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The Learning Curve in Minimally Invasive Esophagectomy – Can This Be Reduced? A Systematic Review

Authors
Kai Siang CHAN1,2, Aung Myint OO1,2,3

Affiliations

  1. Department of General Surgery, Tan Tock Seng Hospital, Singapore
  2. Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
  3. Yong Loo Lin School of Medicine, National University of Singapore, Singapore

Introduction
Minimally-invasive esophagectomy (MIE) has changed the landscape in oesophageal cancer, with reduced morbidity and mortality, yet with comparable lymph node (LN) harvest compared with open esophagectomy. However, MIE is technically challenging. This study aims to review the number of cases required to overcome the learning curve (i.e. NLC) in MIE.

Methods
PubMed, Embase, Scopus, and the Cochrane Library were systematically searched on June 2022. Inclusion criteria were articles which reported LC in video-assisted MIE (VAMIE) and/or robot-assisted MIE (RAMIE). Poisson means (95% confidence interval (CI)) was used to determine NLC. Negative binomial regression was used for comparative analysis.

Results
There were 41 articles with 45 data sets (n= 7755 patients). Majority of tumors were located in the lower esophagus or gastroesophageal junction (66.7%, n=3962/5939). Majority of data sets on VAMIE (n=16/26, 61.5%) used arbitrary analysis, while majority of data sets (n=14/19, 73.7%) on RAMIE used cumulative sum control chart analysis. Most commonly outcomes reported were overall operating time (n=30/45) and anastomotic leak (n=28/45). There were 24 data sets (53.3%) which reported on LN harvest. The overall NLC was 34.6 (95% CI: 30.4-39.2), 68.5 (95% CI: 64.9-72.4), 27.5 (95% CI: 24.3-30.9) and 35.9 (95% CI: 32.1-40.2) for hybrid VAMIE, total VAMIE, hybrid RAMIE and total RAMIE respectively. NLC was significantly lower for total RAMIE compared to total VAMIE (incidence rate ratio: 0.52, p=0.032). One study showed that a proctorship programme reduced NLC from 70 cases (proctor) to 24 cases (mentee).

Conclusion
Studies reporting NLC in MIE are heterogeneous. Further studies should assess patient-reported outcome measures and long-term oncological outcomes using non-arbitrary analysis.