[Surgical learning curve for creation of vascular accesses for haemodialysis: value of medico-radio-surgical collaboration].
BACKGROUND
Creation of a vascular access (VA) for haemodialysis is a surgical procedure which comprises a failure rate related to the quality of the vessels and the operator's experience. The authors report the first 2 years of a young urologist's experience with this procedure in a local hospital in collaboration with the nephrology team.


METHODS
Patients undergoing creation of VA were divided into 2 chronological groups. The patient's age and gender, the cause of renal failure, the presence of diabetes, clinical examination of the upper limb, preoperative assessment of upper limb vessels, the type of anaesthesia, the operating time and the start of dialysis after the operation, as well as the functional results of the VA at 6 months were studied. Results concerning the patients of the first period were discussed by the operator and the nephrology team.


RESULTS
During the first 9 months, 28 patients were operated, corresponding to 36 operations including 32 direct fistulas. Over the following 15 months, 61 patients were operated, with the creation of 63 VAs, including 55 direct fistulas. The failure rate (thrombosis or non-functioning VA) decreased from 32.1% to 11.1% (p=0.07), while the 2 groups were globally comparable.


CONCLUSIONS
Evaluation of a new surgical procedure shows a number of failures, as for all learning curves. However, it helps to improve the results. Collaboration with nephrologists must comprise a discussion allowing the acceptance of certain failures, as they reflect compliance with a strategy of preservation of the vascular capital and a rational attempt to avoid a non-essential proximal access or bypass graft. The support of a motivated radiology team (preoperative assessment and management of complications) and the assistance of a more experienced operator are essential.
Van Glabeke
Emmanuel
E
Service de Chirurgie Viscérale et Urologique, CHI André Grégoire, Montreuil, France. Emmanuel.van-glabeke@chi-andre-gregoire.fr
Belenfant
Xavier
X
Barrou
Benoît
B
Adhemar
Jean-Pierre
JP
Laedrich
Joëlle
J
Mavel
Marie-Christine
MC
Challier
Emmanuel
E
D002408:Catheters, Indwelling; D005260:Female; D013502:General Surgery / Q000193:education*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010348:Patient Care Team; D006435:Renal Dialysis