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Learning Curve for Total Gastrectomy with D2 Lymph Node Dissection: Cumulative Sum Analysis for Qualified Surgery

¹ Center for Gastric Cancer, National Cancer Center, 809 Madul-dong, Ilsandong-gu, Goyang-si, Gyeonggi-do, 411–769, South Korea
² Cancer Registration Branch, Research Institute for National Cancer Control and Evaluation, National Cancer Center, 809 Madul-dong, Ilsandong-gu, Goyang-si, Gyeonggi-do, 411–769, South Korea
³ Cancer Biostatistics Branch, Research Institute for National Cancer Control and Evaluation, National Cancer Center, 809 Madul-dong, Ilsandong-gu, Goyang-si, Gyeonggi-do, 411–769, South Korea

Correspondence: Address correspondence and reprint requests to: Keun Won Ryu, MD, PhD; E-mail: docryu{at}korea.com

Background: This study was conducted to evaluate the leaning curve of D2 lymph node dissection for patients with gastric cancer in a high-volume center.

Methods: The authors prospectively reviewed the data of all patients who underwent total gastrectomy with D2 lymph node dissection during a 4-year period. Retrieved lymph node number was used as a surrogate marker of oncological outcome. The retrieved lymph node number cut-off value required for satisfactory D2 lymph node dissection was defined as >25. Cumulative sum analysis was used to examine the learning curves of individual surgeons at target accuracy rates of 85%, 90%, 92.5%, 95%, and 98%.

Results: Two junior staff surgeons performed 198 curative-intent total gastrectomies with D2 lymph node dissections during the study period; their success rates exceeded 90%. Operating time decreased with operative experience (Pearson correlation coefficient = –0.515, P < 0.001). The learning period for total gastrectomy with D2 lymph node dissection for these two junior members of staff was calculated as 23–35 cases, presuming a 92.5% success rate.

Conclusions: The current study suggests that the surgical learning period for D2 lymph node dissection extends to at least 23 cases or 8 months. In clinical trials containing gastric cancer surgery, the learning curve for qualified surgery from the standpoint of oncological outcome should be considered to minimize bias due to surgeon-associated factors.

Key Words: Gastric cancer • Total gastrectomy • D2 lymph node dissection • Learning curve • Cumulative sum analysis

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