Minimally invasive Ivor Lewis esophagectomy: description of a learning curve

Minimally invasive Ivor Lewis esophagectomy (MIE) is gaining popularity for the treatment of esophageal cancer. However, as it is a technically demanding operation, a learning curve should be defined to guide training and allow implementation at institutions not currently using this technique.

Our study included a retrospective series of the first 80 consecutive patients undergoing MIE by a single surgeon with advanced training in minimally invasive esophageal surgery in independent practice at a high-volume tertiary center. Patients were stratified into 2 groups of 40 patients, with chronological order defining early and late experiences. Primary end points included conversion to open procedure, surgical time, blood loss, chest drainage duration, time to oral intake, hospital stay, postoperative morbidity, and mortality. The cumulative sum methodology was used and analyzed by visually inspecting the plots.

Conversion to open procedure occurred in 2 (5%) patients in the early group and none in the late group (p = 0.49). Comparing early vs late experience, mean surgical time was 364 vs 316 minutes (p < 0.01), estimated blood loss was 205 vs 176 mL (p = 0.14), median hospital stay was 7 vs 6 days (p < 0.01), and morbidity was observed in 16 (40%) and 14 (35%) patients (p = 0.82), respectively. There were no anastomotic leaks or 30-day mortality. Cumulative sum plots showed decreasing surgical time after patient 54 (plateau after patient 31), decreasing chest tube duration after patients 38 and 33, sooner oral intake after patient 35, and decreased hospital stay after patient 33.

Improved operative and perioperative parameters for MIE were observed in the last 40 patients when compared with the first 40 patients. A reasonable learning curve for MIE would require the operation and perioperative care of 35 to 40 patients.