Epidemiology, presentation, diagnosis, and outcomes of choledochal cysts in adults in an urban environment.

BACKGROUND: Choledochal cysts (CDC) are rare congenital cystic lesions of the biliary tract. In North America the incidence of CDC is estimated as 1/150,000; it is not clear that the disease pattern in North America is similar to that in Asia. METHODS: Retrospective chart review. Statistical analysis was under taken using Fisher's exact test. RESULTS: Presentation, epidemiology, diagnosis, and outcome were evaluated in 51 patients with CDC. Malignant transformation was identified in 4 patients presenting uniformly with jaundice (P = .027). Type 4a cysts (54.9%) were the most common cyst identified. Four (14%) type IVa and two (13%) type I cysts developed postoperative stricture. No patient developed cholangiocarcinoma after complete resection of their cyst. CONCLUSIONS: Types I and IVa cysts can be treated similarly with excellent outcome. However, our observation of a high proportion of type 4a cysts may represent a specific North American pattern of this disease requiring a re-evaluation of the classification system.

Surgeons' anonymous response after bile duct injury during cholecystectomy.

BACKGROUND: Bile duct injuries remain one of the most devastating injuries during laparoscopic cholecystectomy. Few studies target surgeons who have experienced bile duct injuries for their insight, their perspective, and their suggestions concerning this problem. METHODS: A confidential questionnaire was sent to all practicing general surgeons under the age of 65 years in British Columbia, Canada. RESULTS: Seventy-five percent of surgeons responded to the survey. Of the 114 questionnaires completed, more than 97% of respondents had completed formal training in laparoscopic cholecystectomy. One half of surgeons reported experience with laparoscopic bile duct injury. A significant difference in years in practice between surgeons with injury and surgeons without injury was noted. The majority of injuries occurred after the surgeons's first 100 cholecystectomies performed. The first thoughts of surgeons after injury uniformly concerned the patient's well being. The next most common thoughts were in relation to obtaining help or a second opinion from another surgeon. Surgeons cited inflammation and short or anomalous cystic ducts as the most responsible factors contributing to injury. The majority of surgeons felt that these injuries are unavoidable and less than half felt that it was always a surgical error. Fewer than 15% thought injuries could be avoided by performing a cholangiogram. Surgeons suggested meticulous dissection and less haste to divide structures may prevent an injury. Surgeons recommend educating colleagues to remove the stigma of failure associated with conversion to laparotomy. CONCLUSIONS: General surgeons in British Columbia have a one in two chance of experiencing a bile duct injury in their career. There were more injuries in surgeons who had already been in practice for 10 years at the time of introduction of laparoscopic cholecystectomy. The injuries are likely to occur despite high volumes of procedures and increased experience. The incidence of bile duct injuries does not seem to be different in surgeons who perform routine cholangiography and most surgeons feel that cholangiography would have little effect on injury incidence. Surgeons tend to have patient-centered concerns after injury and little concern for medicolegal issues. The majority of surgeons felt that these injuries could not be anticipated and as such it is an inherent risk of this procedure.