Liver resection safety in a developing country: Analysis of a collective learning curve

•Potential for safety improvement in surgery remains underexploited.•Safety is a critical issue during the implementation of a liver surgery program.•Severe postoperative complications rate is a simple proxy for overall safety performance.•Collective learning curve analysis brings actionable insight on the improvement process. To analyze the collective learning curve in the performance of safe liver resections, using the decrease of severe postoperative complications (SPC) as a proxy for overall safety competency. This was a retrospective analysis of a prospective database in the setting of a liver surgery program implementation in a tertiary center in Morocco. The 100 first consecutive cases of elective liver resections starting from January 1st, 2018 were included in the analysis. SPC were defined as CD>IIIa during the first 90 postoperative days. We used a cumulative sum (CUSUM) technique to determine the number of cases required to achieve safety competency. We then compared case characteristics before and after the learning curve completion. SPC occurred in 15 cases (15%), including 5 deaths (5%). The CUSUM chart revealed a learning curve completion at the 49th case, marked by an inflection point towards the decrease in SPC (24.5% vs 5.9%; P=0.009). In period 2 (after), cases were associated with less diabetes, less synchronous digestive resection, more cirrhosis, and more prolonged preoperative chemotherapy. The rates of major resection (30.6% vs 29.9%; P=0.89) and biliary reconstruction were comparable, as were the operating time, and estimated blood loss. Approximately 50 cases were required to complete the learning curve and improve the overall safety of liver resection. In our setting, the learning curve chronology was consistent with collective measures, including team stabilization and protocol development.