title: Evaluation of the learning curve of laparoscopic choledochal cyst excision and Roux-en-Y hepaticojejunostomy in children: CUSUM analysis of a single surgeon's experience.
abstract: Laparoscopic cyst excision and Roux-en-Y hepaticojejunostomy is gaining popularity as a treatment for choledochal cyst (CDC) in children. However, the learning curve for this challenging laparoscopic procedure has not been addressed. The aim of this study is to determine the characteristics of the learning curve of this procedure. This may guide the training in institutions currently not using this technique.
  
  
  
  A prospectively collected database comprising all medical records of the first 104 consecutive patients undergoing laparoscopic CDC excision and Roux-en-Y hepaticojejunostomy performed by one surgeon was studied. Multifactorial linear/logistic regression analysis was performed to identify patient-, surgeon-, and procedure-related factors associated with operating times, rates of adverse event, and length of postoperative stay.
  
  
  
  Cumulative sum analysis demonstrated a learning curve for laparoscopic choledochal cyst excision of 37 cases. Comparing the early with the late experiences (37 vs. 67 cases), the surgeon-specific outcomes significantly improved in terms of operating times (352 vs. 240 min; P < 0.001), postoperative complication rate (13.5 vs. 1.5 %; P = 0.02), and the length of hospital stay (9.4 vs. 7.8 days; P = 0.01). After multivariate analyses, independent predictors of operating times included the completion of the learning curve (CLC) (OR 0.68, 95 % CI 0.63-0.73) and adhesion score (ORmiddle1.25, 95 % CI 1.08-1.45; ORhigh1.40, 95 % CI 1.20-1.62; compared with the low score); significant predictors of perioperative adverse outcomes were CLC (OR 0.07, 95 % CI 0.02-0.34) and comorbidities prior to the surgery (OR 30.65, 95 % CI 1.71-549.63). The independent predictors of length of postoperative stay included CLC, preoperative comorbidities, and perioperative adverse events.
  
  
  
  CLC for laparoscopic choledochal cyst excision is 37 cases. After CLC, not only the operative time is reduced, the complications, adverse results, and the length of hospital stay all decreased significantly. The learning curve can be used as the basis for performance guiding the training.
authors.affiliation: Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9 Jinsui Road, Tianhe District, Guangzhou, 510623, China.
authors.forename: Zhe
authors.identifier: 0000-0002-6062-1242
authors.initials: Z
authors.lastname: Wen
authors.affiliation: Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China.
authors.forename: Huiying
authors.initials: H
authors.lastname: Liang
authors.affiliation: Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9 Jinsui Road, Tianhe District, Guangzhou, 510623, China.
authors.forename: Jiankun
authors.initials: J
authors.lastname: Liang
authors.affiliation: Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9 Jinsui Road, Tianhe District, Guangzhou, 510623, China.
authors.forename: Qifeng
authors.initials: Q
authors.lastname: Liang
authors.affiliation: Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9 Jinsui Road, Tianhe District, Guangzhou, 510623, China. huimin.xia876001@gmail.com.
authors.forename: Huimin
authors.initials: H
authors.lastname: Xia
mesh_terms: D000713:Anastomosis, Roux-en-Y / Q000379:methods*; D000714:Anastomosis, Surgical; D001662:Biliary Tract Surgical Procedures / Q000379:methods*; D002675:Child, Preschool; D015529:Choledochal Cyst / Q000601:surgery*; D016208:Databases, Factual; D005260:Female; D006801:Humans; D007223:Infant; D007582:Jejunostomy / Q000379:methods*; D010535:Laparoscopy / Q000379:methods*; D059032:Learning Curve; D007902:Length of Stay; D016014:Linear Models; D008099:Liver / Q000601:surgery*; D016015:Logistic Models; D008297:Male; D015999:Multivariate Analysis; D061646:Operative Time; D011183:Postoperative Complications / Q000453:epidemiology*; D012189:Retrospective Studies; D066231:Surgeons
keywords: Choledochal cyst; Laparoscopy; Learning curve