“Right place at the right time” impacts outcomes for acute intestinal obstruction

Abstract

Background The purpose of this study was to measure how the duration of nonoperative intervention for intestinal obstruction impacted patient outcomes and whether hospital characteristics influenced the timing of operative intervention. Methods The State Inpatient Database (Florida) of the Health Care Utilization Project and the Annual Survey database of the American Hospital Association were linked from 2006 to 2011. Included were patients ≥18 years of age with a primary diagnosis of intestinal obstruction. Patient factors included age, sex, socioeconomic factors, and comorbid conditions. Results A total of 116,195 patients met our inclusion criteria, and 43,079 underwent operative intervention (37.1%). Patients who required operative correction of the intestinal obstruction after the fifth day of hospitalization, compared with patients who underwent an operation on the day of admission, had increases in mortality (6.1% vs 1.8%, P < .001), complication rates (15.4% vs 4.0%, P < .001), and postoperative hospital stay (9 vs 5 days, P < .001). Patients cared for at a large teaching facility (with surgery residents) had increased odds of early operative intervention by 23% (odds ratio 1.23, [1.20–1.28]), whereas patients at low-volume hospitals had decreased odds of early intervention (odds ratio 0.88, [0.73–0.91]). Conclusion Initial nonoperative treatment in patients with uncomplicated intestinal obstruction is an important strategy, but the odds of having an adverse event increase as intestinal obstruction is delayed. Importantly, the presence of surgery residents and increasing bed size are hospital characteristics associated with earlier operative intervention, suggesting a quality benefit for care at large teaching hospitals.

Adhesive Bowel Obstruction Following Urologic Surgery: Improved Outcomes with Early Intervention

“…Seror et al [15] found in their retrospective review that with up to 5 days of non-operative management, 73% of patients experienced resolution of symptoms without an increase in mortality or small bowel resection. Kothari et al [17] recently reported that in patients admitted with intestinal obstruction, there was a stepwise increase in all complications (myocardial infarction, pulmonary embolism, postoperative sepsis, deep venous thrombosis, pneumonia, and urinary tract infection) and mortality for each day following admission that surgical management is delayed. The results of our study are in line with these reports, with 71.6% of ASBO patients ultimately managed conservatively (non-operatively) with a median length of stay of 4 (range 3-8) days.…”

“…Management during the ASBO admission was considered surgical or conservative, dependent on if the patient was discharged with or without having undergone operative intervention (included surgical interventions listed in table 1). Among surgical patients, based on existing literature demonstrating improved perioperative outcomes with early surgical intervention [15,17], patients were considered to have undergone early surgery or delayed surgery. As patients managed conservatively had a median (interquartile range) length of stay of 4 (range 3-8 days) days, surgical patients were considered early surgery if they underwent intervention onor-before hospital day four, and delayed surgery if performed on day five or later.…”

“…While early studies suggested that the duration of conservative management could extend up to 10-14 days without increased morbidity and mortality in patients who underwent delayed operative intervention [14], more recent studies suggest extended courses of conservative management for ASBO are associated with increased rates of complications, mortality, and length of stay [15,16,17]. …”

Only Surgical Treatment to Be Considered for Adhesive Small Bowel Obstruction: A New Paradigm

“…In patients with abdominal pain, SBO is a common cause that accounts for 4% of all emergency department admissions and 20% of emergency surgical procedures [ 2 ]. Mortality rates of patients surgically treated for SBO remain surprisingly high (5–10%) [ 1 , 3 – 5 ].…”

“…However, no consensus has been reached regarding conservative treatment duration or when to switch to operative treatment in case of failure. Despite two large cohort studies demonstrating that mortality rates were increased in SBO patients undergoing surgery with a 24-hour delay [ 5 , 7 ], the 2013 World Society of Emergency Surgery recommendations state that surgical treatment should be considered in the absence of SBO resolution after a 72-hour nonoperative management duration [ 6 ]. These conflicting results are due to the usually heterogeneous nature of patients' inclusion.…”