Incidence Of Bile Duct Injury Research Articles

Laparoscopic Revisional Hepaticojejunostomy for Biliary Stricture After Open Repair Following Common Bile Duct Injury: A Case Report

Incidence of bile duct injury has been reported more frequently following laparoscopic cholecystectomy. A 43-year-old female with a past medical history of laparoscopic cholecystectomy that was converted to open because of a common bile duct injury now presents with a stenosis at the hepaticojejunostomy that is causing recurrent cholangitis episodes. After the lysis of adhesions and dissection of the anastomotic area, a stricture was identified. The authors exposed and redid the hepaticojejunostomy with 4-0 Monocryl sutures without tension. The follow-up period was unremarkable. No leaks were documented, and the patient was discharged home on postoperative day 3. After percutaneous or endoscopic procedure failure for the treatment of hepaticojejunostomy strictures, the laparoscopic redo anastomosis is safe and feasible when performed by surgeons who are strongly trained in advanced laparoscopic surgery.

Surgicalvspercutaneous radiofrequency ablation for hepatocellular carcinoma in dangerous locations

To compare the long-term outcome of percutaneous vs surgical radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC) in dangerous locations. One hundred and sixty-two patients with HCC in dangerous locations treated with percutaneous or surgical RFA were enrolled in this study. The patients were divided into percutaneous RFA group and surgical RFA group. After the patients were regularly followed up for a long time, their curative rate, hospital stay time, postoperative complications and 5-year local tumor progression were compared and analyzed. No significant difference was observed in curative rate between the two groups (91.3% vs 96.8%, P=0.841). The hospital stay time was longer and more analgesics were required while the incidence of bile duct injury and RFA-related hemorrhage was lower in surgical RFA group than in percutaneous RFA group (P<0.05). The local progression rate of HCC in dangerous locations was significantly lower in surgical RFA group than in percutaneous RFA group (P=0.05). The relative risk of local tumor progression was 14.315 in percutaneous RFA group. The incidence of severe postoperative complications and local tumor progression is lower after surgical RFA than after percutaneous RFA.

Elective Laparoscopic Cholecystectomy without Routine Intraoperative Cholangiography: A Retrospective Analysis of 1101 Consecutive Cases

Laparoscopic cholecystectomy (LC) is today the operation of choice for symptomatic gallstone disease. Before the laparoscopic era intraoperative cholangiography (IOC) was generally considered as a fundamental step in cholecystectomy while nowadays the role of IOC is controversial: is there a need for IOC to specify anatomy of biliary tree in order to avoid bile duct injuries (BDI) and to detect possible common bile duct (CBD) stones or not? We studied retrospectively all the elective LCs done in Turku City Hospital for Surgery during the ten years (1992-2001). Cholecystectomy was performed to 1101 patients, 874 (79%) female and 227 (21%) male patients, mean age 53y (range 15-89). LC was possible in 1022 (93%) cases while 79 (7%) had to be converted to open procedure. The number and severity of bile duct injuries were recorded. The cases with endoscopic retrograde cholangiopancreatography (ERCP) and/or magnetic resonance cholangiopancreatography (MRCP) during the follow-up and the findings in ERCP and MRCP were recorded from patient records and radiological database. IOC was performed in 32 operations (20 in LC and 12 after conversion) and CBD stones were found in seven patients. There were four primary BDIs: two CBD injuries and two minor bile leaks. During a mean follow-up of 72 months (range 36-144) ERCP was performed in 16 and MRCP in three patients. Three patients underwent both MRCP and ERCP. CBD stones were detected in ten patients and a postoperative late CBD stricture was found in one case. According to our data, both the incidence of BDIs (0.5%) and symptomatic postoperative CBD stones (0.9%) remain low without the routine use of IOC.

Medicolegal claims and intra-operative cholangiography

The vast majority of this piece is sensible and reasonable. Predictably, perhaps inevitably, the authors move into troubled waters when they discuss intra-operative cholangiography (IOC). Is there an issue in gastrointestinal surgery that engenders more controversy or discord? Inevitably, participants in this debate quote evidence to support their own prejudice. It is true that ‘the routine use of IOC has been reported to reduce the incidence of bile duct injuries by clarifying the anatomy’.1 It is also true that numerous national and international series have shown that the use of IOC is not associated with any reduction in the risk or rate of bile duct injury. However, the numbers in these series range between 5 and 70,000 whereas the Flum study already referred to involves 1.5 million procedures. The authors make the statement: ‘an IOC should be used to confirm the anatomy if any doubt exists’. Is there any evidence to support this statement? The Flum paper demonstrates that when the ‘frequent cholangiographer’ (essentially a surgeon who attempts to perform routine IOC) performs a cholan-giogram, a significantly lower incidence of bile duct injury results. This is unarguable. However, the other extremely interesting and seldom mentioned finding of this study is that if the ‘infrequent cholangiographer’ (arbitrarily set at less than 25 % of cases but often much less than this) performs a cholangiogram, the bile duct injury rate, far from decreasing, significantly increases. The authors argue, I believe plausibly, that in this instance the cholangiogram was being done in a ‘difficult’ case. So much for the evidence, what about logic/simple common sense. We have all been faced with a situation where we cannot confidently identify the anatomy in the area of Calot's triangle. Let us analyse what performing a cholangiogram in these circumstances actually means. It involves selecting a bile duct, the identity of which (it is clearly conceded) is uncertain, putting two clips across it and making a hole in it. Is this justifiable or appropriate? I would argue absolutely not. The safe, and therefore the correct, approach in this situation is to dissect the gall-bladder, fundus first, off the liver. This approach can sometimes lead to confident identification of the anatomy at the neck of the gallbladder but in my experience rarely. The sensible course of action is then to stay well clear of Calot's triangle, amputate the gallbladder across Hartmann's pouch, remove any stones and over-sew the remnant It is, of course, possible to do this laparoscopically but many surgeons might prefer to employ open surgery and, if this is the case, they should convert without a moment's hesitation. This approach has served me well for over 20 years, or just under 2500 procedures, with a bile duct injury rate of zero (so far, touch wood!). The advice that cholangiography should be done if the anatomy is unclear is supported by no convincing evidence, is not sensible or logical and should be ignored by all surgeons, particularly those in training.

Characteristics of bile duct injury induced by laparoscopic cholecystectomy： a single center report

Objective To study the characteristics and changes of bile duct injury induced by lapa- roscopic cholecystectomy （LC） in recent years. Methods The clinical data of patients who underwent LC between October 1992 and June 1998 （ early group） were compared with those between June 2003 and March 2009 （recent group）. Results Of 18,613 cases in recent group, the bile duct injury occurred in 11 cases （0.06%） , which included 2 cases of bile duct transection （ occurred during open cholecystectomy in 1 case）, 3 cases of dissociation impairment,-2 eases of electric coagulation injury （1 in common hepatic duct, the other accessory hepatic duct）, 2 cases of partial shearing in common bile duct, 1 case of accessory he- patic duct transection, 1 case of suture injury in common hepatic duct during open eholecystectomy. In 11, 796 cases of early group, bile duct injury occurred in 15 cases （0.13%） , including 6 cases of bile duct transection, 6 cases of electric coagulation injury to lateral extrahepatic bile duct and 3 cases of dissociation impairment of bile duct. Injury-rate.of bile duct in recent group was significantly lower than that of the early group （χ2 = 3.92, P = 0. 04784）. Conclusion The incidence of bile duct injury induced by LC in recent years is significantly lower than that in years before, so is the severity of injury, while the types of bile duct injury are increasing. Individualized management can prevent further injury to the bile duct, as well as post- operative complications. Key words: Cholecystectomy,laparoscopic ; Bile duct injury

Article Commentary: Management of Bile Duct Injuries: A Practical Approach

The incidence of bile duct injury (BDI) has increased after the introduction of laparoscopic cholecystectomy. A BDI can occur in the hands of experienced surgeons also. It can result in serious complications and may even cause death of the patient; it also has financial and legal implications. Proper training, sound surgical technique, and conversion to an open operation can prevent a large number of injuries. An injury that is missed during the operation manifests in the postoperative period as a bile leak and external biliary fistula or during the follow up as a biliary stricture. Management of a BDI depends on the nature of the bile duct injured, type of injury, and expertise available; it may range from simple subhepatic drainage to Roux-en-Y hepaticojejunostomy. Excellent results can be obtained when BDI is managed at a hepatobiliary center.

Laparoscopic subtotal cholecystectomy for severe cholecystitis

To evaluate the efficacy and outcome of laparoscopic subtotal cholecystectomy (LSC) for patients with severe cholecystitis. Between April 1992 and May 2008, 1226 patients underwent laparoscopic cholecystectomy (LC). From 2000 onward 60 patients with severe cholecystitis underwent LSC. The outcomes of LC were compared between patients who underwent the procedure between 1992 and 1999 (group A; n = 643) and those who underwent the procedure between 2000 and 2008 after the introduction of LSC (group B; n = 583), respectively. In Group B, operative outcomes were also compared between the LC and LSC groups. The incidence of bile duct injury (1.6% vs 0.3%, P = 0.040) and conversion to open cholecystectomy (2.2% vs 0.3%, P = 0.046) was significantly lower in group B. The mean operative time was significantly longer (119.6 min vs 71.0 min., P < 0.001), and the mean blood loss was significantly higher (53.4 ml vs 12.9 ml, P < 0.001) in the LSC group. No significant differences were observed between LC and LSC in the incidence of postoperative morbidities or postoperative hospital stay. No patient had remnant gallstones or gallbladder cancers after a median follow-up of 42 months. Laparoscopic subtotal cholecystectomy is safe and effective for preventing bile duct injuries and lowering the conversion rate in patients with technically difficult severe cholecystitis.

Timing of referral impacts surgical outcomes in patients undergoing repair of bile duct injuries

Bile duct injury (BDI) after laparoscopic cholecystectomy (LC) remains a significant surgical challenge. Despite claims to the contrary, the incidence of bile duct injury has remained elevated since the introduction of LC. Several issues regarding the surgical management of BDI are controversial, including: (i) identification of the surgeon and centre most capable of managing the injury, (ii) timing of surgical repair, (iii) incidence and significance of associated vascular injury and (iv) identification of patient factors which significantly impact outcome after repair. Variability in timing of referral of BDI to tertiary centres has been noted in the literature. The impact of timing of referral upon post-operative outcomes after definitive surgery has yet to be clearly investigated. We report our experience with 44 patients who required reconstructive surgery after BDI. In contrast to the many studies available in the literature, patients in the current study were classified according to a modern injury classification system. Additionally, we examined the impact of delayed referral to our centre on short- and long-term outcomes after surgical repair of BDI.

Management of major bile duct injury after laparoscopic cholecystectomy: a case report

IntroductionBile duct injury is a severe and potentially life-threatening complication of laparoscopic cholecystectomy. Several series have described a 0.5% to 0.6% incidence of bile duct injury during laparoscopic cholecystectomy. The aim of this study was to analyze the presentation, characteristics, related investigation, and treatment results of major bile duct injuries after laparoscopic cholecystectomy.Case presentationA rare case of a 48-year-old Greek woman with a triple bile duct injury (right and left hepatic duct ligation and common bile duct cross-section) is presented. A Roux en Y hepaticojejunostomy was performed after repeated endoscopic retrograde cholangiopancreatographies, percutaneous transhepatic catheterization of the ducts and magnetic resonance cholangiographies to delineate the biliary anatomy and assess the level of injury.ConclusionEarly recognition and an adequate multidisciplinary approach are the cornerstones for the optimal final outcome. Suboptimal management of injuries often leads to more extensive damage to the biliary tree and its vasculature. Early referral to a tertiary care center with experienced hepatobiliary surgeons and skilled interventional radiologists would appear to be necessary to assure optimal results.

Clinical Experiences of Management of Bile Duct Injuries during Laparoscopic Cholecystectomy

Purpose: Laparoscopic cholecystectomy (LC) has become the gold standard of management of gallstone disease. LC is associated with a two-to-four times higher incidence of bile duct injury, which is a rare but more serious complication than open cholecystectomy. We reviewed our experiences with the management of bile duct injury during laparoscopic cholecystectomy. Methods: From January 1999 to April 2009, 13 patients with bile duct injuries following LC were managed in our hospital. Patients’ charts were retrospectively reviewed to analyze perioperative management. Results: Among the 13 patients, 7 patients sustained their bile duct injuries at our hospital. Six patients were referred to our hospital to manage their bile duct injuries. Five patients’ injuries were identified during LC. According to the Strasberg classification, there are 5 cases of type A, 2 cases of type C, 1 case of type D and 5 cases of type E injuries. Four type A bile duct injuries were treated by direct ductal ligation during LC and 1 type A bile duct injury and 1 type C bile duct injury were managed by non-surgical treatment. Type D and type E injuries were managed by Roux-en-Y hepaticojejunostomy. Conclusion: Bile duct injuries are a rare but serious complications that occur during laparoscopic cholecystectomy. Most minor bile duct injuries are well treatable with non-surgical management, whereas major bile duct injuries require surgical management. The combination of non-surgical management and surgical treatment results in successful outcomes in bile duct injuries.

Decreased Bile Duct Injury Rate During Laparoscopic Cholecystectomy in the Era of the 80-Hour Resident Workweek

Considerable concern has been raised about the effects of restricted duty hours on surgical training. However, to our knowledge, the effect of the 80-hour resident workweek on operative outcomes after laparoscopic cholecystectomy has not been well studied. To compare the rates of bile duct injury and overall complications after laparoscopic cholecystectomy before and after the institution of the duty-hour restriction. Retrospective review of patient medical records to determine morbidity and mortality before (January 1, 2000, to June 30, 2003; period 1) and after (July 1, 2003, to June 30, 2006; period 2) implementation of duty hour limitations. Major public teaching hospital. A total of 2470 patients who had undergone laparoscopic cholecystectomy. Bile duct injury and overall complication rates as determined using multivariate analysis. Overall, 2470 laparoscopic cholecystectomy procedures were performed, including 1353 in period 1 and 1117 in period 2. In period 2, more patients had acute cholecystitis as the indication for surgery (49% vs 35% in period 1, P < .001), and a higher percentage of patients were male (22% vs 18%, P = .01). The incidence of bile duct injury and total complications decreased in period 2 from 1% to 0.4%(P = .04) and from 5% to 2% (P < .001), respectively. Mortality was unchanged. Multivariate analysis revealed that period 2 was protective for bile duct injury (odds ratio, 0.31; 95% confidence interval, 0.1-0.96; P = .04). For complications, both female sex (odds ratio, 0.62; 95% confidence interval, 0.38-0.9) and surgery during period 2 (odds ratio, 0.46; 95% confidence interval, 0.28-0.75) were protective, whereas older age (odds ratio, 1.03; 95% confidence interval, 1.02-1.05) was associated with complications. At a major public teaching hospital, the bile duct injury rate and the overall complication rate decreased after implementation of the 80-hour workweek.

Intraductal chilled saline perfusion to prevent bile duct injury during percutaneous radiofrequency ablation for hepatocellular carcinoma

Radiofrequency ablation (RFA) is a promising, minimally invasive treatment for hepatocellular carcinoma (HCC). However, thermal injury sometimes occurs in the bile duct, potentially leading to a critical situation. The aim of the present study was to investigate whether bile duct injury is reduced by an intraductal chilled saline perfusion (ICSP) through a nasobiliary tube during RFA for HCC. The baseline incidence of bile duct injury at Gifu Municipal Hospital was 3.1% (13 patients) in 424 patients with HCC treated by percutaneous RFA. In all patients, the tumor was within 5 mm of the central bile duct on CT images. The incidence of bile duct injury was 46% among the 28 selected patients whose tumor was close to the central bile duct. To prevent complications in such high-risk patients, we placed a nasobiliary tube endoscopically before RFA, and performed ICSP during RFA. Forty consecutive patients with tumors close to the central bile duct were enrolled in this study. Of the 40 enrolled patients, only one had biliary injury, whereas the remaining 39 patients were able to avoid it. The incidence of biliary injury was significantly reduced in the ICSP group (1/40, 2.5%) compared to that in the control group (13/28, 46%) (P < 0.0001). Moreover, the liver function 6 months after RFA was also better preserved in the ICSP group according to Child-Pugh grading, thus resulting in a better clinical outcome. ICSP through a nasobiliary tube is a potential intervention method to prevent biliary injury by percutaneous RFA.

Iatrogenic Bile Duct Injury During Laparoscopic Cholecystectomy

Laparoscopic cholecystectomy has largely replaced open cholecystectomy as the standard of care for gallbladder excision. A major disadvantage of this trend has been the increased incidence of bile duct injuries, which, while uncommon, are significantly higher with laparoscopic cholecystectomy. Most injuries are not recognized at the time of surgery and present in a delayed fashion, leading to significant patient morbidity and a negative impact on the quality of life of patients. Treatment is governed by the time of presentation and the nature of the bile duct injury incurred and requires a multidisciplinary approach. Radiologists play a key role in management, with diagnosis of complications, accurate depiction of the biliary injury, and facilitating or providing definitive therapy depending on the type of injury.

Endoscopic Management of Postcholecystectomy Bile Duct Strictures

Review of 1.6 million cholecystectomies, from 1992 to 1999, demonstrated a 0.5% incidence of bile duct injury, despite increasing experience with laparoscopy. The incidence has not decreased after the "learning curve." The management of major bile duct injuries has traditionally been by hepaticojejunostomy. Endoscopy has been increasingly used to treat these injuries. This study reviews the senior author's endoscopic treatment of bile duct injuries. This is a retrospective study, from 1991 to 2006, examining data on 292 patients who were referred for postcholecystectomy problems; 199 had cholecystectomy-related injuries and 93 had other pathologies. Sixty-seven patients had bile duct injuries (Amsterdam Academic Medical Center Classification, types B, C, and D). Nineteen patients underwent bilioenteric bypass for complete bile duct occlusion or transection. In the remaining 48, endoscopic retrograde cholangiopancreatography (ERCP) evaluation and treatment were possible. Our protocol called for biliary stenting for 11 to 14 months, with stent changes at 3-month intervals. Short- and longterm results were evaluated by clinical, radiologic, and laboratory studies. Forty-six patients were selected for endoscopic management by balloon dilation and biliary stent placement. The mean +/- SD duration of endoscopic stenting was 12+/-9.8 months and followup was 30+/-24 months after stent removal. During the followup period, 10 of 46 patients (22%) had recurrent stricture: 6 (13%) responded to endoscopic biliary stenting and 4 (9%) required hepaticojejunostomy. Complications included pancreatitis (8%). There were no deaths in the endoscopic group. ERCP intervention is a safe, effective, minimally invasive treatment for bile duct strictures after cholecystectomy and can be an alternative to hepaticojejunostomy.

Laparoscopic cholecystectomy in cirrhotic patients: Feasibility in a developing country

Background/Aims:Although laparoscopic cholecystectomy (LC) has become the procedure of choice for cholelithiasis in the general population, many consider cirrhosis as a relative or absolute contraindication for laparoscopic surgery. The aim of this study was to confirm the safety of LC in cirrhotic patients in our set-up.Materials and Methods:This is a retrospective case series including all the patients with cirrhosis who underwent LC for gallstones from January 2000 to December 2006 at our institution. Data were analyzed for Child class, indication for surgery, hospital stay, and procedure-related morbidity and mortality. Results are given as mean ± standard deviation.Results:Thirty patients, including 21 females (median age: 42 years) underwent LC during the study period. There was no operative mortality. Twenty-four patients belonged to Child class A and 6 belonged to Child class B. Mean operative time was 80 ± 26 min. There was no incidence of bile duct injury, but two patients (6.7%) required conversion to open procedure. Mean hospital stay was 3 ± 2.7 days. Postoperative morbidity was observed in seven patients, including postoperative deterioration of liver function in 2, worsening of ascites in 2 and pneumonia, and port-site infection in 1. Two patients had significant drop in hemoglobin requiring blood transfusion.Conclusions:Cirrhosis is not a contraindication for LC and it can be performed safely in compensated cirrhotic patients with acceptable morbidity and mortality.

Intraoperative ultrasound as an educational guide for laparoscopic biliary surgery

To analyze the efficacy of routine intraoperative ultrasound (IOUS) as a guide for understanding biliary tract anatomy, to avoid bile duct injury (BDI) after laparoscopic cholecystectomy (LC), as well as any burden during the learning period. A retrospective analysis was performed using 644 consecutive patients who underwent LC from 1991 to 2006. An educational program with the use of IOUS as an operative guide has been used in 276 cases since 1998. IOUS was highly feasible even in patients with high-grade cholecystitis. No BDI was observed after the introduction of the educational program, despite 72% of operations being performed by inexperienced surgeons. Incidences of other morbidity, mortality, and late complications were comparable before and after the introduction of routine IOUS. However, the operation time was significantly extended after the educational program began (P < 0.001), and the grade of laparoscopic cholecystitis (P = 0.002), use of IOUS (P = 0.01), and the experience of the surgeons (P = 0.05) were significant factors for extending the length of operation. IOUS during LC was found to be a highly feasible modality, which provided accurate, real-time information about the biliary structures. The educational program using IOUS is expected to minimize the incidence of BDI following LC, especially when performed by less-skilled surgeons.

The Prevention of Laparoscopic Bile Duct Injuries: An Analysis of 300 Cases of from a Human Factors and Cognitive Psychology Perspective

Application of human factors concepts to high-risk activities has facilitated reduction in human error. With introduction of laparoscopic cholecystectomy, the incidence of bile duct injury increased. Seeking ideas for prevention, we analyzed 300 laparoscopic bile duct injuries within the framework of human error analysis. The primary cause of error (97%) was a visual perceptual illusion. The laparoscopic environment contributed to 75% of injuries, poor visibility 22%. Most injuries involved deliberate major bile duct transection due to misperception of the anatomy. This illusion was so compelling that the surgeon usually did not recognize it. Even when irregular cues were detected, improper rules were employed, eliminating feedback. Since the complication-causing error occurred at few key steps during laparoscopic cholecystectomy; we instituted focused training to heighten vigilance, and have formulated specific rules to decrease the incidence of bile duct injury. In addition, factors in the laparoscopic environment contributing to this illusion are discussed.

A Case of Cystic Duct Drainage into the Left Intrahepatic Duct and the Importance of Laparoscopic Fundus-First Cholecystectomy for Prevention of Bile Duct Injury

The laparoscopic cholecystectomy is the gold standard for the treatment of cholecystolithiasis, although it has been reported that the incidence of bile duct injury is higher for this method than for conventional open surgery. These injuries are mainly attributable to a misunderstanding of the biliary tract anatomy owing to severe cholecystitis, large impacted stones, and anatomic variations. In this paper, we report on the successful treatment of a 59-year-old male patient with cholecystolithiasis accompanied with extremely unusual biliary junction, in which the cystic duct drained into the left hepatic duct while using the laparoscopic fundus-first-cholecystectomy approach (i.e., the doom down technique) without any serious intraoperative complications. If the doom-down technique was not indicated in this particular case, the authors believe that a careless division of the cystic duct may have resulted in operative morbidity.

Laparoscopic Cholecystectomy Without Intraoperative Cholangiography

The aim of this retrospective study was to evaluate the outcome of laparoscopic cholecystectomies (LCs) performed in our Academic Surgical Unit, and the impact of our policy not to perform intraoperative cholangiograms (IOCs) on the incidence of bile duct injuries (BDIs). Data was collected for the time period from 1992 (when the laparoscopic procedure was first introduced in our Unit) until 2005. During this time, 1851 patients underwent an LC. Patients with a history of jaundice, ultasonographic bile duct dilatation, bile duct stones, or deranged liver function tests were referred initially for an endoscopic retrograde cholangiopancreatography procedure. An IOC was not performed on any patient. The conversion rate was 23.9% among the patients with acute cholecystitis and 1.6% among the patients with a noninflamed gallbladder. This difference was statistically significant. The morbidity reached 1.1%, as minor or major complications were present in 22 of 1851 patients. Complications consisted of BDI in 7 patients (0.37%). Six patients presented with minor BDI. Two of the BDIs occurred among the group of patients with acute cholecystitis, whereas the remaining 5 occurred in the group of patients with a noninflamed gallbladder. This distribution was not statistically significant. The low BDI rate in our series allowed us to recommend an LC procedure without an IOC. Performing a cholangiogram either routinely or selectively is not wrong. However, adherence to a meticulous hemostatic technique, thorough knowledge of the anatomy, and a low threshold for conversion may also enable satisfactory results to be achieved.

Who should perform laparoscopic cholecystectomy? A 10-year audit

Laparoscopic cholecystectomy is one of the most common operations in general surgery. It is performed by surgeons with a specialist interest in biliary disease as well as by surgeons with other specialist interests. This retrospective audit of all cholecystectomies was conducted in a single hospital over a 10-year period from 1996 to 2005. Data were extracted from two independent electronic databases and supplemented by a full note review of cases with extended postoperative stay or unplanned readmission. The outcomes for cases under the care of specialist upper gastrointestinal (GI) consultants were compared with outcomes for cases of general surgery consultants from other firms. Data from 4,139 cholecystectomies were obtained. More cholecystectomies performed by upper GI firms were completed laparoscopically (96.2% vs 80.1%) with a higher rate of intraoperative cholangiograms (83.4% vs 16.9%). The mean operating time was shorter for upper GI cases (69 vs 84 min), as was the postoperative hospital stay (2 vs 3.6 days). There also was a significantly lower incidence of bile duct injury in upper GI cases (0.1% vs 0.9%). In their institution, the authors found evidence of improved outcomes when laparoscopic cholecystectomy was performed under the care of surgeons with a specialist interest in upper GI or hepatopancreaticobiliary surgery.