SAN DIEGO – Patients who underwent adhesiolysis within 24 hours of hospital admission for acute small bowel obstruction had a significant reduction in 30-day major morbidity, mortality, and hospital length of stay, compared with those who underwent adhesiolysis after 24 hours, results from an analysis of national data showed.
"Historically, the teaching was that surgeons should never let the sun rise and set on a complete small bowel obstruction," Dr. Kristin N. Kelly said at the national conference of the American College of Surgeons/National Surgical Quality Improvement Program. "The consequences of bowel ischemia, perforation, and peritonitis were feared. Interestingly, over the past 2 decades, practice patterns have shifted."
For example, she said, a recent study of data from the 2009 Nationwide Inpatient Sample researchers found that only 18% of patients with small bowel obstruction received surgical intervention and the rest were managed with conservative measures including intravenous fluid and nasogastric decompression (J. Trauma Acute Care Surg. 2013;74:181-7).
In addition, recently released guidelines (World J. Emerg. Surg. 2011;6:5) "have suggested that without peritoneal signs or evidence of bowel ischemia, nonoperative management can be extended for 3-5 days before contrast studies or surgery [is] recommended," said Dr. Kelly of the Surgical Health Outcomes and Research Enterprise (SHORE) and the department of surgery at the University of Rochester (N.Y.) Medical Center. "The concern remains that surgery may be difficult or dangerous or promote additional adhesion formation. Alternatively, delaying surgical treatment may increase morbidity and mortality. We wondered if perhaps we’ve moved too far toward conservative management. We sought to address if there is a benefit to a prompt surgical approach. Our aim was to examine whether adhesiolysis within 24 hours of admission for acute small bowel obstruction is associated with improved 30-day morbidity and mortality compared with those undergoing later adhesiolysis."
She and her associates searched the 2005-2010 American College of Surgeons/National Surgical Quality Improvement Program database for patients who had a diagnosis of adhesive small bowel obstruction. They limited their analysis to patients who were operated on within 1 week of admission. The time from admission to operation was classified as early (within 24 hours) or late (after 24 hours). The groups were compared using univariate and multivariate analysis to examine the association between numerous patient and operative factors.
Of the 8,912 patients who met inclusion criteria, 3,240 (36%) underwent early adhesiolysis while the remaining 5,692 (64%) underwent the procedure late. The mean time to surgery was 1.7 days, while about three-quarters of patients in the late group had surgery between 1 and 3 days after admission.
Compared with patients in the late adhesiolysis group, those in the early adhesiolysis group had higher rates of emergency operations (60% vs. 45%, respectively; P less than .0001), and more laparoscopic operations (19% vs. 13%; P less than .0001), but both groups had similar operative times (a mean of 93 vs. 89 minutes) and similar rates of small bowel resection (27% vs. 28%). The mean postoperative length of stay was about 2 days shorter in the early group (7.4 days vs. 9.5 days; P less than .0001).
"Patients in the early group were slightly younger, had fewer comorbodities, and better functional status," Dr. Kelly added. "But the rates of preoperative sepsis and systemic inflammatory response syndrome were similar."
On multivariate analysis patients in the early adhesiolysis group had 17% fewer major complications (odds ratio, 0.83; P = .005) and a 26% lower mortality rate (OR, 0.74; P = .041) at 30 days, compared with their counterparts in the late adhesiolysis group. The three most common complications were respiratory complications (28%), sepsis/septic shock (25%), and unexpected return to the operating room (18%).
Dr. Kelly acknowledged certain limitations of the study, including the potential for selection bias and that "perhaps surgeons postpone operating on patients with many comorbodities and poorer functional status, or perhaps it takes several days for a surgical referral," she said. "We are also limited because we do not have information regarding all of the clinical, personal, and administrative factors that may go into any individual surgeon’s decision to take a patient to the OR. Finally, we don’t have data on the case difficulty or any intraoperative occurrences. These would be useful in evaluating whether the timing really affected how challenging the case might be." Nevertheless, the findings "support early surgeon involvement and an expeditious approach to small bowel obstruction," she concluded.
Dr. Kelly said she had no relevant financial disclosures.