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An appreciation for the aforementioned predictors of conversion will allow appropriate planning by the patient, the institution, and the surgeon.

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Gallstone disease is very common and laparoscopic cholecystectomy is one of the most common surgical procedures all over the world. Parallel to the increase in the number of laparoscopic cholecystectomies, bile duct injuries also increased. The reported incidence of bile duct injuries ranges from 0.3% to 1.4%. Many of the bile duct injuries during laparoscopic cholecystectomy are not due to inexperience, but are the result of basic technical failures and misinterpretations. A working group of expert hepatopancreatobiliary surgeons, an endoscopist, and a specialist of forensic medicine study searched and analyzed the publications on safe cholecystectomy and biliary injuries complicating laparoscopic cholecystectomy under the organization of Turkish Hepatopancreatobiliary Surgery Association. After a series of e-mail communications and two conferences, the expert panel developed consensus statements for safe cholecystectomy, management of biliary injuries and medicolegal issues. The panel concluded that iatrogenic biliary injury is an overwhelming complication of laparoscopic cholecystectomy and an important issue in malpractice claims. Misidentification of the biliary system is the major cause of biliary injuries. To avoid this, the "critical view of safety" technique should be employed in all the cases. If biliary injury is identified intraoperatively, reconstruction should only be performed by experienced hepatobiliary surgeons. In the postoperative period, any deviation from the expected clinical course of recovery should alert the surgeon about the possibility of biliary injury.

For patients with gallstones, suggestive ultrasonographic findings in those younger than 71 years and elevated direct or total bilirubin level in those older than 70 years are the most valuable and practical predictors of CBDS, and thus are the proper indications for preoperative endoscopic retrograde cholangiography.

Objective: Oral amino-acid-combination supplements have become a common intervention to maintain or potentially increase the lean body mass (LBM) in the elderly. Our aim was to determine the tolerance and efficacy of the 8-week beta-hydroxy beta-methylbutyrate/arginine/glutamine (HMB/Arg/Gln) supplementation on anthropometrics, LBM, muscle strength, and gait speed in elderly patients. Methods: In this longitudinal observational study, a total of 131 elderly patients were evaluated at two consecutive visits, including baseline (Week 0) and single follow-up (Week 8). The use of HMB/Arg/Gln was evaluated in terms of patient compliance, the efficacy on anthropometrics, LBM (kg, measured with bioelectrical impedance analysis-BIA), muscle strength (kg), gait speed, and safety. Results: The mean (standard deviation, SD) age was 74.7 (6.8) years (57.3% of participants were males). Of the patients were diagnosed with malnutrition (according to the Subjective Global Assessment test). The main indications for the HMB/Arg/Gln supplementation were sarcopenia (45.8%) and cancer cachexia (42.0%). Only two patients stopped supplementation because of taste problem (1.5%). Overall, 79.4% of patients were still on HMB/Arg/Gln at the follow-up. The mid-upper-arm circumference (MUAC, 25.3–27.0 cm, p=0.017), mid-upper-arm muscle circumference (MUAMC, 21.7–22.2 cm, p=0.006), hand grip strength (16.0–19.0 kg, p=0.0001), and gait speed (0.5–0.7 m/sec, p=0.008) were increased after the HMB/Arg/Gln supplementation. The adverse events were reported in 14 (10.7%) patients. No serious adverse events were reported in association with HMB/Arg/Gln. Conclusion: Our findings showed that 8 weeks of the HMB/Arg/Gln supplementation applied twice daily were well tolerated and safe in the elderly. The supplementation seems to improve the MUAC, MUAMC, muscle strength, and gait speed.

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