左胸前外侧小切口冠状动脉旁路移植术学习曲线

摘要

目的：探讨左胸前外侧小切口冠状动脉旁路移植术（ minimally invasive direct coronary artery bypass，MIDCAB）的学习曲线。方法回顾性分析2012年5月～2013年9月由同一术者连续完成的80例左胸前外侧小切口MIDCAB资料，根据手术时间顺序分为A、B、C、D四个组，每组20例。比较各组获取乳内动脉时间、吻合时间及总手术时间，术后当日引流量、术后呼吸机辅助时间及术后住院时间，以及术后并发症情况。将手术例数取对数作为自变量，以获取乳内动脉时间、总手术时间分别为因变量进行拟合得出学习曲线。结果各组术前资料无统计学差异。80例均顺利完成MIDCAB手术，无中转正中开胸，无死亡，无围术期心肌梗死发生。获取乳内动脉时间B、C、D组较A组显著缩短[（53．7±19．2）min、（50．2±17．7） min、（43．2±10．3） min vs．（77．0±30．0） min，P＝0．001、0．000、0．000]，B、C、D组无显著差异（P＞0．05）。总手术时间B、C、D组较A组显著缩短[（128．7±21．7） min、（129．0±33．3） min、（112．2±14．5） min vs．（165．2±41．8） min，P均＝0．000]， B、C、D组无显著差异（P＞0．05）。学习曲线相关模型为：获取乳内动脉时间（min）＝113．77－16．869×ln（手术例数），总手术时间（min）＝220．281－25．276×ln（手术例数）。结论经左前外侧小切口冠状动脉旁路移植术是一种安全有效的治疗方法，手术学习曲线约为20例。%Objective To investigate the learning curve of minimally invasive direct coronary artery bypass ( MIDCAB) via left anterior small thoracotomy. Methods We retrospectively reviewed results of a consecutive series of 80 patients underwent MIDCAB via left anterior small thoracotomy performed by a single surgeon.The patients were divided into 4 groups ( group A, B, C, D, n=20 in each group) according to the sequence of the operation.The left internal mammary artery ( LIMA) harvesting time, anastomosis time, total operative time, the drainage volume of the first day postoperation, mechanical ventilation time, hospital stays postoperation, in-hospital morbidity and mortality were compared.The learning curve was assessed by means of regression analysis with logarithmic curve fitting. Results The basic clinical characters were similar in all groups before the operation.The operations were accomplished successfully in all the 80 cases.No intraoperative conversion to sternotomy, death, or perioperative myocardial infarction happened.The LIMA-harvesting time in the group B, C, and D was significantly shorter than that in the group A [(53.7 ±19.2) min, (50.2 ±17.7) min, and (43.2 ±10.3) min vs.(77.0 ±30.0) min, P =0.001, 0.000, and 0.000].There was no difference between group B and C, B and D, C and D in the LIMA-harvesting time (P>0.05).The total operative time in the group B, C, and D was significantly shorter than in the group A [ (128.7 ±21.7) min, (129.0 ±33.3) min, and (112.2 ±14.5) min vs. (165.2 ±41.8) min, all P=0.000], without difference between the group B and C, B and D, C and D (P>0.05).The learning curve models were obtained: LIMA-harvesting time ( min) =113.77 -16.869 × ln ( operation number); total operative time (min)=220.281 -25.276 ×ln (operation number). Conclusion MIDCAB via left anterior small thoracotomy is safe and effective, with a learning curve of approximately 20 cases.