title: One surgeon's learning curve for video-assisted thoracoscopic esophagectomy for esophageal cancer with the patient in lateral position: how many cases are needed to reach competence?
abstract: BACKGROUND
  Minimally invasive esophagectomy is a feasible technique shown to be safe and oncologically adequate for the treatment of esophageal cancer. This study aimed to describe one surgeon's learning curve for video-assisted thoracoscopic esophagectomy with the patient in lateral position.
  
  
  METHODS
  From May 2010 to June 2012, 89 thoracoscopic esophagectomies for esophageal cancer were performed by one surgeon. The patients were divided into three groups. Group A included the first 30 cases. Group B comprised cases 31 to 60, and group C included the final 29 cases. The demographic characteristics and the intra- and postoperative variables were collected retrospectively and analyzed.
  
  
  RESULTS
  One postoperative death occurred. Eight patients required conversion. No significant difference in background or clinicopathologic factors among the three groups was observed. Compared with group A, a significant decrease in intrathoracic operative time (107.7 ± 16.2 min; P = 0.0000), total operative time (326.3 ± 40.7 min; P = 0.0002), and blood loss (290.8 ± 114.3 ml; P = 0.0129) was observed in group B, whereas more retrieved nodes were harvested (20.1 ± 9.5; P = 0.0002). The last 29 patients (group C) involved significantly less intrathoracic operative time (82.8 ± 18.4 min; P = 0.0386), total operative time (294.7 ± 37.4 min; P = 0.0009), and blood loss (234.7 ± 87.8 ml; P = 0.0125) as well as a shorter postoperative hospital stay (12.4 ± 3.7 days; P = 0.0125) compared with group B. A significant decline in the overall morbidity from group A to group C (P = 0.0005) also was observed.
  
  
  CONCLUSIONS
  The results of this study suggest that at least 30 cases were needed to reach the plateau of thoracoscopic esophagectomy. After more than 60 cases of thoracoscopic esophagectomies had been managed, lower morbidity could be obtained.
authors.affiliation: Department of Thoracic Surgery, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Changjiang Route 10#, Daping, Chongqing, 400042, People's Republic of China.
authors.forename: Wei
authors.initials: W
authors.lastname: Guo
authors.forename: Ying-Bo
authors.initials: YB
authors.lastname: Zou
authors.forename: Zheng
authors.initials: Z
authors.lastname: Ma
authors.forename: Hui-Jun
authors.initials: HJ
authors.lastname: Niu
authors.forename: Yao-Guang
authors.initials: YG
authors.lastname: Jiang
authors.forename: Yun-Ping
authors.initials: YP
authors.lastname: Zhao
authors.forename: Tai-Qian
authors.initials: TQ
authors.lastname: Gong
authors.forename: Ru-Wen
authors.initials: RW
authors.lastname: Wang
mesh_terms: D002983:Clinical Competence; D004938:Esophageal Neoplasms / Q000601:surgery*; D016629:Esophagectomy / Q000379:methods*; D005260:Female; D006801:Humans; D059032:Learning Curve; D008297:Male; D008875:Middle Aged; D056888:Patient Positioning / Q000379:methods*; D012189:Retrospective Studies; D020775:Thoracic Surgery, Video-Assisted / Q000193:education*