Major common bile duct injury and risk of litigation: a surgeon’s perspective. Am J Surg

University of New South Wales, Department of Surgery, Bankstown-Lidcombe Hospital, Bankstown, Australia.
American journal of surgery (Impact Factor: 2.29). 08/2011; 204(5). DOI: 10.1016/j.amjsurg.2011.06.009
Source: PubMed


Risk for a lawsuit for medical malpractice has unfortunately become part of physicians' daily professional activities, with a blowout in indemnity insurance premiums, especially in high-risk medical specialties. Common bile duct injury following laparoscopic cholecystectomy is a well-recognized and feared complication for surgeons because of its associated morbidity, and it also ranks among the leading sources of medical malpractice claims against surgeons in the world. The purpose of this article is to raise awareness within the medical community and in particular among specialist surgeons on the important threat they could be facing in terms of litigation in the event of an adverse surgical outcome following such a commonly performed procedure. There is a real need for open debate on this concerning topic, as the fear of lawsuits and exorbitant malpractice premiums are pushing a substantial number of medical professionals to practice defensive medicine, reflected by the avoidance of performing certain procedures or treating high-risk patients perceived to have higher litigation rates, or simply walking away from their current practices, creating a chronic shortage of specialized doctors in certain surgical areas.

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    • "(video laparoscopy) (2,3). Despite their low prevalence, iatrogenic BDIs are significant with regard to their absolute numbers (4) and are important in terms of health care costs (5,6); furthermore, they are among the leading causes of negligence claims against surgeons (7-10). "
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    ABSTRACT: The aim of this study was to evaluate the effect of oral tamoxifen treatment on the number of myofibroblasts present during the healing process after experimental bile duct injury. The sample consisted of 16 pigs that were divided into two groups (the control and study groups). Incisions and suturing of the bile ducts were performed in the two groups. Tamoxifen (20 mg/day) was administered only to the study group. The animals were sacrificed after 30 days. Quantification of myofibroblasts in the biliary ducts was made through immunohistochemistry analysis using anti-alpha smooth muscle actin of the smooth muscle antibody. Immunohistochemical quantification was performed using a digital image system. In the animals treated with tamoxifen (20 mg/day), there was a significant reduction in immunostaining for alpha smooth muscle actin compared with the control group (0.1155 vs. 0.2021, p = 0.046). Tamoxifen reduced the expression of alpha smooth muscle actin in the healing tissue after bile duct injury, suggesting a decrease in myofibroblasts in the scarred area of the pig biliary tract. These data suggest that tamoxifen could be used in the prevention of biliary tract stenosis after bile duct surgeries.
    Clinics (São Paulo, Brazil) 01/2013; 68(1):101-6. DOI:10.6061/clinics/2013(01)OA16 · 1.19 Impact Factor
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    ABSTRACT: To compare the operative outcomes of early and delayed cholecystectomy for acute cholecystitis. Randomized trials comparing early to delayed cholecystectomy for acute cholecystitis have limited contemporary external validity. Furthermore, no study to date has been large enough to assess the impact of timing of cholecystectomy on the frequency of serious rare complications including bile duct injury and death. This is a population-based retrospective cohort study of patients emergently admitted to hospital with acute cholecystitis and managed with cholecystectomy over the period of April 1, 2004, to March 31, 2011. We used administrative records for the province of Ontario, Canada. Patients were divided into 2 exposure groups: those who underwent cholecystectomy within 7 days of emergency department presentation on index admission (early cholecystectomy) and those whose cholecystectomy was delayed. The primary outcome was major bile duct injury requiring operative repair within 6 months of cholecystectomy. Secondary outcomes included major bile duct injury or death, 30-day postcholecystectomy mortality, completion of cholecystectomy with an open approach, conversion among laparoscopic cases, and total hospital length of stay. Propensity score methods were used to address confounding by indication. From 22,202 patients, a well-balanced matched cohort of 14,220 patients was defined. Early cholecystectomy was associated with a lower risk of major bile duct injury [0.28% vs 0.53%, relative risk (RR) = 0.53, 95% confidence interval [CI]: 0.31-0.90], of major bile duct injury or death (1.36% vs 1.88%, RR = 0.72, 95% CI: 0.56-0.94), and, albeit non-significant, of 30-day mortality (0.46% vs 0.64%, RR = 0.73, 95% CI: 0.47-1.15). Total hospital length of stay was shorter with early cholecystectomy (mean difference 1.9 days, 95% CI: 1.7-2.1). No significant differences were observed in terms, open cholecystectomy (15% vs 14%, RR = 1.07, 95% CI: 0.99-1.16) or in conversion among laparoscopic cases (11% vs 10%, RR = 1.02, 95% CI: 0.93-1.13). These results support the benefit of early overdelayed cholecystectomy for patients with acute cholecystitis.
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