Ann Hepatobiliary Pancreat Surg.  2021 Feb;25(1):54-61. 10.14701/ahbps.2021.25.1.54.

Surgical outcomes of perihilar cholangiocarcinoma based on the learning curve of a single surgeon at a tertiary academic hospital: A retrospective study

• Park HJ
• Han DH
• Choi GH
• Choi JS

• KMID: 2513176
• DOI: http://doi.org/10.14701/ahbps.2021.25.1.54

Abstract

Backgrounds/Aims
Although it is difficult to master the surgical learning curve for treatment of perihilar cholangiocarcinoma (HCCA), there have been no studies on surgical outcomes between a novice and an experienced surgeon. Thus, the current study attempted to evaluate surgical outcomes from a single surgeon based on learning curve for surgical treatment of HCCA.
Methods
From January 2008 to December 2016, a single surgeon performed surgical treatment for 108 patients with HCCA at Severance Hospital, Seoul, Korea. Among them, 101 patients with curative surgical resection were included in this study. The learning curve was assessed by a moving average graph and CUSUM method using operation time. Surgical outcomes between the early period group (EPG) and the late period group (LPG) were compared according to learning curve.
Results
Operation time (603.17±117.59 and 432.03±91.77 minutes; p＜0.001), amount of bleeding during operation (1127.86±689.54 and 613.05±548.31 ml; p＜0.001), and severe complication rates (47.6% and 27.1%, p=0.034) were significantly smaller in the LPG. There was no significant difference in R0 resection rate (85.7% and 76.3%; p=0.241) as well as long-term survival rate.
Conclusions
In this study, operation time, amount of bleeding during operation, length of hospital stay, and severe complication rate were improved after stabilization of the learning curve. However, R0 resection rate and survival outcomes were not significantly influenced by the learning curve for surgical treatment of HCCA.

Keyword

Perihilar cholangiocarcinoma; Learning curve; Surgical outcome

Figure

• 

  Fig. 1 Flow diagram of study design. For the study, 101 of 108 consecutive patients who underwent surgical treatment for HCCA were selected. Of these, 73 patients with one-side liver resection without vascular resection were selected to evaluate the learning curve. The 27th of 73 selected patients was the first test patient after stabilization of the learning curve. This 27th patient was matched to the 43rd consecutive of 101 patients. Thus, the study group was subdivided into the early period group (n=42) and the late period group (n=59).

• 

  Fig. 2 CUSUM and moving average graph by operation time for evaluating the learning curve. (A) CUSUM with operation time for 73 consecutive patients with hemi-hepatectomy or trisectionectomy without vascular resection. A CUSUM=0 meant the operation time was the same as the mean operation time. A positive CUSUM meant the operation time was shorter than the mean operation time. The operation times were steadily shorter than the mean operation time after the 27th case. (B) Moving average graph for each of five serial cases. A logistic regression graph was drawn to identify the learning achievement point. The steep slope of the logistic regression graph before the 27th case started to flatten after the 27th case. Thus, the learning curve may be stabilized after the 27th of 73 consecutive patients.

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  Fig. 3 Early versus late period group assignment according to case-matching. The 27th of 73 patients with a one-side hepatectomy without vascular resection (b, green bar) was matched to the 43rd of 101 consecutive patients. The first 42 patients were classified as the early period group, and the subsequent 59 patients were classified as the late period group.

• 

  Fig. 4 Comparison Overall survival and Disease free survival graph between two groups. (A) The 5-year overall survival rate was 21.6% and 37.8% in the EPG and LPG, respectively (p=0.412). (B) The 5-year disease free survival rate was 28.5% and 30.2% for the EPG and LPG, respectively (p=0.642).

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