node number cut-off value required for satisfactory D2 lymph node dissection was defined as >25. Cumulative sum analysis was used to examine the learning curves of individual surgeons at target accuracy rates of 85%, 90%, 92.5%, 95%, and 98%.
Results
Two junior staff surgeons performed 198 curative-intent total gastrectomies with D2 lymph node dissections during the study period; their success rates exceeded 90%. Operating time decreased with operative experience (Pearson correlation coefficient = −0.515, P < 0.001). The learning period for total gastrectomy with D2 lymph node dissection for these two junior members of staff was calculated as 23–35 cases, presuming a 92.5% success rate.
Conclusions
The current study suggests that the surgical learning period for D2 lymph node dissection extends to at least 23 cases or 8 months. In clinical trials containing gastric cancer surgery, the learning curve for qualified surgery from the standpoint of oncological outcome should be considered to minimize bias due to surgeon-associated factors.
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References
Kim JP. Surgical results in gastric cancer. Semin Surg Oncol 1999; 17:132–8
Shin HR, Ahn YO, Bae JM, et al. Cancer incidence in Korea. Cancer Res Treat 2002; 34:405–08
Schwarz RE, Smith DD. Extended lymph node dissection for gastric cancer: who may benefit? Final results of the randomized Dutch Gastric Cancer Group trial. J Clin Oncol 2005; 10:5404–05
Brennan MF. Lymph node dissection for gastric cancer. N Engl J Med 1999; 340:956–7
Yoo CH, Noh SH, Shin DW, et al. Recurrence following curative resection for gastric carcinoma. Br J Surg 2000; 87:236–42
Bonenkamp JJ, Hermans J, Sasako M, et al. Extended lymph-node dissection for gastric cancer. Dutch Gastric Cancer Group. N Engl J Med 1999; 340:908–14
Cuschieri A, Fayers P, Fielding J, et al. Postoperative morbidity and mortality after D1 and D2 resections for gastric cancer: preliminary results of the MRC Randomised Controlled Surgical Trial. The Surgical Cooperative Group. Lancet 1996; 347:995–9
Macdonald JS, Smalley SR, Benedetti J, et al. Chemoradiotherapy after surgery compared with surgery alone for adenocarcinoma of the stomach or gastroesophageal junction. N Engl J Med 2001; 345:725–30
Stocchi L, Nelson H, Sargent DJ, et al. Impact of surgical and pathologic variables in rectal cancer: a United States community and cooperative group report. J Clin Oncol 2001; 15:3895–902
Japanese Research Society for Gastric Cancer. Japanese Classification of Gastric Carcinoma. Tokyo: Kanehara, 1–71, 1995
Sobin LH, Wittenkind C. International Union Against Cancer (UICC) TNM Classification of Malignant Tumours, 5th ed. New York: Wiley-Liss, pp 59–62, 1997
Tekkis PP, Senagore AJ, Delaney CP, et al. Evaluation of the learning curve in laparoscopic colorectal surgery: comparison of right-sided and left-sided resections. Ann Surg 2005; 242:83–91
Parikh D, Johnson M, Chagla L, et al. D2 gastrectomy: lessons from a prospective audit of the learning curve. Br J Surg 1996; 83:1595–9
Wagner PK, Ramaswamy A, Ruschoff J, et al. Lymph node counts in the upper abdomen: anatomical basis for lymphadenectomy in gastric cancer. Br J Surg 1991; 78:825–7
Siewert JR, Bottcher K, Stein HJ, et al. Relevant prognostic factors in gastric cancer: ten-year results of the German Gastric Cancer Study. Ann Surg 1998; 228:449–61
Callahan MA, Christos PJ, Gold HT, et al. Influence of surgical subspecialty training on in-hospital mortality for gastrectomy and colectomy patients. Ann Surg 2003; 238:629–36
O’Connor GT, Plume SK, Olmstead EM, et al. A regional intervention to improve the hospital mortality associated with coronary artery bypass graft surgery. The Northern New England Cardiovascular Disease Study Group. JAMA 1996; 20:841–6
Hillner BE, Smith TJ, Desch CE. Hospital and physician volume or specialization and outcomes in cancer treatment: importance in quality of cancer care. J Clin Oncol 2000; 18:2327–40
Feinstein AR, Sosin DM, Wells CK. The Will Rogers phenomenon: stage migration and new diagnostic techniques as a source of misleading statistics for survival in cancer. N Engl J Med 1985; 20:1604–08
Dahr DK, Kubota H, Tachbana M, et al. Body mass index determines the success of lymph node dissection and predicts the outcomes of gastric carcinoma patients. Oncology 2000; 59:18–23
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Lee, J.H., Ryu, K.W., Lee, JH. et al. Learning Curve for Total Gastrectomy with D2 Lymph Node Dissection: Cumulative Sum Analysis for Qualified Surgery. Ann Surg Oncol 13, 1175–1181 (2006). https://doi.org/10.1245/s10434-006-9050-8
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DOI: https://doi.org/10.1245/s10434-006-9050-8