Analysis of the learning process for laparoscopic sleeve gastrectomy: CUSUM-curve of 110 consecutive patients with 1-year follow-up.

ABSTRACT

INTRODUCTION: Laparoscopic sleeve gastrectomy (LSG) is the most popular bariatric procedure worldwide. A tremendous recent increase in the number of LSGs has not been driven by an accurate learning process, especially in low volume bariatric centers. The cumulative-sum (CUSUM) method is an effective analysis of the learning process, taking intraoperative and postoperative variables into account. This study was aimed at establishing a CUSUM learning curve for LSG in order to define the number of procedures needed to achieve sufficient surgical skill. METHODS: All LSGs performed by a single general surgeon between September 2014 and November 2017 were considered. We hypothesized that the key t variables related to the LSG learning process (LP) are operative time (OT), intraoperative complications or difficulties, need for expert assistance, length of hospital stay (LOS), and 3-month postoperative morbidity. All of these parameters are binary variables analyzed with the risk-adjusted CUSUM method. Two groups, learning group (LG) and experienced group (EG), were identified and compared by univariate analysis. Multivariate analysis was performed to identify the variables most closely associated with operative time and surgical success. One-year weight loss outcomes were likewise analyzed. RESULTS: One hundred and ten (110) consecutive LSGs were considered. CUSUM-LSG showed that the mean number of consecutive interventions necessary to reach proficiency in LSG was 58. In multivariate analysis, surgical success was negatively correlated with longer operative time and need for expert assistance. Body mass index was not correlated with surgical success. CONCLUSION: Fifty-eight LSG procedures were required to achieve surgical skill. Operative time and the need for expert assistance were variables most closely associated with surgical success. ACGME COMPETENCY Practice-based learning and improvement.