BACKGROUND: Postcholecystectomy complex bile duct injuries involving the hilar confluence, which are often associated with vascular injuries and liver atrophy, remain a considerable surgical challenge. The aim of this study is to report our experience of major hepatectomy with long-term outcome in these patients. METHODS: From January 1987 to January 2002, 18 patients underwent a major hepatectomy for complex bile duct injuries. The hilar confluence was involved in all cases and was associated with vascular injuries in 13 (72%), including arterial injuries in 11, and partial liver atrophy in 15 (83%). The average time interval between the initial cholecystectomy and hepatectomy was 43 +/- 63 months and 16 (88%) patients had previously undergone an average of 2 (range 1-3) surgical repairs. RESULTS: Major liver resection included a right hepatectomy in 14 (78%) patients, a left hepatectomy in 3, and a left trisectionectomy in one. There was no postoperative mortality, but severe postoperative morbidity was experienced in 11 (61%) patients, including biliary fistula in 7 (39%), prolonged ascites in 8 (44%) and hemorrhage requiring reoperation in one. With a median follow-up time of 8 years (range 3 to 12), 17 (94%) patients have excellent or good results, including 13 patients without symptoms. CONCLUSION: This study shows that salvage major hepatectomy is an efficient treatment for patients with complex hilar bile duct injuries and should be considered before liver transplantation or recourse to metallic stents.

BACKGROUND: Iatrogenic bile duct injury remains a current complication of laparoscopic cholecystectomy. One uniform and standardized protocol, based on the "critical view of safety" concept of Strasberg, should reduce the incidence of this complication. Furthermore, owing to the rapid development of minimally invasive surgery, technicians are becoming more frequently involved. To improve communication between the operating team and technicians, standardized actions should also be defined. The aim of this study was to compare existing protocols for laparoscopic cholecystectomy from various Dutch hospitals. METHODS: Fifteen Dutch hospitals were contacted for evaluation of their protocols for laparoscopic cholecystectomy. All evaluated protocols were divided into six steps and were compared accordingly. RESULTS: In total, 13 hospitals responded-5 academic hospitals, 5 teaching hospitals, 3 community hospitals-of which 10 protocols were usable for comparison. Concerning the trocar positions, only minor differences were found. The concept of "critical view of safety" was represented in just one protocol. Furthermore, the order of clipping and cutting the cystic artery and duct differed. Descriptions of instruments and apparatus were also inconsistent. CONCLUSIONS: Present protocols differ too much to define a universal procedure among surgeons in The Netherlands. The authors propose one (inter)national standardized protocol, including standardized actions. This uniform standardized protocol has to be officially released and recommended by national scientific associations (e.g., the Dutch Society of Surgery) or international societies (e.g., European Association for Endoscopic Surgery and Society of American Gastrointestinal and Endoscopic Surgeons). The aim is to improve patient safety and professional communication, which are necessary for new developments.

BACKGROUND: Medical liability is a great concern in current surgical practice. The medical liability system in the US is under discussion in surgical literature, as the system is associated with high costs and expensive liability premiums. The aim of this study was to evaluate the Dutch arbitration system for claims filed after bile duct injury (BDI). STUDY DESIGN: Data were extracted from the largest Dutch insurance company for medical liability. Outcomes of the claim and factors associated with awarded financial compensation were determined. RESULTS: BDI litigation after laparoscopic cholecystectomy occurred in 0.08%(+/- 0.02% SD) without a substantial increase. Currently, 88 of 133 claims are closed after a median duration of 2 years (range 5 months to 6.5 years). In 61 of 88 cases (69%) liability was rejected, and in 16 cases (18%) liability was acknowledged. Median compensation (in Euros) was euro 9.826,07 (range euro 15,88 to euro 55.301,06). Rejection of liability increased from 50% in the period 1994 to 1998 versus 72% in 2004 to 2006 (p = 0.023). Factors associated with recognition were patient employment (p = 0.005) and patient death (p = 0.01). Factors associated with an increase in financial compensation are delay in imaging (p = 0.033), delay in diagnosis (p = 0.009), and relaparotomy with repair in the initial hospital (p = 0.028). CONCLUSIONS: The Dutch arbitration system for medical liability after BDI is associated with a short time to resolution and high rejection rates, and payments to BDI patients are low.

BACKGROUND: The benefits of preoperative biliary drainage, which was introduced to improve the postoperative outcome in patients with obstructive jaundice caused by a tumor of the pancreatic head, are unclear. METHODS: In this multicenter, randomized trial, we compared preoperative biliary drainage with surgery alone for patients with cancer of the pancreatic head. Patients with obstructive jaundice and a bilirubin level of 40 to 250 micromol per liter (2.3 to 14.6 mg per deciliter) were randomly assigned to undergo either preoperative biliary drainage for 4 to 6 weeks, followed by surgery, or surgery alone within 1 week after diagnosis. Preoperative biliary drainage was attempted primarily with the placement of an endoprosthesis by means of endoscopic retrograde cholangiopancreatography. The primary outcome was the rate of serious complications within 120 days after randomization. RESULTS: We enrolled 202 patients; 96 were assigned to undergo early surgery and 106 to undergo preoperative biliary drainage; 6 patients were excluded from the analysis. The rates of serious complications were 39%(37 patients) in the early-surgery group and 74%(75 patients) in the biliary-drainage group (relative risk in the early-surgery group, 0.54; 95% confidence interval [CI], 0.41 to 0.71; P<0.001). Preoperative biliary drainage was successful in 96 patients (94%) after one or more attempts, with complications in 47 patients (46%). Surgery-related complications occurred in 35 patients (37%) in the early-surgery group and in 48 patients (47%) in the biliary-drainage group (relative risk, 0.79; 95% CI, 0.57 to 1.11; P=0.14). Mortality and the length of hospital stay did not differ significantly between the two groups. CONCLUSIONS: Routine preoperative biliary drainage in patients undergoing surgery for cancer of the pancreatic head increases the rate of complications.(Current Controlled Trials number, ISRCTN31939699.)

Differentiating between periampullary carcinoma and chronic pancreatitis with an inflammatory mass is difficult. Consequently, 6% to 9% of pancreatic resections for suspected carcinoma are done inappropriately for chronic pancreatitis. Here, we test if matrix metalloproteinase 7 (MMP-7), a secreted protease frequently expressed in pancreatic carcinoma, can be measured in plasma, pancreatic, and duodenal juice, and if it can distinguish between periampullary carcinoma and chronic pancreatitis. Ninety-four patients who underwent pancreatic surgery for a (peri)pancreatic neoplasm (n = 63) or chronic pancreatitis (n = 31) were analyzed. Median plasma MMP-7 levels were significantly higher in carcinoma (1.95 ng/mL; interquartile range, 0.81-3.22 ng/mL) compared with chronic pancreatitis and benign disease (0.83 ng/mL; interquartile range, 0.25-1.21 ng/mL; P < 0.01). MMP-7 levels in pancreatic juice were higher, although not significantly, in carcinoma (62 ng/mg protein; interquartile range, 18-241 ng/mg protein) compared with chronic pancreatitis and benign disease (23 ng/mg protein; interquartile range, 8.5-99 ng/mg protein; P = 0.17). MMP-7 levels in duodenal juice were universally low. At an arbitrary cutoff of 1.5 ng/mL in plasma, positive and negative predictive values were 83% and 57%, respectively, values comparable to those of today's most common pancreatic tumor marker, carbohydrate antigen 19-9 (CA19-9; 83% and 53%, respectively). Positive and negative likelihood ratios for plasma MMP-7 were 3.35 and 0.52, respectively. The area under the receiver operating characteristic curve for MMP-7 was 0.73 (95% confidence interval, 0.63-0.84) and for CA19-9, 0.75 (95% confidence interval, 0.64-0.85). Combined MMP-7 and CA19-9 assessment gave a positive predictive value of 100%. Thus, plasma MMP-7 levels discriminated between patients with carcinoma and those with chronic pancreatitis or benign disease. The diagnostic accuracy of plasma MMP-7 alone is not sufficient to determine treatment strategy in patients with a periampullary mass, but combined evaluation of plasma MMP-7 with CA19-9 and other markers may be clinically useful.(Cancer Epidemiol Biomarkers Prev 2007;16(5):886-91).

BACKGROUND: For patients with chronic pancreatitis and a dilated pancreatic duct, ductal decompression is recommended. We conducted a randomized trial to compare endoscopic and surgical drainage of the pancreatic duct. METHODS: All symptomatic patients with chronic pancreatitis and a distal obstruction of the pancreatic duct but without an inflammatory mass were eligible for the study. We randomly assigned patients to undergo endoscopic transampullary drainage of the pancreatic duct or operative pancreaticojejunostomy. The primary end point was the average Izbicki pain score during 2 years of follow-up. The secondary end points were pain relief at the end of follow-up, physical and mental health, morbidity, mortality, length of hospital stay, number of procedures undergone, and changes in pancreatic function. RESULTS: Thirty-nine patients underwent randomization: 19 to endoscopic treatment (16 of whom underwent lithotripsy) and 20 to operative pancreaticojejunostomy. During the 24 months of follow-up, patients who underwent surgery, as compared with those who were treated endoscopically, had lower Izbicki pain scores (25 vs. 51, P<0.001) and better physical health summary scores on the Medical Outcomes Study 36-Item Short-Form General Health Survey questionnaire (P=0.003). At the end of follow-up, complete or partial pain relief was achieved in 32% of patients assigned to endoscopic drainage as compared with 75% of patients assigned to surgical drainage (P=0.007). Rates of complications, length of hospital stay, and changes in pancreatic function were similar in the two treatment groups, but patients receiving endoscopic treatment required more procedures than did patients in the surgery group (a median of eight vs. three, P<0.001). CONCLUSIONS: Surgical drainage of the pancreatic duct was more effective than endoscopic treatment in patients with obstruction of the pancreatic duct due to chronic pancreatitis.(Current Controlled Trials number, ISRCTN04572410.) Copyright 2007 Massachusetts Medical Society.

In three patients, a man aged 52 years, a woman aged 35 years and a man aged 72 years, respectively, severe bile duct injury occurred following conversion from laparoscopic to open cholecystectomy. Treatment included percutaneous transhepatic drainage, abdominal drainage and bile return via a duodenal canula, and hepaticojejunostomy with Roux-and-Y reconstruction. Bile duct injury is the most significant complication following cholecystectomy, with substantial long term morbidity. The most common treatment for gallstones is laparoscopic cholecystectomy, irrespective of the presence of risk factors for conversion and bile duct injury. Generally, when the 'critical view of safety' cannot be obtained during laparoscopic cholecystectomy, conversion to open surgery is advocated to prevent bile duct injury. Surgical residents however, now have little or no experience with the open procedure. Conversion does not always provide a better view of the anatomy and, without experience with this procedure, it may even lead to more severe bile duct injury, such as transection or resection of the duct. In the case of a difficult laparoscopic cholecystectomy, a change of surgical strategy, such as antegrade or subtotal cholecystectomy or even drainage, may be more important than conversion per se.

Aim: Cholestasis is associated with increased morbidity and mortality in patients undergoing major liver surgery. An additional risk is induced when vascular inflow occlusion is applied giving rise to liver ischemia/reperfusion (I/R) injury. The role of the coagulation system in this type of injury is elusive. The aim of the current study was to assess activation of coagulation following hepatic I/R injury in cholestatic rats. Methods: Male Wistar rats were randomized into two groups and subjected to bile duct ligation (BDL) or sham laparotomy. After 7 days, both groups underwent 30 min partial liver ischemia. Animals were sacrificed before ischemia or after 6 h, 24 h, and 48 h reperfusion. Results: Plasma AST and ALT levels were higher after I/R in cholestatic rats (P < 0.05). Hepatic necrosis, liver wet/dry ratio and neutrophil influx were increased in the BDL group up to 48 h reperfusion (P < 0.05). Liver synthetic function was decreased in the BDL group as reflected by prolonged prothrombin time after 6 h and 24 h reperfusion (P < 0.05). I/R in cholestatic rats resulted in a 12-fold vs. 7-fold (P < 0.01) increase in markers for thrombin generation and a 6-fold vs. 2-fold (P < 0.01) increase in fibrin degradation products (BDL vs. control, respectively). In addition, the cholestatic rats exhibited significantly decreased levels of antithrombin (AT) III and increased levels of the fibrinolytic inhibitor plasminogen activator inhibitor (PAI-1) during reperfusion. Conclusions: Cholestasis significantly enhances I/R-induced hepatic damage and inflammation that concurs with an increased activation of coagulation and fibrinolysis.

BACKGROUND/AIMS: Portal vein embolization (PVE) has reached worldwide acceptance to increase future remnant liver (FRL) volume before undertaking major liver resection. The aim of this overview is to point out and discuss current controversies in the application of PVE. METHODS: Review of literature pertaining to techniques of PVE, complications, tumor proliferation, timing of resection, and hypertrophy response after PVE. RESULTS: Procedure-related complications after PVE include hematoma, hemobilia, overflow of embolization material, and thrombosis of portal vein branch(es) of the non-embolized lobe. Persistence of the embolized, atrophic lobe is usually not harmful. Embolization of the portal branches to segment 4 in addition to embolization of the right portal trunk is controversial and is advised only in selected cases. It remains undecided whether embolization of the portal venous system is more effective in inducing hypertrophy of the FRL than ligation of the portal vein. Accelerated tumor growth after PVE is a major concern and requires consideration of post-PVE chemotherapy. A waiting time of 3 weeks between PVE and liver resection is advised. Post-hepatectomy regeneration is not hampered after preoperative PVE. CONCLUSION: PVE is a useful preoperative intervention to increase volume and function of the FRL. Further progress awaits clarification of the mechanisms of the hypertrophy response induced by PVE in conjunction with new embolization materials and protective chemotherapy.

BACKGROUND: Chylous ascites (CA) is a complication that follows thoracic and abdominal surgery, recognized after provocation by enteral feeding and characterized by its milky appearance from an elevated triglyceride level. The aim of this study was to evaluate incidence, management, and predisposing factors of CA and its impact on outcomes after pancreaticoduodenectomy. STUDY DESIGN: Between 1996 and 2007, 609 consecutive patients underwent pancreaticoduodenectomy. Patients having a drain output with a milky appearance, and with a triglyceride level greater than 1.2 mmol/L, were compared with patients without significant drain production or with a low triglyceride level. Management of CA was reviewed. RESULTS: Sixty-six patients had isolated CA (11%) of any measurable volume, 440 patients (72%) had no CA, and 109 patients (16%) were excluded from analysis. CA was diagnosed on postoperative day 6 (median; interquartile range 5 to 8), generally after introduction of a normal (polymeric low-chain-triglyceride) diet. Female gender (odds ratio, 1.79; 95% CI, 1.05 to 3.03) and chronic pancreatitis at pathology (odds ratio, 2.52; 95% CI, 1.19 to 5.32) were independently associated with development of isolated CA. A low-chain-triglyceride-restricted diet was initiated in 47 patients, 3 were started on total parenteral nutrition, and an expectative approach was followed in 16 patients. CA resolved after 3.5 days (median; interquartile range, 2 to 5). Isolated CA was significantly associated with prolonged hospital stay (p=0.002). CONCLUSIONS: We propose a novel definition and grading system for CA after pancreaticoduodenectomy, according to which the incidence is 9%, with clinically significant CA occurring in 4%(grades B and C). Although female gender and (focal) chronic pancreatitis were associated with development of isolated CA, no predisposing factors that could readily anticipate CA were identified. Isolated CA was associated with prolonged hospital stay.

Biliary complications occur because of causes such as obscure or variant anatomy, predisposing conditions such as fibrosis or severe inflammation, equipment failure, and surgeon factors. The aim of this study was to review the optimal surgical treatment. Analysis of 81 patients with bile duct injuries treated in a single referral unit over an 8.5-year period was done. Time of detection of biliary injury and its presentation were ascertained as well as the level of injury (Strasburg's). In 8 patients, injury was detected intraoperatively, and 41 were detected in the early postoperative period with bile leak (n = 25) or obstructive jaundice (n = 10). Those diagnosed in the delayed postoperative period (n = 32) presented with recurrent cholangitis (n = 9), obstructive jaundice (n = 16), and a cholestatic enzymatic profile (n = 1). Roux-en-Y hepatico-jejunostomy was the preferred option (n = 64). One patient died because of biliary peritonitis. Improper treatment is associated with disastrous results, but early recognition and correct management can lead to a successful outcome and good prognosis.

AIM: Numerous reports in the 1990s pointed to a learning curve for laparoscopic cholecystectomy (LC), critical in achieving excellent outcomes. As LC is now standard therapy for acute cholecystitis (AC), we aimed to determine if surgeon volume is still vital to patient outcomes. METHODS: The Nationwide Inpatient Sample was used to query 80,149 emergent/urgent cholecystectomies performed for AC from 1999 to 2005 in 12 states with available surgeon/hospital identifiers. Volume groups were determined based on thirds of number of cholecystectomies performed per year for AC; two groups were created [low volume (LV):</=15/year; high volume (HV):>15/year]. Primary endpoints were the rate of open conversion, bile duct injury (BDI), in-hospital mortality, and prolonged length of stay (LOS). Propensity scores were used to create a matched cohort analysis. Logistic regression models were created to further assess the effect of surgeon volume on primary endpoints. RESULTS: The number of cases performed by HV surgeons increased from 24% to 44% from 1999 to 2005. HV surgeons were more likely to perform LC, had fewer conversions, lower incidence of prolonged LOS, lower BDI, and lower in-hospital mortality. After matching the volume cohorts to create a case-controlled analysis, multivariate analysis confirmed that surgeon volume was an independent predictor of open conversion and prolonged LOS but not BDI and in-hospital mortality. CONCLUSIONS: Increasing surgical volume remains associated with improved outcomes after surgery during emergent/urgent admission for AC with fewer open conversions and prolonged LOS. Our results suggest that referral to HV surgeons has improved outcomes after LC for AC.

BACKGROUND: Little is known about surgeon characteristics associated with common bile duct injury (CBDI) during laparoscopic cholecystectomy (LC). Risk-taking preferences can influence physician behavior and practice. We evaluated self-reported differences in characteristics and risk-taking preference among surgeons with and without a reported history of CBDI. STUDY DESIGN: A mailed survey was sent to 4,100 general surgeons randomly selected from the mailing list of the American College of Surgeons. Surveys with a valid exclusion (retired, no LC experience) were considered responsive, but were excluded from data analysis. RESULTS: Forty-four percent responded (1,412 surveys analyzed), 37.7% reported being the primary surgeon when a CBDI occurred, and 12.9% had more than one injury. Surgeons reporting an injury were slightly older (52.8 +/- 9.0 years versus 51.3 +/- 9.8 years; p < 0.004) and in practice longer (20.8 +/- 9.7 years versus 18.9 +/- 10.5 years; p < 0.001). Surgeons not reporting a CBDI were more likely trained in LC during residency (63.3% versus 55.4% injuring) as compared with surgeons reporting a CBDI, who were more likely trained at an LC course (29.8% versus 38.2%). Surgeons in academic practice or who work with residents had lower reported rates of CBDI (7.9% versus 14.5%[academics]; 18.7% versus 25.0%[residents]). Mean risk score was 12.4 +/- 4.4 (range 6 to 30 [30 = highest]) with a similar average between those who did (12.2 +/- 4.5) and did not (11.9 +/- 4.4) report a CBDI (p < 0.23). Compared with surgeons in the lowest three deciles of risk score, relative risk for CBDI among surgeons in the upper three deciles was 17% greater (p = 0.07). CONCLUSIONS: More years performing LC and certain practice characteristics were associated with an increased rate of CBDI. The impact of extremes of risk-taking preference on surgical decision making can be an important part of decreasing adverse events during LC and should be evaluated.

Shoulder pain is a common musculoskeletal complaint. Patients with shoulder pain who are seeking care in a military tertiary setting in the United States have not been previously described. This study describes the clinical features of 55 patients (47 men, 8 women) undergoing shoulder surgery at a tertiary care military medical center. Patients presenting to a military medical center are different than other previously described samples in the literature. Specifically, the patients in this study had a known mechanism of injury (n = 42; 76%), multiple structures involved (n = 46; 84%) and a high prevalence of glenoid labral involvement (n = 44; 80%). Further research is needed to determine if these patient characteristics identified in this study warrant different management strategies and resource utilization in both the tertiary care center, and in the primary care center where these patients are typically seen before referral to a tertiary care center.

BACKGROUND: Bile duct injuries are the main serious technical complication of laparoscopic cholecystectomy (LC). Each lesion is peculiar in its features as well as the surgeon's reaction when face it. AIM: To reveal the place of the human error according to accepted principles of cognitive psychology, beside other risk-factors involved in biliary accidents during LC. METHOD: Retrospective study on 18 patients treated for severe biliary lesions during LC in 1st Surgical Clinic of "Sf. Spiridon" Hospital, Iaşi, Romania, between March 1993 and March 2008. According to Strasberg's classification the lesions were: type C (n=1; 3%), type D (n=13; 39.4%), type E1-2 (n=2; 6.1%) and type E5 (n=2; 6.1%). In the medical records we followed up the technical aspects of the procedure (section, dissection, clips) and the lesional and anatomic factors attended at the moment of LC. We also assessed the concerned surgeons experience based on the number of the LC at time of the biliary accident. RESULTS: In our experience (10046 LC) the incidence of the biliary injuries was 0.1% only. We met four lesional and/or anatomic factors (mean) on each case with biliary lesion. Only five cases (27.7%) were detected intraoperatively, but Spearman's correlation between time of detection and surgeons experience is insignificant. CONCLUSION: Our results, rounded with cognitive psychology data from literature, suggest the role of the absence of haptic perception during laparoscopic procedures, in the occurrence of some errors, even in circumstances with "perfect visibility".

BACKGROUND: Surgeons are rarely formally trained in giving bad news to patients. The aim of our study was to examine and compare techniques of disclosure of iatrogenic and incidental operative findings among surgical residents. METHODS: General surgery residents performed a laparoscopic cholecystectomy on the SurgicalSIM device in a mock operating room. Half (n = 8) were presented with a common bile duct injury, and half (n = 7) encountered metastatic gallbladder cancer during the operation. Both groups disclosed this information to a patient's scripted family member and completed a questionnaire. All encounters were videotaped and independently rated using a modified SPIKES protocol, a validated tool for delivering bad news. We compared disclosure of iatrogenic versus unexpected findings by year of training. Analysis was performed using the Mann-Whitney test. RESULTS: Regardless of the year of training, more residents were comfortable with disclosure of an incidental finding than disclosure of an iatrogenic injury (47 vs. 33%). Senior residents (PGY4-PGY5) had better ratings by SPIKES (p < 0.05), most notably for tailoring disclosure to what patient and family understand, exploring patient and family expectations, and offering to answer any questions (p < 0.05). Even though all residents felt more comfortable with disclosure of an incidental finding, the quality of the disclosure by SPIKES score was the same for iatrogenic and incidental operative findings (p = NS). CONCLUSION: In general, trainees are ill prepared for delivering bad news. Disclosure of iatrogenic injuries was more challenging compared to that of incidental findings. Senior residents do better than junior residents at delivering bad news.

BACKGROUND: Prevention of iatrogenic injuries is of paramount importance in difficult laparoscopic cholecystectomies (LC). The objective of this study was to analyze the effectiveness of cholangiography using a pre-inserted endoscopic naso-biliary drain (ENBD) for navigation during difficult cholecystectomies. METHODS: The study design was a retrospective case analysis. In 508 patients who underwent LC in a tertiary referral university hospital from 1996 through 2007, difficult cholecystectomy was anticipated in 26 patients due to possibly aberrant biliary anatomy (four patients), unclear cystic duct anatomy during magnetic resonance cholangiopancreatography (MRCP) and/or endoscopic retrograde cholangiopancreatography (ERCP)(three patients), and acute cholecystitis (19 patients). An ENBD was inserted during ERCP prior to LC for cholangiography (ENBDC) to facilitate safe dissection during LC. Prevalence of biliary complications was assessed as the main outcome measurement. RESULTS: The majority (68%) of the patients who underwent ENBDC had complicated cholecystitis. Advanced technical expertise was not required for insertion of an ENBD. In retrospect, ENBDC was useful in prevention of a possible catastrophe in 69% of cases. Open conversion was necessary in five patients and biliary complications occurred in five patients only in the non-ENBD group. There were no procedure-related complications. One limitation of the study was that it was not randomized and there was no comparison with patients without ENBDC. CONCLUSIONS: ENBDC is a useful and safe tool in the prevention of iatrogenic bile duct injuries in LC.

Open cholecystectomy has been associated historically with 0.2% to 0.5% risk of postoperative biliary injury. Laparoscopic cholecystectomy, which has become the first-line surgical treatment of calculous gallbladder disease, has been associated with a 2.5-fold to fourfold increase in the incidence of postoperative bile duct injury. The biliary endoscopist can expect to see a varied spectrum of complications after cholecystectomy by either technique, including postoperative biliary strictures, bile leaks, and retained calculi in the biliary tree. Proper diagnosis and treatment are paramount in ensuring a satisfactory outcome after bile duct injury. Endoscopic retrograde cholangiopancreatography (ERCP) has become the primary modality for treatment and effectively manages most bile duct injuries.

Litigation regarding personal injury takes up a large amount of court time and space. Persons with litigation are often different in several ways from those who do not have litigation. In this study 88.7% of these plaintiffs had nongenuine abnormalities characteristic of malingering on neurological examination compared to 5.4% of controls, and their symptoms and abnormalities were often unexplainably persistent. It appears that our legal system usually rewards persons with false and exaggerated claims. This results in higher insurance premiums and taxes for the citizens of this country while making attorneys that represent these persons with false claims wealthy. This encourages additional claims.

OBJECTIVE: To summarize the reasons for bile duct injury (BDI) after laparoscopic cholecystectomy (LC), and to determine the effect of multiple treatment after BDI. METHODS: A retrospective cohort study was performed. The medical records of 110 patients diagnosed with BDI after LC from October 1993 to November 2007, in ten large hospitals in Guangdong of China, were reviewed. RESULTS: Among 110 patients with BDI, 58 cases (52.7%) were local patients, whereas 52 cases (47.3%) were transferred from outside hospitals. Reasons for BDI following LC were:(1) Lack of experience of the LC operator (48.2%);(2) LC performed during acute cholecystitis (20.0%);(3) The structure of Calot triangle was unclear (15.5%);(4) Variable anatomical position (11.8%);(5) Intra-operation bleeding (4.5%). The commonest sites of injury were the choledochus and common hepatic duct (76.4%). Following BDI, endoscopic stenting or operative repair was performed in 106 patients. The overall success rate was 95.3%(101/106), with a mortality rate was 0.9%(1/106). Cholangitis occurred in 3.8%(4/106) cases. Choledocho-enterostomy operation was performed in almost 60.0%(63/106) cases, and the success rate was 93.7%(59/63). Endoscopic stenting or operative repair was performed immediately following BDI in 23.6%(25/106) patients, the success rate was 100%; and within 30 days in 63.2%(67/106) patients. Eighty-eight out of 106 patients who underwent repair were successful following the first operative procedure. CONCLUSIONS: Factors such as an un-experienced operator and unclear anatomical position were causes of BDI following LC. Early operative repair should be regarded as the treatment of choice, in patients diagnosed with BDI. Early refer to an experienced hepatobiliary operator ensures a high success rate.