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Three hundred six injuries or complications coincident to 296 laparoscopic cholecystectomies were analyzed for the nature and extent of injuries and litigious outcomes that followed. The data were drawn from 31 member companies of the Physician Insurers Association of America, a trade association that initiated the study. The outcomes were compared to 261 contemporaneous open cholecystectomy claims. Biliary tract injuries were the most common, accounting for almost two thirds of all injuries. The spectrum of cases, originally selected for indemnity potential, reflected relative incidences in the medical literature. Laparoscopic injuries were significantly more severe, more likely to result in indemnity, and more apt to involve higher mean +/- standard deviation dollar values (160 dollars +/- 154 x 10(3)) to surviving claimants than injuries resulting from open procedures (106 dollars +/- 122 x 10(3), P = 0.01). Injury recognition at the time of the original procedure had no discernible mitigating effect because 80% of recognized injuries required an additional operative procedure. Risk-aversive behavior should include paying particular attention to placement of the first port, more liberal use of the Hasson technique, placement of all other ports under direct vision, elimination of intraoperative anatomic uncertainty, programmed inspection of the abdomen before withdrawing the laparoscope, and acquiring sufficient knowledge of electrosurgical principles to ensure the safe use of this potentially dangerous modality.

The metabolic effects of high-carbohydrate (70%), high-fiber (70 g) (HCHF) and low-carbohydrate (39%), low-fiber (10 g) (LCLF) diets were examined for 10 subjects with insulin-dependent diabetes mellitus (IDDM). After a 1-wk control period subjects on a metabolic ward were randomly allocated to HCHF or LCLF diets for 4 wk. After a 6-wk washout period subjects re-entered the metabolic ward for 4 wk on the alternate diet. Artificial-pancreas studies were performed on each diet for measurement of insulin requirements. Compared with the LCLF diet, the HCHF diet reduced basal insulin requirements (P less than 0.025), increased carbohydrate disposed of per unit insulin (P less than 0.0008), and lowered total (P less than 0.0004) and high-density-lipoprotein cholesterol (P less than 0.0013). Glycemic control and other lipid fractions did not differ significantly. These results suggest that in IDDM patients, HCHF diets enhance peripheral glucose disposal, decrease basal insulin requirements, and lower total cholesterol without altering glycemic control or triglycerides.