Learning curve and postoperative outcomes of minimally invasive esophagectomy

Surgical innovation is necessary to increase surgical effectiveness and to decrease postoperative complications, but can be associated with learning curves. The significance of surgical learning curves is increasing and it is important to take surgical learning curves into account when interpreting outcome data that is acquired during an implementation period. This may especially be the case for a technically challenging procedure like minimally invasive esophagectomy (MIE). This review article provides an overview of the published literature that has described a learning curve for MIE, with particular interest in the relationship between the learning curve and postoperative complications. Twenty two studies reported learning curves of different types of MIE. These studies showed that the length of the learning curve of MIE can be significant, but most studies are single center studies of limited methodological quality. In addition, several learning curve analysis methods are used but a clear recommendation regarding the preferred method is lacking. Most studies use intraoperative parameters (e.g., operative time) to define the length of the learning curve. However, significant learning curve effects have been found for clinically more relevant parameters (e.g., anastomotic leak), especially for Ivor Lewis MIE. These studies suggest that patient safety can be substantially compromised during learning curves. To increase patient safety and shorten the learning curve, evidence based and effective safe implementation programs are necessary.