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Re-examining “Never Letting the Sun Rise or Set on a Bowel Obstruction” in the Era of Acute Care Surgery



Small bowel obstruction (SBO) no longer mandates urgent surgical evaluation raising the question of the role of operating room (OR) access on SBO outcomes.


Data from our 2015 survey on emergency general surgery (EGS) practices, including queries on OR availability and surgical staffing, were anonymously linked to adult SBO patient data from 17 Statewide Inpatient Databases (SIDs). Univariate and multivariable associations between OR access and timing of operation, complications, length of stay (LOS), and in-hospital mortality were measured.


Of 32,422 SBO patients, 83% were treated non-operatively. Operative patients were older (median 66 vs 65 years), had more comorbidities (53% vs 46% with ≥ 3), and experienced more systemic complications (36% vs 23%), higher mortality (2.8% vs 1.4%), and longer LOS (median 10 vs 4 days). Patients had lower odds of operation if treated at hospitals lacking processes to tier urgent cases (aOR 0.90, 95% CI [0.83–0.99]) and defer elective cases (aOR 0.87 [0.80–0.94]). Patients had higher odds of operation if treated at hospitals with surgeons sometimes (aOR 1.14 [1.04–1.26]) or rarely/never (aOR 1.16 [1.06–1.26]) covering EGS at more than one location compared to always. Odds of systemic complication (OR 2.0 [1.6–2.4]), operative complication (OR 1.5 [1.2–1.8]), and mortality were increased for very late versus early operation (OR 2.6 [1.7–4.0]).


Although few patients with SBO require emergency surgery, we identified EGS structures and processes that are important for providing timely and appropriate intervention for patients whose SBO remains unresolved and requires surgery.

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The authors would like to thank Dr. Catarina I Kiefe, Professor and Chair, and Ms. M. Didem Ayturk, Biostatistician Department of Population & Quantitative Health Sciences at the University of Massachusetts Medical School, for their contributions to the overall aims of the project from which this research originates and for earlier analyses, respectively.


This research is supported by a grant from the Agency for Healthcare Research Quality (R01HS022694) to HPS. The content represents the thoughts and opinions of the authors and not the funding agencies. Dr. Heena Santry and Dr. Victor Heh had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

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Authors and Affiliations



Literature Search: AD, HPS

Study Design: AD, APR, AMI, KBR, AZP, VTD, VH, HEB, SAS, HPS

Data Collection: AD, APR, AMI, KBR, AZP, ATD, VH, HEB, SAS, HPS

Data Analysis: VH, HPS

Data Interpretation: AD, APR, AMI, KBR, AZP, ATD, VH, HEB, SAS, HPS


Critical Revision: AD, APR, AMI, KBR, AZP, VTD, VH, HEB, SAS, HPS, WMO

Oversight of Study: AD, HPS

Corresponding author

Correspondence to Heena P. Santry.

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Conflict of Interest

Dr. Santry is a paid consultant by the Johnson & Johnson Company on a fragility fracture advisory board. The submitted work is not related to this topic.

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Electronic Supplementary Material

Appendix 1:

The Emergency General Surgery Survey. The survey included questions on how access to surgical care is assured through a number of key structure and process features such as overnight presence of OR staff, EGS surgery block time, process for tiering emergency cases. (PDF 318 kb)

Appendix 2

(DOCX 15 kb)

Appendix 3

(DOCX 64 kb)

Appendix 4

(DOCX 36 kb)

Appendix 5:

The cover letter included with the Emergency General Surgery Survey. The letter stated that survey results would be anonymously linked to routinely collected patient data and released in aggregate form only. (PDF 81 kb)

Appendix 6

(DOCX 107 kb)

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Diaz, A., Ricci, K.B., Rushing, A.P. et al. Re-examining “Never Letting the Sun Rise or Set on a Bowel Obstruction” in the Era of Acute Care Surgery. J Gastrointest Surg 25, 512–522 (2021).

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  • Emergency general surgery
  • workforce
  • mortality
  • survey
  • small bowel obstruction