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Multifactorial Analysis of the Learning Curve for Robot-Assisted Laparoscopic Biliopancreatic Diversion With Duodenal Switch

Sudan, Ranjan MD; Bennett, Kyla M. MD; Jacobs, Danny O. MD, MPH; Sudan, Debra L. MD

doi: 10.1097/SLA.0b013e31824c1d06
Original Articles

Objective: To assess the impact of surgeon, patient, and case-specific factors on the learning curve of robot-assisted laparoscopic biliopancreatic diversion with duodenal switch (RA-LBPD/DS).

Background: The BPD/DS has better resolution of diabetes and hypercholesterolemia, and the best long-term weight loss compared to the laparoscopic gastric band or the Roux-en-Y gastric bypass. Despite excellent results, the BPD/DS is least commonly performed because of greater malabsorption, longer operative duration, and higher technical complication rates. A reduction in technical complications and operative duration will enable the BPD/DS to be offered more frequently.

Methods: Consecutive patients (N = 120) undergoing RA-LBPD/DS between October 2000 and August 2008 were analyzed using univariate and multivariate logistic regression to determine the influence of surgeon and patient factors on complications and operative duration. Independent variables were case number, age, gender, body mass index, American Society of Anesthesiologists (ASA) score, difficult anatomy, and need for extensive adhesiolysis. Dependent variables were complications (leaks, bleeding, and conversion) and operative duration. The best-fit model predicted the risk factors for complications, and a risk-adjusted cumulative sum analysis estimated the learning curve.

Results: Operative duration decreased an average of 3 minutes with each successive case (P < 0.001, R 2 = 0.63) and with patient's female gender. Adhesiolysis, difficult anatomy, liver biopsy, and higher ASA score increased operative duration. The incidence of high blood loss (13.3%), conversion (2.2%), and leaks (5.8%) were experienced by a total of 22 patients (18.3%). There was no mortality. Complications declined after 50 cases and were strongly predicted by increasing surgeon case number.

Conclusions: The learning curve for the RA-LBPD/DS is 50 cases. Risk factors influencing outcomes were identified.

The impact of surgeon, patient, and case-specific factors on the learning curve for 120 consecutive robot-assisted biliopancreatic diversions with duodenal switch were analyzed using regression analysis and the cumulative sum method. Risk factors associated with complications and prolonged operative durations were defined.

From the Duke University Medical Center, Department of Surgery, Durham, NC. Presented at the Second World Congress of the Clinical Robotic Surgery Association, Chicago, IL, October 1–2, 2010.

Reprints: Ranjan Sudan, MD, Duke University Medical Center, Box 2834, Durham, NC 27710. E-mail:

Disclosure: The authors declare no conflicts of interest.

© 2012 Lippincott Williams & Wilkins, Inc.