Analysis of the learning curve for three-port laparoscopic sleeve gastrectomy using risk-adjusted CUSUM

Liu Bin; Yang Chengcan; Dai Qiancheng; Yin Yue; Wang Wenyue; Wang Yupeng; Yan Xiaolei; Chen Qi; Yan Jia; Wang Bing

doi:10.3969/j.issn.1003-5591.2026.05.006

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Analysis of the learning curve for three-port laparoscopic sleeve gastrectomy using risk-adjusted CUSUM

更新时间：2026-10-22

- Analysis of the learning curve for three-port laparoscopic sleeve gastrectomy using risk-adjusted CUSUM
- J Abdominal Surg Vol. 39, Issue 5, Pages: 357-363(2026)
- 作者机构：
  
  1.上海交通大学医学院附属第九人民医院，普外科，上海 200011
  2.上海交通大学医学院附属第九人民医院，规范化培训办公室，上海 200011
  3.上海交通大学医学院附属第九人民医院，麻醉科，上海 200011
- 作者简介：
  
  Wang Bing，Email：wingping01@126.com
- 基金信息：
- DOI：10.3969/j.issn.1003-5591.2026.05.006
  CLC： R615
- Received：05 July 2026，
  
  Published：22 October 2026
- 稿件说明：
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刘斌,杨珵璨,戴谦诚等.使用风险校正CUSUM方法分析三孔腹腔镜胃袖状切除术的学习曲线[J].腹部外科,2026,39(05):357-363.

Liu Bin,Yang Chengcan,Dai Qiancheng,et al.Analysis of the learning curve for three-port laparoscopic sleeve gastrectomy using risk-adjusted CUSUM[J].J Abdominal Surg,2026,39(05):357-363.
刘斌,杨珵璨,戴谦诚等.使用风险校正CUSUM方法分析三孔腹腔镜胃袖状切除术的学习曲线[J].腹部外科,2026,39(05):357-363. DOI： 10.3969/j.issn.1003-5591.2026.05.006.

Liu Bin,Yang Chengcan,Dai Qiancheng,et al.Analysis of the learning curve for three-port laparoscopic sleeve gastrectomy using risk-adjusted CUSUM[J].J Abdominal Surg,2026,39(05):357-363. DOI： 10.3969/j.issn.1003-5591.2026.05.006.

摘要

目的

采用风险校正累积和（risk-adjusted cumulative sum，RA-CUSUM）模型分析单术者连续200例三孔腹腔镜胃袖状切除术（three-port laparoscopic sleeve gastrectomy，TPLSG）学习曲线。

方法

回顾性收集2018年1月至2020年12月在上海交通大学医学院附属第九人民医院由同一组具有丰富腹腔镜胃袖状切除术经验的减重外科团队连续完成的200例TPLSG病人完整临床资料，以手术时间、术中出血量作为核心指标分别构建传统累积和（cumulative sum，CUSUM）曲线。以Clavien-Dindo分级≥Ⅱ级术后并发症为不良结局构建RA-CUSUM风险校正模型，设定风险偏移系数

=2、

ARL

=1 000、

ARL

=30，结合双侧CUSUM曲线拐点将全队列分为初始学习期、熟练期、精通期3组，比较3组基线资料、手术相关指标、术后并发症及住院时间等差异。

结果

纳入的200例病人，基于并发症RA-CUSUM曲线识别两个关键拐点分别为：第61例及第1

14例。初始学习期手术时间显著高于熟练期及精通期［（136.5±22.8） min、（98.3±16.4） min、（76.2±12.1） min，

0.001］。初始学习期术中出血量高于熟练期及精通期［（68.4±19.7） mL、（37.6±11.3） mL、（21.5±8.6） mL，

0.001］。高体重指数（≥40 kg/m

）、合并重度睡眠呼吸暂停病人集中于早期病例，该阶段Clavien-Dindo≥Ⅱ级并发症发生率显著更高。熟练期上侧RA-CUSUM回落至控制限内，胃大弯游离、切割吻合操作流程标准化，并发症发生率接近模型预期水平。精通期下侧RA-CUSUM突破下控制限，曲线整体平稳波动小，校正后并发症发生率低于预期，术后住院时间最短。

结论

经RA-CUSUM风险校正后，术者完成61例TPLSG后进入熟练期，114例手术后进入精通期。RA-CUSUM可消除肥胖病人基线风险混杂，进而区分TPLSG学习周期。

Abstract

Objective

To analyze the learning curve of 200 consecutive cases of three-port laparoscopic sleeve gastrectomy（TPLSG） performed by a single surgeon using a risk-adjusted cumulative sum（RA-CUSUM） model.

Methods

The complete clinical data of 200 patients who underwent consecutive TPLSG performed by the same bariatric surgical team with extensive experience in laparoscopic sleeve gastrectomy at Shanghai Ninth People's Hospital， Shanghai Jiao Tong University School of Medicine， from January 2018 to December 2020 were retrospectively collected. Traditional cumulative sum （CUSUM） curves were constructed using operative time and intraoperative blood loss as core indicators. An RA-CUSUM risk-adjusted model was constructed using postoperative complications of Clavien-Dindo grade ≥Ⅱ as the adverse outcome， with the risk offset coefficient set as

=2，

ARL

=1 000， and

ARL

=30. Based on the inflection points of the bilateral CUSUM curves， the entire cohort was divided into an initial learning phase， a proficiency phase， and a mastery phase. Differences in baseline characteristics， surgery-related indicators， postoperative complications， and length of hospital stay among the three groups were compared.

Results

Among the 200 included patients， two key inflection points identified by the complicat

ion-based RA-CUSUM curve were case 61 and case 114. Operative time in the initial learning phase was significantly longer than that in the proficiency and mastery phases （［136.5±22.8］ min，［98.3±16.4］ min， and ［76.2±12.1］ min，

0.001）. Intraoperative blood loss in the initial learning phase was greater than that in the proficiency and mastery phases （［68.4±19.7］ mL，［37.6±11.3］ mL， and ［21.5±8.6］ mL，

0.001）.Patients with a high body mass index （≥40 kg/m

） and severe sleep apnea were concentrated in the early cases， and the incidence of Clavien-Dindo grade ≥Ⅱ complications was significantly higher during this phase. In the proficiency phase， the upper RA-CUSUM curve fell back within the control limit， the procedures of greater curvature mobilization and stapling/anastomosis were standardized， and the complication rate approached the expected model level. In the mastery phase， the lower RA-CUSUM curve broke through the lower control limit， the overall curve remained stable with only minor fluctuations， the adjusted complication rate was lower than expected， and the postoperative length of hospital stay was the shortest.

Conclusion

After RA-CUSUM risk adjustment， the surgeon entered the proficiency phase after completing 61 TPLSG procedures and the mastery phase after 114 procedures. RA-CUSUM can eliminate confounding by baseline risk in obese patients and thereby distinguish the learning phases of TPLSG.

关键词

Keywords

references

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