title: Assessment of the learning curve for pancreaticoduodenectomy.
abstract: BACKGROUND
  Experience with the Whipple procedure has been associated with improved outcomes, but the learning curve for this complex procedure is not well defined.
  
  
  METHODS
  Outcomes with 162 consecutive Whipple procedures during the 1st 11.5 years of practice was documented in a prospective database. A period of low (≤11/y) and high (≥23/y) case volume was compared using the Wilcoxon rank-sum test and Fisher exact test.
  
  
  RESULTS
  With low case volume, blood loss was higher (800 vs 400 mL, P = .001), more patients were transfused (44% vs 18%, P = .027), there were more complications (58% vs 46%, P = .0337), and a longer length of stay (10 vs 7 days, P = .006). There was only 1 mortality (.7%).
  
  
  CONCLUSIONS
  Frequent repetition of the Whipple procedure is associated with an improvement in quantifiable quality benchmarks, and improvement continues with extensive experience. However, with proper training and the right environment, this procedure can be performed during the learning curve with acceptable outcomes.
authors.affiliation: The Elkins Pancreas Center, Michael E DeBakey Department of Surgery, Baylor College of Medicine, 1709 Dryden, Suite 1500, Houston, TX 77030, USA. wfisher@bcm.edu
authors.forename: William E
authors.initials: WE
authors.lastname: Fisher
authors.forename: Sally E
authors.initials: SE
authors.lastname: Hodges
authors.forename: Meng-Fen
authors.initials: MF
authors.lastname: Wu
authors.forename: Susan G
authors.initials: SG
authors.lastname: Hilsenbeck
authors.forename: F Charles
authors.initials: FC
authors.lastname: Brunicardi
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016063:Blood Loss, Surgical / Q000706:statistics & numerical data; D001803:Blood Transfusion / Q000706:statistics & numerical data; D002983:Clinical Competence; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D059032:Learning Curve; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D010182:Pancreatic Diseases / Q000601:surgery; D016577:Pancreaticoduodenectomy / Q000193:education / Q000401:mortality / Q000523:psychology / Q000592:standards*; D011183:Postoperative Complications / Q000453:epidemiology; D011446:Prospective Studies; D019984:Quality Indicators, Health Care / Q000706:statistics & numerical data; D016896:Treatment Outcome