Prompt surgery may yield better outcomes for adhesive small bowel obstruction

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1. Surgical intervention within 24 hours of admission for an adhesive small bowel obstruction (ASBO) results in lower morbidity, less infectious complications and shorter length of stay. 

2. Longer delays in intervention resulted in progressively higher mortality and morbidity rates. 

Evidence Rating Level: 2 (Good)       

Study Rundown: Current guidelines from the World Society of Emergency Surgery and the Eastern Association for the Surgery of Trauma (EAST) endorse the decision to delay surgical intervention for an ASBO for up to three or five days respectively. This large multi-center cohort study demonstrates that even a 24-hour delay results in statistically significant increases in mortality, morbidity and length of hospital stay.  Several possible confounding variables such as patient age and prior operation were not controlled for in this study which may limit its generalizability to current practice.  Reluctance of surgeons to operate immediately on older patients, those with prior abdominal surgery, or others with surgical risks factors may have contributed to the results seen in this study.  If true, the conclusions of this study would markedly change the clinical practice guidelines for ASBO management.  A prospective study is therefore warranted to validate the results seen here.

Click to read the study in Annals of Surgery

Relevant Reading: Early operation or conservative management of patients with small bowel obstruction?

In-Depth [retrospective cohort]: Over four thousand patients with an ASBO requiring emergent surgery between 2005 and 2010 were identified from the American College of Surgeons’ National Surgical Quality Improvement Program (NSQIP) database. Patient characteristics and time delay to operation were analyzed with respect to 30-day mortality as the primary outcome.   Secondary outcomes included patient complications and length of hospital stay.  Over half (61%) of the surgeries were performed beyond 24 hours from admission. Logistic regression analysis demonstrated that along with 12 other independent predictors of mortality, longer delays in surgical intervention resulted in progressively higher mortality and complication rates. A 72-hour delay increased mortality 3-fold and increased systemic infection rates 2-fold.  A delay of greater than 24 hours showed an independent association with mortality (OR = 1.64, 95% CI = 1.15-2.32, p = 0.005) and was associated with a statistically significant increase in mortality (adjusted OR = 1.58, 95% CI = 1.12-2.24, p = 0.009]. Complications followed a similar trend with respect to 24-hour delay, particularly for surgical site and systemic infections (adjusted OR = 1.33 and 1.62 respectively). Length of hospital stay was also significantly increased with delayed operations with an adjusted mean difference of 5.2 days (95% CI = 4.49 to 5.90).

By Asya Ofshteyn and Chaz Carrier

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