title: Cytoreduction and hyperthermic intraperitoneal chemotherapy: The learning curve reassessed.
abstract: BACKGROUND
  CytoReductive Surgery and Hyperthermic IntraPEritoneal Chemotherapy (CRS-HIPEC) is now the preferred treatment of many peritoneal surface malignancies. In this retrospective study we aimed to analyze how several performance indicators changed during the first 100 CRS-HIPEC procedures in hospitals which recently introduced this treatment, and compare those with an experienced institution.
  
  
  METHODS
  The first consecutive 100 CRS-HIPEC procedures of three institutions were compared to those of the pioneer hospital. The training provided by the pioneer hospital consisted of hands-on training during the first ten procedures; hereafter guidance was available on consult basis. Operation characteristics, morbidity and completeness of cytoreduction were evaluated by case sequence. Locally-estimated-scatter-plot smoothing was used to evaluate the learning curve.
  
  
  RESULTS
  From four institutions 372 cases were included. A macroscopic complete cytoreduction was reached in 66% of the cases in the pioneer hospital and in 86% in the new hospitals (p < 0.001). Complete cytoreduction rates were higher at start off in the new institutions compared with the experienced institution and increased significantly in the first 100 procedures. The new hospitals started with lower morbidity than the experienced hospital, which did not significantly decrease during the study period.
  
  
  CONCLUSIONS
  New institutions that were trained and mentored by an experienced CRS-HIPEC hospital performed better from the beginning with regard to complete cytoreduction and morbidity rate with than the experienced center. An improvement in complete cytoreduction rate during the first 100 procedures was observed in the new institutions.
authors.affiliation: Department of Surgical Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands. Electronic address: a.kuijpers@nki.nl.
authors.forename: A M
authors.initials: AM
authors.lastname: Kuijpers
authors.affiliation: Department of Epidemiology and Biostatistics, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands.
authors.forename: M
authors.initials: M
authors.lastname: Hauptmann
authors.affiliation: Department of Surgical Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands.
authors.forename: A G
authors.initials: AG
authors.lastname: Aalbers
authors.affiliation: Department of Surgery, Catharina Hospital Eindhoven, The Netherlands.
authors.forename: S W
authors.initials: SW
authors.lastname: Nienhuijs
authors.affiliation: Department of Surgery, Catharina Hospital Eindhoven, The Netherlands.
authors.forename: I H
authors.initials: IH
authors.lastname: de Hingh
authors.affiliation: Department of Surgery, Sint Antonius Hospital Nieuwegein, The Netherlands.
authors.forename: M J
authors.initials: MJ
authors.lastname: Wiezer
authors.affiliation: Department of Surgery, Sint Antonius Hospital Nieuwegein, The Netherlands.
authors.forename: B
authors.initials: B
authors.lastname: van Ramshorst
authors.affiliation: Department of Surgery, University Medical Center Groningen, The Netherlands.
authors.forename: R J
authors.initials: RJ
authors.lastname: van Ginkel
authors.affiliation: Department of Surgery, University Medical Center Groningen, The Netherlands.
authors.forename: K
authors.initials: K
authors.lastname: Havenga
authors.affiliation: Department of Surgical Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands.
authors.forename: V J
authors.initials: VJ
authors.lastname: Verwaal
mesh_terms: D000328:Adult; D000368:Aged; D000970:Antineoplastic Agents / Q000008:administration & dosage*; D015179:Colorectal Neoplasms / Q000473:pathology*; D065426:Cytoreduction Surgical Procedures / Q000009:adverse effects / Q000193:education / Q000592:standards*; D005260:Female; D006801:Humans; D006979:Hyperthermia, Induced / Q000009:adverse effects / Q000592:standards*; D007263:Infusions, Parenteral; D007318:Inservice Training; D059032:Learning Curve; D007902:Length of Stay; D008297:Male; D008611:Mentors; D008875:Middle Aged; D016685:Mitomycin / Q000008:administration & dosage*; D061646:Operative Time; D010534:Peritoneal Neoplasms / Q000556:secondary / Q000628:therapy*; D019106:Postoperative Hemorrhage; D011553:Pseudomyxoma Peritonei / Q000628:therapy*; D012189:Retrospective Studies; D055815:Young Adult
chemical_list: D000970:Antineoplastic Agents; D016685:Mitomycin
keywords: CytoReductive surgery; HIPEC; Learning curve; Peritoneal metastasis