The learning curve of laparoscopic rectal cancer surgery of millennial surgeons: Lessons for a safe implementation in low- and middle-income countries.

Objective: This study aimed to analyse the learning curve (LC) in laparoscopic rectal cancer resections of 2 millennial surgeons during the implementation of the first laparoscopic rectal cancer surgery programme in low- and middle-income country (LMIC) cancer centre. Methods: All consecutive patients operated by two millennial surgeons for primary rectal adenocarcinoma between January 2018 and March 2020 were included. The LC was analysed for operative duration and conversion to open surgery using both cumulative sum (CUSUM) and/or variable life-adjusted display (VLAD) charts. Results: Eighty-four patients were included, 45 (53.6%) men with a mean age of 57.3 years. Abdominoperineal resection was performed in 31 (36.9%) cases and resections were extended to other organs in 20 (23.8%) patients. Thirteen patients (15.5%) had conversion to open surgery. Using CUSUM, Learning curve based on conversion was completed at 12 cases for the first surgeon versus 10 cases for the second. While using VLAD and learning curve-CUSUM (LC-CUSUM), the cases needed were 26 vs 24 respectively. The median operative duration was 314 min with a LC completed at cases (17 vs. 26), and (18 vs. 29) using, respectively, standard and LC-CUSUM. Conclusions: This study shows a safe and short LC of millennial surgeons during the implementation of a laparoscopic rectal cancer surgery in an LMIC cancer centre, and the valuable use of modern statistical methods in the prospective assessment of LC safety during surgical training.

Available prediction scores of conversion for laparoscopic rectal cancer surgery seem to be unsuitable for nowadays rectal cancer management.

INTRODUCTION: This study aimed to externally evaluate the accuracy of four predictive scores for conversion to open surgery after rectal laparoscopic resection. None of the four scores achieved external validation previously. METHODS: This was a retrospective analysis of two prospectively maintained databases from two academic centers in France and Morocco. All consecutive patients who underwent laparoscopic resection for rectal adenocarcinoma between 2005 and 2020 were included. Logistic regression was used to assess the association between the factors present in the four scores and conversion. The accuracy of each score was assessed using the area under the curve (AUC). Observed and predicted conversion rates were compared for each score using the Chi-square goodness-of-fit test. RESULTS: Four hundred patients were included. There were 264 men (66%) with a mean age of 65.95 years (standard deviation 12.2). The median tumor height was 7 cm (quartiles 4-11) and 29% of patients had low rectal tumors. Conversion rate was 21.75%. The accuracy to predict conversion was low with an AUC lower than 0,62 for the four models. The observed conversion rates were significantly different from the predicted rates, except for one score. CONCLUSIONS: The four models had low accuracy in predicting the conversion to open surgery for laparoscopic rectal resection. There is a need for new well-designed studies, analyzing more specific variables, in a multicentric design to ensure generalizability of the results for daily surgical practice.