Volume, specialty background, practice pattern, and outcomes in endoscopic retrograde cholangiopancreatography: an analysis of the national inpatient sample.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is a complex endoscopic procedure performed by both gastroenterologists and surgeons. There has been recent controversy regarding training paradigms for gastrointestinal endoscopy. No prior studies have evaluated comparative outcomes for ERCP in relation to specialty training background. This study utilized the National Inpatient Sample (NIS) to assess ERCP outcomes as a function of training background, practice pattern, and individual provider volume. METHODS: NIS data was queried from 2007 to 2009. Gastroenterologists and surgeons were identified by procedural profiles and unique physician identifiers. Comorbidity was assessed via Charlson Score. Outcomes including cost, length of stay (LOS), and mortality were analyzed, with and without propensity score matching (PSM). Analysis of outcomes as a function of provider procedural volume was also performed. Comparison for statistical significance was accomplished via t test. RESULTS: A total of 110,811 ERCP's were identified, of which 42,025 (37.9%) were performed by surgeons. Surgeons exhibited longer LOS (8.7 vs. 7.2 days), overall cost ($24,739 vs. $16,960), and mortality (3.9 vs. 1.2%, odds ratio 3.3), with p < 0.001 for all measures. 71.6% of surgical patients, versus 19.6% of gastroenterologic, underwent subsequent inpatient laparoscopic cholecystectomy or laparotomy. Outcome differences persisted when PSM included performance of subsequent laparoscopic cholecystectomy. Evaluation of minimum performance standards revealed up to a fivefold increased mortality for providers who performed less than 5 ERCP's/year, irrespective of specialty background. CONCLUSIONS: Gastroenterologists demonstrate favorable gross outcomes compared to surgeons performing ERCP. Differences may correlate in part with more frequent subsequent surgical management of comorbid conditions by surgical providers. Lower volume providers achieve inferior outcomes regardless of specialty background. Analyses of this type may help inform discussions on optimal training and proficiency paradigms, including maintenance of proficiency, for therapeutic endoscopic procedures.

True benefit or selection bias: an analysis of laparoscopic versus open splenectomy from the ACS-NSQIP.

BACKGROUND: By virtue of the benefits associated with minimally invasive approaches, laparoscopic splenectomy (LS) is believed to have better patient-related outcomes compared to open splenectomy (OS). However, there are limited data directly comparing the two techniques. METHODS: Patients who underwent elective LS and OS between 2005 and 2010 were identified from the public use file of the ACS-NSQIP database using the Current Procedural Terminology codes 38120 and 38100. Patients who had concomitant procedures were excluded. Because of the nonrandom assignment of surgical techniques, a selection bias could have been responsible for the differences in patient outcomes. Therefore, patient characteristics and comorbidities that were available and could have been potential confounders were compared and regression analysis was performed to determine independent risk factors associated with serious and overall morbidity as well as mortality. RESULTS: During the study period 1,644 and 851 patients underwent LS and OS, respectively. Compared to patients who underwent LS, patients who had OS had a longer median length of hospital stay (3 vs. 6 days, P < 0.0001) and higher incidences of serious (7 vs. 17 %, P < 0.0001) and overall morbidity (12 vs. 25 %, P < 0.0001) and mortality (1.4 vs. 3.3 %, P = 0.02). However, there were certain significant differences in the characteristics and comorbidities of the patients that could have confounded outcomes. On regression analysis, OS was not associated with higher mortality (OR = 1.43, 95 % CI 0.7-2.7, P = 0.28) but was associated with higher serious morbidity (OR = 1.8, 95 % CI 1.4-2.3, P = 0.001) and overall morbidity (OR = 2.0, 95 % CI 1.6-2.4, P = 0.0001). CONCLUSION: After adjusting for available confounders, patients who underwent LS had lower morbidity and similar mortality rates. Although certain confounders such as previous surgical history, underlying pathology, and spleen size could still have potentially influenced outcomes, the data suggest that patient outcomes after LS are excellent and when technically possible a minimally invasive technique should be the preferred approach for splenectomy.

Does resident involvement effect surgical times and complication rates during laparoscopic appendectomy for uncomplicated appendicitis? An analysis of 16,849 cases from the ACS-NSQIP.

BACKGROUND: Controversy exists regarding whether resident involvement during surgery impacts patient outcomes. We compared surgical times and perioperative complications of patients undergoing laparoscopic appendectomy with and without residents. METHODS: Patients undergoing laparoscopic appendectomy for uncomplicated acute appendicitis during 2005 to 2008 were identified from the American College of Surgeons National Surgical Quality Improvement Program database. RESULTS: During the study period, 16,849 patients underwent laparoscopic appendectomy for uncomplicated appendicitis (residents participated in 68% of procedures). There were no statistical and/or clinically meaningful differences between median age, sex, body mass index, American Society of Anesthesiology score, and morbidity probability between the 2 groups, suggesting that case mix was not a significant confounder. Patients undergoing laparoscopic appendectomy with residents compared with patients undergoing laparoscopic appendectomy without residents had a higher incidence of serious and overall morbidity and longer surgical times. However, surgical times and complications were similar between residents in postgraduate years 1 to 5. CONCLUSIONS: Regardless of the postgraduate year level, resident involvement resulted in a clinically appreciable increase in surgical times and a statistically significant increase in certain complications.

Cs+ -selective membrane electrodes based on ethylene glycol-functionalized polymeric microspheres.

A new strategy for improving the robustness of membrane-based ion-selective electrodes (ISEs) is introduced based on the incorporation of microsphere-immobilized ionophores into plasticized polymer membranes. As a model system, a Cs(+)-selective electrode was developed by doping ethylene glycol-functionalized cross-linked polystyrene microspheres (P-EG) into a plasticized poly(vinyl chloride) (PVC) matrix containing sodium tetrakis-[3,5-bis(trifluoromethyl)phenyl] borate (TFPB) as the ion exchanger. Electrodes were evaluated with respect to Cs(+) in terms of sensitivity, selectivity, and dynamic response. ISEs containing P-EG and TFPB that were plasticized with 2-nitrophenyl octyl ether (NPOE) yielded a linear range from 10(-1) to 10(-5)M Cs(+), a slope of 55.4 mV/decade, and a lower detection limit (log a(Cs)) of -5.3. In addition, these membranes also demonstrated superior selectivity over Li(+), Na(+), and alkaline earth metal ion interferents when compared to analogous membranes plasticized with bis(2-ethylhexyl) sebacate (DOS) or membranes containing a lipophilic, mobile ethylene glycol derivative (ethylene glycol monooctadecyl ether (U-EG)) as ionophore.