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Objective: To describe the learning curve for the performance of minimally invasive Ivor Lewis esophagectomy.
Design: Retrospective case series.
Setting: Academic tertiary care center.
Patients: Eighty consecutive patients undergoing minimally invasive Ivor Lewis esophagectomy by a single surgeon. Patients were divided into two groups with 40 patients each in chronological order defining early and late experience groups.
Interventions: Minimally invasive Ivor Lewis esophagectomy.
Main Outcome Measures: Conversion to open procedure, surgical time, estimated blood loss, duration of chest drainage, initiation of oral intake, hospital length of stay, postoperative morbidity and mortality. Cumulative sum analysis (CUSUM) was calculated as the running total of differences between individual data points and the mean for all data points.
Results: Open conversion occurred in 2 (5%) patients in the early group (p=0.494). Mean surgical time was 364 ± 46.4 vs. 316 ± 41.4min (p<0.0001) early vs. late, respectively. There were no differences in estimated blood loss (205±68.4cc vs. 176±99.3cc; p=0.139). Median hospital length of stay was 7 days (6-10) vs. 6 (5-8) (p=0.0001). Morbidity was observed in 16 (40%) and 14 (35%) patients early vs. late (p=0.818). There were no anastomotic leaks or 30-days mortality. CUSUM revealed an inflexion point for decreasing surgical time after case 54 (but a plateau after case 31), decreasing chest tube duration after case 38 and 33; earlier initiation of oral intake after case 35 and decreased hospital stay after case 33.
Conclusions: Improved operative and perioperative parameters were observed in the last 40 cases when compared to the first 40 cases. A reasonable learning curve for minimally invasive Ivor Lewis esophagectomy would require the execution and perioperative care of 35-40 cases.