Safety, Efficacy, and Cost-Analysis of Percutaneous Endoscopic Gastrostomy and Ventriculoperitoneal Shunt Placement in a Simultaneous Surgery.

BACKGROUND: Limited historical data suggest that concomitant placement of both a ventriculoperitoneal (VP) shunt and percutaneous endoscopic gastrostomy (PEG) tube is associated with an increased risk of complications, including VP shunt infections. Here we compare the outcomes and cost difference between 2 groups of patients, one in which a VP shunt and PEG tube were placed in the same operation and the other in which separate operations were performed. METHODS: A total of 10 patients underwent simultaneous placement of a VP shunt and PEG tube. This group was compared with a group of 18 patients that underwent separate placements. Hospital billing charges were used to compare the total cost of the procedures in the 2 groups. RESULTS: Eight of the 10 patients presented with aneurysmal subarachnoid hemorrhage. The average length of stay was 25 ± 2 days for the simultaneous procedure group and 43 ± 7 days for the separate procedures group. The average duration of follow-up was 12 ± 3 months after simultaneous placement. No patient in the simultaneous surgery group had signs of infection or shunt malfunction at last follow-up. The overall complication rate was significantly lower in the simultaneous surgery group. A cost analysis demonstrated significant cost savings by completing both procedures in the same surgical procedure. CONCLUSIONS: Simultaneous placement of a PEG tube and VP shunt is safe, efficacious, and cost-effective. Thus, in patients requiring both a VP shunt and PEG tube, placement of both devices in a single surgical procedure should be considered.

Implementation and enforcement of ventilator-associated pneumonia prevention strategies in trauma patients.

BACKGROUND: We hypothesized that strict enforcement of ventilator-associated pneumonia (VAP) prevention (VAPP) strategies would decrease the incidence of VAP and improve patient outcomes. METHODS: This retrospective study examined 696 consecutive ventilated patients in a Level One trauma center. Three study groups were compared: Pre-VAPP, VAPP implementation, and VAPP enforcement. Ventilator days were compared with occurrences of VAP, defined by the U.S. Centers for Disease Control and Prevention National Nosocomial Infection Surveillance criteria. Patients with and without VAP were compared to evaluate the effect of VAP on patient outcome. Fisher exact, Kruskal-Wallis, and chi-square analyses were used, and p < 0.05 was considered significant. RESULTS: During the pre-VAPP protocol period, 5.2 cases of VAP occurred per 1,000 days of ventilator support. The number of cases of VAP decreased to 2.4/1,000 days (p = 0.172) and 1.2/1,000 days (p = 0.085) in the implementation and enforcement periods, respectively. However, when including all trauma patients, regardless of head Abbreviated Injury Score (AIS) score, the difference in the rate of VAP was statistically significant in the enforcement period, but not in the implementation period, compared with the pre-VAPP period (p = 0.014 and 0.062, respectively). A significant decrease was seen in the mortality rate (p = 0.024), total hospital days (p = 0.007), intensive care unit days (p = 0.002), ventilator days (p = 0.002), and hospital charges (p = 0.03) in patients without VAP compared with patients having VAP. CONCLUSIONS: There was a statistically significant decrease in the occurrence of VAP with strict enforcement of a VAPP protocol, regardless of head AIS score. Although the difference in patients with a head AIS score <3 was not statistically significant, it was clinically meaningful, decreasing the already-low rate of VAP by half. Strict enforcement of VAPP protocols may be cost efficient for hospitals and prevent decreased reimbursement under the Medicare pay-for-performance strategies.

Teaching surgical residents dome-down laparoscopic cholecystectomy in an academic medical center.

BACKGROUND: Although laparoscopic cholecystectomy is the most commonly performed laparoscopic procedure in the United States, complications may still arise, especially when acute inflammation or aberrant anatomy is present. In these situations, surgeons may choose to convert to a variation of the traditional laparoscopic cholecystectomy, the "dome-down" approach. We assessed the best approach to teaching this technique as a secondary method in an academic teaching hospital. METHODS: Surgical residents were first given didactic instruction on the dome-down laparoscopic cholecystectomy, then trained in the animate laboratory, and finally graduated to the operating room. Following training, the residents completed a 7-question questionnaire to assess their reaction to this method. The charts of 98 patients who underwent dome-down laparoscopic cholecystectomy were retrospectively reviewed to assess the complications associated with the procedure, the average operative time, and length of hospital stay. RESULTS: The resident questionnaire showed that the learning curve was dramatically affected when an adequate number of cases were performed. The mean number needed to gain competency was 14.7. The use of animate simulators was also important. The mean operative time was 78.40 minutes, with most cases performed by postgraduate year-2 and -3 residents. Only one complication, bile peritonitis, arose early in the study. CONCLUSION: Dome-down laparoscopic cholecystectomy must be taught to surgical residents as a secondary approach to use when faced with a difficult case. The most important factor in teaching this technique is exposure to an adequate number of cases. The use of animate simulators and didactic training is also helpful.