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In the present paper 10 questions regarding gallstones will be answered. The questions relate to the symptoms, diagnostic approach and treatment of gallstones. Additionally, the management of complicated gallstone disease such as cholecystitis, cholangitis or pancreatitis will be discussed. The aim of this work is to provide insight into the multidisciplinary management of gallstone disease including outcomes of treatment. Since the prevalence of gallstones is rising rapidly, it is of importance both in primary as in secondary care to provide our patients with an optimal selection for the most appropriate treatment.

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.

Objective: To evaluate the frequency of claims for damages initiated by patients referred to a tertiary centre for the treatment of bile-duct injury after a (laparoscopic) cholecystectomy. To determine the relationship between patient characteristics and the initiation of a claim procedure., Design: Descriptive., Method: Between 1 January 1990 and 31 December 2005, 500 patients with a bile-duct injury were referred to the Academic Medical Centre, Amsterdam, 454 of whom in the period up to 31 December 2004. Of these, 403 received a mailed questionnaire about the initiation of legal claims for damages., Results: The questionnaire was completed and returned by 278 patients (69%), a representative cohort ofthe 500. Of these, 53 (19%) had submitted a claim for damages. The percentage of claims did not increase over the periods 1991-1995 (19%), 1996-2000 (18%) and 2001-2005 (20%). In the univariate analysis, factors associated with the initiation of a claim procedure were: younger age, the severity of the injury, surgical treatment, being employed at the time of the initial cholecystectomy, and having been placed on sick leave. A complete transection of the common bile duct was the only independent predictive factor for starting a claim procedure (odds ratio: 7.5; 95% CI: 1.9-30.6).

Bile leakage following laparoscopic cholecystectomy for symptomatic cholelithiasis developed in 3 patients, two women aged 51 and 44, respectively, and a 45-year-old man. The first woman recovered after drainage and was discharged 1 day later. The second woman had persistent symptoms for several months but recovered after invasive examination and restorative surgery. The man died after 2 months of intensive therapy. The Netherlands Healthcare Inspectorate recently published a report on quality of care in Dutch healthcare institutions. Quality of care was assessed on the basis of a set of developed performance indicators, including bile leakage after laparoscopic cholecystectomy. The reported prevalence of bile leakage ranged between 0 and 7%; however, the cause, localisation and severity of the bile leakage and bile-duct injury were not reported. Bile leakage may be used as an indicator to identify hospitals in which this patient population should be analysed in more detail. This analysis could provide more information about the incidence of severe complications (such as bile-duct injury or transection) in order to analyse the quality ofcare. Bile leakage is not directly suitable for the comparison of quality of care by the general population.