Letting the sun set on small bowel obstruction: Can a simple risk score tell us when nonoperative care is appropriate?

O'Leary, Elizabeth Ann; Yi, William S.; Fujita, Kari A; Hynes, Conor F.; Chandra, Suma; Desale, Sameer; Sava, Jack

doi:10.1016/j.jamcollsurg.2012.06.078

Cited by 3 publications

(3 citation statements)

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“…Still other studies have applied prediction modeling to determine which patient features indicate the need for an early exploratory surgery for SBO. 14,25,26 There remains uncertainty about the comparative effectiveness between the historic standard early surgery for all SBOs and the apparently common yet varied practice of expectant management and predictive modeling studies have not resolved this gap in evidence. Second, we have excluded data from studies published prior to 1990.…”

Section: Discussionmentioning

confidence: 99%

The Safety of Expectant Management for Adhesive Small Bowel Obstruction: A Systematic Review

Thornblade

Verdial

Bartek

et al. 2019

Journal of Gastrointestinal Surgery

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Background: Surgical training has long been to "never let the sun set on a bowel obstruction" without an operation to rule out and/or treat compromised bowel. However, advances in diagnostics have called into question the appropriate timing of non-emergent operations and expectant management is increasingly used. We performed a systematic review to evaluate the safety and effectiveness of expectant management for adhesive small bowel obstruction (aSBO) compared to early, non-emergent operation. Materials & Methods: We queried PubMed, EMBASE, and Cochrane databases for studies (1990-present) comparing early, nonemergent operations and expectant management for aSBO (PROSPERO #CRD42017057676). Results: Of 4873 studies, 29 cohort studies were included for full-text review. Four studies directly compared early surgery with expectant management, but none excluded patients who underwent emergent operations from those having early non-emergent surgery, precluding a direct comparison of the two treatment types of interest. When aggregated, the rate of bowel resection was 29% in patients undergoing early operation vs. 10% in those undergoing expectant management. The rate of successful, nonoperative management in the expectant group was 58%. There was a 1.3-day difference in LOS favoring expectant management (LOS 9.7 vs. 8.4 days), and the rate of death was 2% in both groups. Conclusion: Despite the shift towards expectant management of aSBO, no published studies have yet compared early, nonemergent operation and expectant management. A major limitation in evaluating the outcomes of these approaches using existing studies is confounding by indication related to including patients with emergent indications for surgery on admission in the early

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Section: Discussionmentioning

confidence: 99%

The Safety of Expectant Management for Adhesive Small Bowel Obstruction: A Systematic Review

Thornblade

Verdial

Bartek

et al. 2019

Journal of Gastrointestinal Surgery

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“…Incomplete high-grade obstruction shows moderately discrepant luminal diameters between the proximal and distal small bowel adjacent to the transition point with minimal passage of air or fluid into the distal small bowel and ascending colon. High-grade obstruction is predictive of failure of nonoperative management [64] and a need for early surgery [63]. Low-grade obstruction shows mildly discrepant luminal diameters between proximal and distal small bowel adjacent to the transition point, with the passage of air or fluid into the distal small bowel and ascending colon [65].…”

Section: Common Ct Signsmentioning

confidence: 99%

A Systematic Review of the Clinical Presentation, Diagnosis, and Treatment of Small Bowel Obstruction

Reddy¹,

Cappell

2017

Curr Gastroenterol Rep

169

111

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SBO incidence is about 350,000/annum in the USA. Etiologies include adhesions (65%), hernias (10%), neoplasms (5%), Crohn's disease (5%), and other (15%). Bowel dilatation occurs proximal to obstruction primarily from swallowed air and secondarily from intraluminal fluid accumulation. Dilatation increases mural tension, decreases mucosal perfusion, causes bacterial proliferation, and decreases mural tensile strength that increases bowel perforation risks. Classical clinical tetrad is abdominal pain, nausea and emesis, abdominal distention, and constipation-to-obstipation. Physical exam may reveal restlessness, acute illness, and signs of dehydration and sepsis, including tachycardia, pyrexia, dry mucous membranes, hypotension/orthostasis, abdominal distention, and hypoactive bowel sounds. Severe direct tenderness, involuntary guarding, abdominal rigidity, and rebound tenderness suggest advanced SBO, as do marked leukocytosis, neutrophilia, bandemia, and lactic acidosis. Differential diagnosis includes postoperative ileus, narcotic bowel, colonic pseudo-obstruction, mesenteric ischemia, and large bowel obstruction. Medical resuscitation includes intravenous hydration, correcting electrolyte abnormalities, intravenous antibiotics, nil per os, and nasoenteral suction. Abdominal CT with oral and intravenous gastrografin contrast is highly sensitive and specific in detecting/characterizing SBO. SBO usually resolves with medical therapy but requires surgery, preferentially by laparoscopy, for unremitting total obstruction, bowel perforation, severe ischemia, or clinical deterioration with medical therapy. Overall mortality is 10% but increases to 30% with bowel necrosis/perforation. Key point in SBO is early diagnosis, emphasizing abdominal CT; aggressive medical therapy including rehydration, antibiotics, and nil per os; and surgery for failed medical therapy.

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“…Although opinions vary, in the absence of clinical or biochemical deterioration of the patient, this approach can be continued for up to 3-5 days. Conversely, if the patient is noted to develop clinical, biochemical or radiological findings that suggest bowel ischemia, urgent surgical intervention is warranted [3][4][5][6][7][8][9]. None of these guidelines focused specifically on patients with SBO who had no prior abdominal surgery .…”

Section: Introductionmentioning

confidence: 99%

Small Bowel Obstruction in Patients without Prior Abdominal Surgery: To Operate or Not?

et al. 2022

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Introduction Surgical exploration is still considered mandatory in the setting of small bowel obstruction (SBO) in patients without prior intra‐abdominal surgery. However, recent studies have challenged this ‘classic’ approach describing success with conservative non‐surgical treatment. The aim of this study is to identify clinical, radiological and biochemical variables that may be associated with the absence of intra‐abdominal pathology in patients with SBO who have not undergone previous surgery. Methods This is a retrospective cohort study of prospectively recorded data. Patients with SBO without prior abdominal surgery who presented to a single tertiary referral medical center between 2009 and 2019 were included. Results Eighty‐seven patients were included of whom 61(70.0%) were allocated to the ‘therapeutic exploration’ group and 26 (30.0%) to the ‘non‐therapeutic exploration’ group. Forty‐eight patients (55.0%) had adhesions, 17.2% had closed‐loop obstruction, 10.0% had an internal hernia, 27.6% had bowel ischemia and 5.7% had bowel necrosis. Although multiple clinical, laboratory, radiological and preoperative factors were examined, none were significantly associated with pathological findings during surgical exploration. There was no statistically significant difference in the incidence of complications when comparing between those groups. Conclusions In this series, no variables were associated with intra‐abdominal pathology in patients who underwent surgery for SBO with no history of prior abdominal surgery. However, the fact that 27.0% had ischemic bowel upon surgical exploration suggests that this approach is still mandatory for this specific group of patients. Furthermore, clinicians and patients should be aware that negative exploration may be expected in up to 30.0%.

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Letting the sun set on small bowel obstruction: Can a simple risk score tell us when nonoperative care is appropriate?

Cited by 3 publications

References 0 publications

The Safety of Expectant Management for Adhesive Small Bowel Obstruction: A Systematic Review

The Safety of Expectant Management for Adhesive Small Bowel Obstruction: A Systematic Review

A Systematic Review of the Clinical Presentation, Diagnosis, and Treatment of Small Bowel Obstruction

Small Bowel Obstruction in Patients without Prior Abdominal Surgery: To Operate or Not?

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