Early National Experience with Laparoscopic Pancreaticoduodenectomy for Ductal Adenocarcinoma: Is This Really a Short Learning Curve?

Abstract

We read with interest the article by Sharpe and colleagues in which outcomes from patients undergoing laparoscopic pancreaticoduodenectomy (LPD) were compared with those from patients having open PD. The authors reported higher adjusted 30-day mortality in the LPD group. To investigate this relationship, they dichotomized hospitals based on a volume cutoff of 10 LPDs, demonstrating higher mortality rates only in the <10 LPD group, concluding that there is a learning curve for PD that is surmountable. In our current competitive health care environment, there is a temptation for rapid introduction of minimally invasive techniques, but widespread adoption without introspection might cause harm. We commend the authors for a timely analysis on the matter in PD, but express concerns about the exclusion from the analysis of LPD cases that were converted to open PD, which, in combination with other confounders, such as tumor location and vessel involvement, introduces selection bias. In a similar study, Abdelgadir Adam and colleagues used intentionto-treat to evaluate minimally invasive PD, and the conversion rate was 30%. It is likely that if Sharpe and colleagues had used this criterion, the outcomes of LPD would be less favorable. The authors performed a sensitivity analysis on the minimum case cutoff for LPD and identified 10 cases as the learning curve minimum threshold before mortality risk evened out. It is important to emphasize that this was a cross-sectional analysis aggregating all the data for a hospital or surgeon down to a single number, reflecting a volume to outcomes relationship. A learning curve, by contrast, is an analysis of repeated measures of the same surgeon or hospital at multiple time points. For example,

DOI: 10.1016/j.jamcollsurg.2015.11.004

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@article{Fong2016EarlyNE, title={Early National Experience with Laparoscopic Pancreaticoduodenectomy for Ductal Adenocarcinoma: Is This Really a Short Learning Curve?}, author={Zhi Ven Fong and David C. W. Chang and Cristina Rosa Ferrone and Keith D. Lillemoe and Carlos Fernandez del Castillo}, journal={Journal of the American College of Surgeons}, year={2016}, volume={222 2}, pages={209} }