D-2 GASTRECTOMY - LESSONS FROM A PROSPECTIVE AUDIT OF THE LEARNING-CURVE

A 3-year prospective study of the learning curve for D-2 gastrectomy w as carried out by one surgeon beginning to perform the operation indep endently after intensive specialist training. Some 38 patients were tr eated; there were four postoperative deaths and 22 patients had compli cations. Postoperative morbidity decreased significantly with time (r( S) = -0.38, P = 0.02, 95 per cent confidence interval -0.62 to -0.07). The physiological component of POSSUM (Physiological and Operative Se verity Score for the enUmeration of Mortality and morbidity) was signi ficantly lower in the third year (median value 15, 16 and 14 for years 1, 2 and 3, n = 31, chi(2) = 7.5, 2 d.f., P = 0.02, Kruskal-Wallis te st), but the operative POSSUM scores and the number of lymph nodes fou nd were not decreased (median operative POSSUM score 19, 18 and 21, n = 31, chi(2) = 0.2, 2 d.f., P = 0.91, Kruskal-Wallis test). The result s suggest a learning curve lasting about 18-24 months or 15 to 25 proc edures before a plateau is reached. Improved results were associated w ith changes in case selection and operative tactics but not with reduc ed extent of lymphadenectomy. D-2 gastrectomy should be restricted to specialist centres where adequate training and supervision can be prov ided during the learning curve.