The features of cholangitis were analyzed in 99 consecutive cases treated in the last ten years. The disease was severe and refractory in half the cases due to malignant stricture, and in 20% of those due to gallstones. Benign strictures, sclerosing cholangitis, and most cases of choledocholithiasis were associated with less severe cholangitis, which responded promptly to antibiotic therapy. High fever, a serum bilirubin level above 4 mg/dl, and hypotension characterized the most severe refractory cases in which emergency surgery was mandatory. Patients without manifestations were nearly always controlled successfully with antibiotics. We conclude that the term "suppurative cholangitis" is an unsatisfactory synonym for severe cholangitis, because the correlation between biliary suppuration and clinical manifestations in cholangitis is inexact; some patients with severe sepsis do not have pus in the bile duct, and a few patients with suppurative bile are only moderately ill.

These data show that errors leading to laparoscopic bile duct injuries stem principally from misperception, not errors of skill, knowledge, or judgment. The misperception was so compelling that in most cases the surgeon did not recognize a problem. Even when irregularities were identified, corrective feedback did not occur, which is characteristic of human thinking under firmly held assumptions. These findings illustrate the complexity of human error in surgery while simultaneously providing insights. They demonstrate that automatically attributing technical complications to behavioral factors that rely on the assumption of control is likely to be wrong. Finally, this study shows that there are only a few points within laparoscopic cholecystectomy where the complication-causing errors occur, which suggests that focused training to heighten vigilance might be able to decrease the incidence of bile duct injury.

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