Department of Surgery, Christchurch Hospital Christchurch, New Zealand.
HPB (Oxford). 2009 Nov;11(7):565-9. doi: 10.1111/j.1477-2574.2009.00091.x.
Endoscopic retrograde cholangio-pancreatography (ERCP) is a complex and technically challenging procedure with a risk of significant complications. Although recommendations exist as to how many ERCPs should be performed before a trainee is deemed competent they lack objective measures of outcome. Cumulative sum (Cusum) analysis allows continuous monitoring of a proceduralist's performance to ensure acceptable outcomes are being achieved. The aim of the present study was to assess a trainee's progress with ERCP using Cusum analysis.
A single trainee performed one supervised ERCP list per week between June 2005 and May 2008. Prospective data were collected and analysed by intention to treat using Cumulative failure charting and Cusum analysis. The binary outcome measure was successful cannulation in patients with a native sphincter. Acceptable and unacceptable cannulation failure rates were set at 20% and 35% respectively, with Type I and II error rates set at 0.10.
A total of 290 ERCPs were performed. Successful cannulation was achieved in 168 of 238 (70.6%) patients with intact biliary sphincters. Although cumulative failure charting suggested the trainee had not yet achieved satisfactory performance, Cusum analysis with sequential probability ratio testing indicated that an acceptable outcome had been achieved for the last 179 consecutive ERCPs.
Cusum analysis enables sensitive and continuous monitoring of a trainee's performance to objectively determine competency. Wider and systematic use may enable appropriate benchmarks to be identified and more objective assessment of a trainee's experience.
内镜逆行胰胆管造影术（ERCP）是一项复杂且技术要求高的操作，存在发生严重并发症的风险。虽然存在关于一名学员在被认为有能力之前应该进行多少次 ERCP 的建议，但这些建议缺乏对结果的客观衡量标准。累积和（Cusum）分析允许对术者的表现进行连续监测，以确保达到可接受的结果。本研究旨在使用 Cusum 分析评估学员进行 ERCP 的进展情况。
一名学员在 2005 年 6 月至 2008 年 5 月期间每周进行一次监督下的 ERCP 检查。采用意向治疗原则收集和分析前瞻性数据，并使用累积失败图表和 Cusum 分析进行分析。二分类结局指标为具有天然括约肌的患者中成功的插管。可接受和不可接受的插管失败率分别设定为 20%和 35%，I 型和 II 型错误率设定为 0.10。
共进行了 290 次 ERCP。在 238 例具有完整胆管括约肌的患者中，成功插管 168 例（70.6%）。尽管累积失败图表表明学员尚未达到满意的表现，但使用序贯概率比检验的 Cusum 分析表明，在过去的 179 例连续 ERCP 中，已经达到了可接受的结果。
Cusum 分析能够敏感且连续地监测学员的表现，客观地确定其能力。更广泛和系统的使用可能会确定适当的基准，并对学员的经验进行更客观的评估。
