Abstract
Background
Small bowel obstruction (SBO) is responsible for 350,000 U.S. hospitalizations and costs ~ $2.3 billion annually. The current standard of care for SBO is to trial 3 to 5 days of non-operative management. This study evaluated the factors associated with operative management.
Methods
This retrospective cohort study included adult patients admitted with adhesive SBO. Exclusions were for operative intervention within 24 h or death.
Results
At baseline (N = 360), mean age was 65.9 years, 57.8% female, 72.3% white, mean BMI 26.1, 38.7% with history of SBO and 98.1% had history of abdominal surgery. Symptom onset prior to hospitalization was 1–2 days. 55.6% had successful non-operative management at discharge (median length of stay 3 days) vs. 44.4% operative conversion. In univariate analyses, BMI, SBO history, surgical history, days symptom onset, vitals, abdominal pain, obstipation, acute kidney injury, and lack of small bowel feces sign on CT scan were significantly associated with operative management. In a multivariable logistic regression, after controlling all other variables, a lack of small bowel feces sign (adjusted odds ratio, aOR = 2.25, 95% CI 1.06–4.77, p = 0.04) and history of exploratory laparotomy (aOR = 0.44, 95% CI 0.21–0.90, p = 0.03) were significantly associated with operative management. Time from admission to surgery averaged 3.89 days: small bowel resection (55/160) was 4.9 days (median = 4), compared to patients without resection (3.4 days, median = 2; p = 0.00; OR = 1.2, 95% CI 1.07–1.35).
Conclusions
A lack of small bowel feces sign can be a potential indicator for operative management and should be further explored. Since the median resolution of symptoms in the non-operative management group was ~ 2 days and a 20% higher odds for bowel resection each day surgery is delayed, the conservative trial period for adhesive SBO should not exceed 3 days.
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References
Behman R et al (2020) Early operative management in patients with adhesive small bowel obstruction: population-based cost analysis. BJS Open 4(5):914–923
Behman R et al (2019) Association of surgical intervention for adhesive small-bowel obstruction with the risk of recurrence. JAMA Surg 154(5):413–420
Zielinski MD et al (2010) Small bowel obstruction—who needs an operation? A multivariate prediction model. World J Surg 34(5):910–919
Maung AA, Johnson DC, Piper GL, Barbosa RR, Rowell SE, Bokhari F, Collins JN, Gordon JR, Ra JH, Kerwin AJ, Eastern Association for the Surgery of Trauma (2012) Evaluation and management of small-bowel obstruction: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg 73(5 Suppl 4):S362–S369. https://doi.org/10.1097/TA.0b013e31827019de
Azagury D et al (2015) Small bowel obstruction: a practical step-by-step evidence-based approach to evaluation, decision making, and management. J Trauma Acute Care Surg 79(4):661–668
Pujahari AK (2016) Decision making in bowel obstruction: a review. J Clin Diagn Res 10(11):PE07
Bauer J et al (2015) Adhesive small bowel obstruction: early operative versus observational management. Am Surg 81(6):614–620
Komatsu I et al (2010) Development of a simple model for predicting need for surgery in patients who initially undergo conservative management for adhesive small bowel obstruction. Am J Surg 200(2):215–223
Suri RR et al (2014) Computed tomography features associated with operative management for non-strangulating small bowel obstruction. Can J Surg 57(4):254
Cho YJ, Park IS, Kim J, Cho HJ, Gwak GH, Yang KH, Bae BN, Kim KH (2020) Factors predicting the need for early surgical intervention for small bowel obstruction. Ann Coloproctol 36(4):223–228. https://doi.org/10.3393/ac.2019.09.30
Hajibandeh S et al (2017) Operative versus non-operative management of adhesive small bowel obstruction: a systematic review and meta-analysis. Int J Surg 45:58–66
Barmparas G et al (2010) The incidence and risk factors of post-laparotomy adhesive small bowel obstruction. J Gastrointest Surg 14(10):1619–1628
Fuchsjäger MH (2002) The small-bowel feces sign. Radiology 225(2):378–379
Keenan JE et al (2014) Trials of nonoperative management exceeding 3 days are associated with increased morbidity in patients undergoing surgery for uncomplicated adhesive small bowel obstruction. J Trauma Acute Care Surg 76(6):1367–1372
Margenthaler JA et al (2006) Risk factors for adverse outcomes following surgery for small bowel obstruction. Ann Surg 243(4):456
Victory Srinivasan N, Khan AI, Mashat GD, Hazique M, Khan KI, Ramesh P, Kanagalingam S, ZarghamUlHaq F, Penumetcha SS (2022) Recurrence of small bowel obstruction in adults after operative management of adhesive small bowel obstruction: a systematic review. Cureus 14(9):e29141. https://doi.org/10.7759/cureus.29141
Zielinski MD et al (2017) Multi-institutional, prospective, observational study comparing the gastrografin challenge versus standard treatment in adhesive small bowel obstruction. J Trauma Acute Care Surg 83(1):47–54
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Dr. van Veen, MD, Mr. Ramanathan, Dr. Ramsey, Dr. Dort, and Dr. Tabello have no conflicts of interest to disclose.
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van Veen, T., Ramanathan, P., Ramsey, L. et al. Predictive factors for operative intervention and ideal length of non-operative trial in adhesive small bowel obstruction. Surg Endosc 37, 8628–8635 (2023). https://doi.org/10.1007/s00464-023-10282-9
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DOI: https://doi.org/10.1007/s00464-023-10282-9