Surgeon experience and trends in intraoperative complications in laparoscopic cholecystectomy.

BACKGROUND: Intraoperative complications, particularly bile duct injuries (BDIs), have increased since the introduction of laparoscopic cholecystectomy (LC). This excess risk is expected to decline as surgeon experience in laparoscopic surgery increases. METHODS: This was a population-based study of trends in intraoperative injuries in 33 309 cholecystectomies carried out in Western Australia between 1988 and 1998, based on hospital discharge abstracts. Endpoints were identified from diagnostic and procedure codes in index or postoperative readmissions, or a register of endoscopic retrograde cholangiopancreatography procedures, and validated using hospital records. Multivariate analysis was used to estimate the risk of complications associated with potential risk factors. RESULTS: Following the introduction of LC in 1991, the prevalence of all complications doubled by 1994 then stabilized, whereas that of BDI declined after 1994. The risk of complications increased with age, was higher in men, teaching and country hospitals, and was higher for LC and more complicated operations. It was lower when intraoperative cholangiography was performed and with increasing surgeon experience. Approximately 20 per cent of all complications and 30 per cent of BDIs were attributable to surgeons who had performed 200 or fewer cholecystectomies in the previous 5 years. CONCLUSION: The risk of intraoperative complications declined with increasing surgical experience and use of intraoperative cholangiography.

Risk of death in prisoners after release from jail.

OBJECTIVE: To compare the risk of death in a cohort of Western Australian released prisoners with the risk experienced by the general population of Western Australia. METHODS: A cohort study of prisoners in Western Australia whose last date of release ranged from 1 January 1994 to 1 January 1999. Overall mortality and cause of death were determined by data linkage to the Registrar General's record of deaths. RESULTS: Aboriginal prisoners had a significantly lower survival rate after release than non-Aboriginal prisoners (p < 0.0001). When compared with their peers in the Western Australian community, both Aboriginal and non-Aboriginal prisoners were found to have an increased relative risk of death. Female non-Aboriginal released prisoners aged between 20 and 40 years were 17.8 (95% CI 8.1-27.5) times more likely to die than other female non-Aboriginals in Western Australia in the same age range. Male non-Aboriginal prisoners aged 20-40 years were 6.3 (95% CI 5.2-7.4) times more likely to die than their counterparts in the WA community. Female Aboriginal released prisoners were 3.4 (95% CI 1.2-5.6) times more likely to die than their peers, while male Aboriginal released prisoners were 2.9 (95% CI 2.2-3.5) times more likely to die. In their first six months after release, female non-Aboriginal prisoners aged 20 to 40 years were 69.1 (95% CI 17.9-120.3) times more likely to die than their counterparts in the WA community. The main causes of excess death were related to drug and alcohol abuse. CONCLUSION: All prisoners were at greater than expected relative risk of death after release from prison, with female non-Aboriginal prisoners at particularly high relative risk.