title: Learning curve for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in peritoneal surface malignancies: analysis of two centres.
abstract: BACKGROUND
  We assessed the learning curve (LC) of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in treating peritoneal surface malignancies (PSM) in two centers and evaluated in which extent surgical tutoring could abbreviate the learning process.
  
  
  METHODS
  Six hundred and forty-one cases submitted to CRS using peritonectomy procedures and HIPEC were considered. After having overcome its own LC, the NCI of Milan has provided technical assistance to Bentivoglio's centre for the development of a new PSM program since 2003. The risk-adjusted sequential probability ratio test (RA-SPRT) was employed to assess the LC of the two centers. Outcomes were incomplete cytoreduction, G3-5 morbidity (NCI-CTCAE.v3) and procedure-related mortality (PRM).
  
  
  RESULTS
  Rates of incomplete cytoreduction, G3-5 morbidity, and PRM were 8.4%, 30.1%, and 3.9%, respectively, in the entire series. The breaking points of the LC concerning incomplete cytoreduction, G3-5 morbidity, and PRM were achieved at 141, 158, and 144 cases, in the Milan's experience, and at 126, 134, and 60 cases in the Bentivoglio's experience.
  
  
  CONCLUSIONS
  Surgical tutoring could substantially shorten the steep LC associated with CRS and HIPEC. Our data should be confirmed by further studies on LC focusing oncological outcomes. Other factors that could influence the length of learning process should be identified.
authors.affiliation: Peritoneal Surface Malignancy Program, Department of Surgery, National Cancer Institute, Milan, Italy.
authors.forename: Shigeki
authors.initials: S
authors.lastname: Kusamura
authors.forename: Dario
authors.initials: D
authors.lastname: Baratti
authors.forename: Salvatore
authors.initials: S
authors.lastname: Virzì
authors.forename: Serena
authors.initials: S
authors.lastname: Bonomi
authors.forename: Domenico Rosario
authors.initials: DR
authors.lastname: Iusco
authors.forename: Antonio
authors.initials: A
authors.lastname: Grassi
authors.forename: Ionut
authors.initials: I
authors.lastname: Hutanu
authors.forename: Marcello
authors.initials: M
authors.lastname: Deraco
mesh_terms: D000328:Adult; D000368:Aged; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000008:administration & dosage*; D017024:Chemotherapy, Adjuvant / Q000379:methods; D010478:Chemotherapy, Cancer, Regional Perfusion / Q000193:education* / Q000379:methods; D013505:Digestive System Surgical Procedures / Q000009:adverse effects / Q000193:education* / Q000401:mortality; D005257:Fellowships and Scholarships; D005260:Female; D006801:Humans; D006979:Hyperthermia, Induced; D007558:Italy; D059032:Learning Curve; D016015:Logistic Models; D008297:Male; D008611:Mentors; D008875:Middle Aged; D018365:Neoplasm, Residual / Q000188:drug therapy*; D016017:Odds Ratio; D010534:Peritoneal Neoplasms / Q000188:drug therapy* / Q000401:mortality / Q000601:surgery*; D018570:Risk Assessment; D012307:Risk Factors; D016896:Treatment Outcome; D014481:United States