The learning curve of TaTME for mid-low rectal cancer: a comprehensive analysis from a five-year institutional experienc
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and Other Interventional Techniques
The learning curve of TaTME for mid‑low rectal cancer: a comprehensive analysis from a five‑year institutional experience Roberto Persiani1,2 · Annamaria Agnes1,2 · Francesco Belia2 · Domenico D’Ugo1,2 · Alberto Biondi1,2 Received: 28 May 2020 / Accepted: 16 October 2020 © The Author(s) 2020
Abstract Background Transanal total mesorectal excision (TaTME) was introduced in 2009 as a dedicated approach for the treatment of mid-low rectal cancer. We aimed to describe and discuss the learning curve for 121 consecutive TaTME procedures performed by the same team. Methods The primary outcome was the number of operations required to decrease the mean operative time (mOT). The secondary outcomes were the number of operations required to decrease the major complication (MC) rate, the anastomotic leakage (AL) rate, the clinical anastomotic failure rate, and the reoperation rate. A cumulative sum (CUSUM) curve analysis was used to identify the inflection points. As an integrative analysis, Bernoulli CUSUM curves, risk-adjusted CUSUM curves based on the observed-expected outcomes, and CUSUM curves targeting results reported in the literature were created. Results Seventy-one cases were needed to overcome the OT learning curve sufficiently to reach mastery. The MC and reoperation rates started to decrease after the 54th case and further decreased after the 69th case. The AL rate started to decrease after the 27th case and remained stable at 5–5.1%. The comparison between the different phases of the learning curves confirmed these turning points. Conclusions TaTME had a learning curve of 71 cases for the mOT, 55–69 cases for MCs and reoperation, and 27 cases for AL. According to our results, attention should be paid during the first part of the learning curve to avoid an increased rate of MCs and AL. Keywords TaTME · Transanal total mesorectal excision · Learning curve · CUSUM · Recurrence Rectal resection with total mesorectal excision (TME) is accepted as the surgical standard for the treatment of rectal cancer [1, 2]. The non-inferiority of laparoscopic compared to open TME in terms of disease-free survival (DFS) has been demonstrated in the phase III COREAN and COLOR II trials [3, 4]. However, two recent randomized controlled trials (RCTs) failed to demonstrate the non-inferiority of the Electronic supplementary material The online version of this article (https://doi.org/10.1007/s00464-020-08115-0) contains supplementary material, which is available to authorized users. * Alberto Biondi [email protected] 1
Dipartimento Scienze Mediche e Chirurgiche, UOC di Chirurgia Generale, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli n. 8, 00168 Rome, Italy
Università Cattolica del Sacro Cuore, Largo Francesco Vito n. 1, 00168 Rome, Italy
2
minimally invasive approach compared to the open approach in terms of pathological results [5, 6]. Laparoscopic TME is associated with increased surgical difficulty when some clinical and anat
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