# Structured surgical training in minimally invasive esophagectomy (MIE) increases textbook outcome–a risk-adjusted learning curve

## TL;DR

Structured training in minimally invasive esophagectomy improves surgical outcomes, with textbook results achieved after about 83 cases.

## Contribution

The study quantifies the learning curve for MIE and shows that textbook outcomes can be achieved through structured training.

## Key findings

- Technical competence in MIE is achieved after 47 cases for operative time and 55 cases for major complications.
- Achieving textbook outcomes requires 83 cases, with no significant difference in survival outcomes between trainer and trainee groups.
- Anastomotic leakage rates remained consistent between trainer and trainee groups.

## Abstract

Minimally Invasive Esophagectomy (MIE) is a complex surgical procedure that has become a cornerstone in the management of esophageal cancer. This study aims to delineate the learning curve associated with MIE and its impact on patient outcomes.

A retrospective analysis was conducted on 191 patients who underwent MIE between 2015 and 2022. The cohort was divided into two groups according to the level of competence: Trainer (n = 100) and Trainee (n = 91). Patient demographics, tumor characteristics, and surgical parameters were examined. RA-CUSUM methodology was employed to monitor patient outcomes, adjusting for variations in risk profiles using varying-coefficient logistic regression models to establish the MIE proficiency learning curve.

The trainee achieved competence in terms of operative time within 47 cases, following risk adjustment. Similarly, the learning curve in terms of major complications was completed after the 55th consecutive case. The LC was completed in terms of increased incidence of TO achievement in the trainee group after 83 cases (Trainer vs. Trainee, 27.00% vs. 40.66%, p = 0.046). Anastomotic leakage (Trainer vs. Trainee, 10.00% vs. 7.69% (p = 0.575)) could be identified with consistent rates for both trainer and trainee during the observational period. Pulmonary complications accounted for the majority of complications. After a follow-up of 2 years, no effect of the learning curve on overall (p = 0.436) or disease-free (p = 0.305) survival could be concluded, indicating consistent quality and patient safety during the surgical training.

While technical competence can be achieved after approximately 55 cases, achievement of 'textbook outcome' (TO) requires 83 cases. The findings demonstrate that structured surgical training can progress in tandem while maintaining oncological safety for patients. While technical competence is crucial, the ultimate goal should be achieving a TO.