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What Have We Learned From Malpractice Claims Involving the Surgical Management of Benign Biliary Disease?

A 128 Million Dollar Question

Gartland, Rajshri M., MD, MPH*,†; Bloom, Jordan P., MD, MPH*; Fong, Zhi Ven, MD, MPH*; DeRoo, Courtney, BS; Dwyer, Kathy, MSN, RN; Quinn, Gene, MD, MPH; Lillemoe, Keith, MD, FACS*; Mort, Elizabeth, MD, MPH†,§

doi: 10.1097/SLA.0000000000003155

Objective: We aimed to study the contributing factors and costs of malpractice claims involving the surgical management of benign biliary disease given the emotional, physical, and financial toll of these claims on patients, providers, and the healthcare system.

Summary Background Data: Cholecystectomy complications carry significant morbidity and rank among the leading sources of surgical malpractice claims.

Methods: Using the CRICO Strategies’ Comparative Benchmarking System database, representing approximately 30% of all paid and unpaid malpractice claims in the United States, 4081 closed claims filed against general surgeons from 1995 to 2015 were reviewed to isolate 745 cholecystectomy-related claims. A multivariable model was used to determine factors associated with claim outcome.

Results: The most common associated complications included bile duct injury (n = 397), bowel perforation (n = 96), and hemorrhage (n = 78). Bile duct injuries were recognized intraoperatively only 19% of the time and required biliary reconstruction surgery 77% of the time. The total cost for all claims over the study period was over $128 M and the median time from event to case close was over 3 years. 40% of claims resulted in patient payout; of these, most claims were settled out of court and the median cost per claim was $264,650. For the 60% of claims not resulting in patient payout, most cases were denied, dropped, or dismissed, yet still averaged over $15,000 per claim in legal and administrative fees. On multivariable analysis, bile duct injury, bowel perforation, and high clinical severity were associated with patient payout, while a resident or fellow being named in a claim was negatively associated with patient payout (P < 0.05).

Conclusion: Cholecystectomy-related claims are costly and time-consuming. Strategies that reduce the risk and aid in recognition of cholecystectomy complications, as well as advance support of patients and families after poor outcomes, may improve clinical care and reduce claim burden.

*Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA

Edward P. Lawrence Center for Quality and Safety, Massachusetts General Hospital, Boston, MA

CRICO Risk Management Foundation, Boston, MA

§Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA.

Reprints: Rajshri M. Gartland, MD, MPH, Department of Surgery, Massachusetts General Hospital, 55 Fruit Street, GRB-425, Boston, MA 02114. E-mail:

This paper was presented as an oral presentation at the American College of Surgeons Clinical Congress in October 2018 in Boston, MA.

The authors report no conflicts of interest.

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