Influence de l'apprentissage et de l'expérience dans le traitement laparoscopique du reflux gastro-œsophagien

Abstract

Learning curve and experience in laparoscopic treatment of gastroesophageal reflux disease.

Study aim: Laparoscopic treatment of gastroesophageal reflux disease (GERD) by partial (PF) or total (TF) fundoplication is the most appropriate surgical treatment after failure of medical treatment. The aim of this study was to compare the results of the same series in three consecutive periods in order to determine the effects of the learning curve and experience on the technique and outcome.

Patients and methods: From January 1993 to January 1998, 150 patients (84 men and 66 women) with a mean age of 52.2 years (18 to 78) were included. Three groups of 49, 50 and 51 patients were chronologically defined. The comparison was established on the following criteria: the operative technique; the conversion rate; the mortality and morbidity rate; the duration of surgery and hospitalization and the results with short and medium follow-up.

Results: The three groups were comparable with respect to patients and GERD characteristics. One hundred and thirty two patients had a TF and 18 had a PF. Rossetti's type TF became the reference procedure (80,3% in group III) and closure of the diaphragmatic crura was performed systematically in group III (100%). The duration of surgery was significantly reduced between group I and the two other groups (138, 100, 80min). The rate of conversion decreased from 10,2% to 4% and then 0%. The average duration of hospitalization decreased from 5.8 to 4.2 days (p=0.01). There was no mortality and the morbidity rate decreased from 14,3% to 4% and then 0%. Seven cases of recurrence occurred(4.6%), 5 in group I (10,2%), 2 in group II (4%), and 0 in group III, (with a shorter follow-up).

Conclusion: The effect of the learning curve has to be taken into account in the training of surgeons (within experienced departments, with «guidance» during initial interventions) and also in the evaluation of results, in order to allow a more accurate comparison between the different treatments for GERD.