Gallbladder surgery complications reduced by limiting resident surgeon's work hours

Gallbladder surgery complications reduced by limiting resident surgeon's work hours

After resident physicians' work hours were limited to 80 hours each week, fewer patients undergoing gallbladder surgery at one major public teaching hospital suffered injuries to their bile ducts of other complications, according to an article released on September 15, 2008 in the Archives of Surgery, one of the JAMA/Archives journals.

In July 2003, the 80-hour workweek was imposed after concerns were raised regarding patient safety and resident well-being, according to the background information in the article. "Previous studies using simulators have indicated that sleep deprivation has substantial adverse effects on laparoscopic skills in residents," the authors write.

They point out that this imposed restriction has met some resistance: "However, some surgical educators have expressed misgivings about the restricted hours because of more frequent shift changes, decreased patient exposure for residents, interruption in continuity of care and increased potential for communication breakdown."

The authors focused on the incidence of bile duct injury, a complication of gallbladder surgery in which the passages between the liver and gallbladder are injured. "Bile duct injury has a potentially devastating long-term adverse effect on the patient," write the authors.

To investigate the effects of this change, Arezou Yaghoubian, M.D., and colleagues at Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, Calif., examined medical records from 2,470 patients who had undergone gallbladder removal, or laparoscopic cholecystectomy, which is usually performed by surgical residents. They analyzed complications before and after the duty hour limitations were imposed on the residents. A total 1,353 procedures performed before the hour restriction were examined, taking place between January 2000 and June 2003. Further, 1,117 procedures were examined that were performed between July 2003 and June 2006, after the restrictions.

After the restriction, the proportion of patients experiencing bile duct injury decreased, with 0.4% having this problem before and 1% having it after. The proportion of all complications was decreased in the transition as well, with 2% of patients having complications before and 5% having complications after. The authors write: "The complication rate in period two decreased despite there being a higher percentage of patients with acute cholecystitis and a greater percentage of male patients, both of which have been shown to be associated with a higher risk of bile duct injury."

The authors conclude that the results of gallbladder surgery were generally improved with the change. "In conclusion, we observed improved outcomes in the era of restricted resident work hours in patients undergoing laparoscopic cholecystectomy," they say. "Despite the concerns that work hour restrictions may have deleterious effects on patient care and resident education, these results clearly indicate otherwise. Whether the better-rested resident surgeon leads to better surgical outcomes needs further study."

Decreased Bile Duct Injury Rate During Laparoscopic Cholecystectomy in the Era of the 80-Hour Resident Workweek

Arezou Yaghoubian, MD; Guy Saltmarsh, MD; David K. Rosing, MD; Roger J. Lewis, MD, PhD; Bruce E. Stabile, MD; Christian de Virgilio, MD

Arch Surg. 2008;143(9):847-851.

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