Surgery Seen as Best Treatment for Small Bowel Obstruction

Patients with small bowel obstruction who were sent to the OR had better long-term outcomes than those treated non-surgically or whose eventual surgery was delayed, according to a retrospective study.

In an analysis of 32,583 cases of small bowel obstruction, mortality was higher among the non-surgery patients, with 8% dying during their hospital stay and 25% in the year after admission. By comparison, 5% of the surgery patients died while in the hospital, and 16% died during the following year.

For some patients, a delay of more than three days between admission and surgery doubled the hospital and one-year mortality rates, researchers reported at the American College of Surgeons clinical congress.

The patients were identified from California’s inpatient database, which tracks four million hospital discharges per year, said a team headed by Marcia L. McGory, M.D., of the University of California in Los Angeles. All the patients were admitted during 1997.

Of the patients, 76% were treated with non-surgical therapy and 24% were treated surgically. The median length of hospital stay was five days for the no-surgery patients and seven days in the surgery patients.

Dr. McGory speculated that the high mortality rate in both groups was due to the overall age of the population (median 63 years in both groups) and the large number of comorbidities. Twenty-three percent of the patients had three or more comorbidities, according to the Charlson Index.

Additionally, 20% of the patients treated non-surgically required re-hospitalization for small bowel obstruction during the next three years, versus 16% of the surgery group (p<.001). Time to readmission was longer in the surgery patients, with a median of 354 days compared with 194 days for the no-surgery patients (p<.0001).

Four types of surgery were common for these patients: lysis of adhesions (LOA) only, hernia repair only, small bowel resection with hernia repair, or small bowel resection with LOA. Patients treated with resection and LOA had the highest in-hospital mortality (about 10%) and one-year mortality (about 30%). The lowest mortality was in the hernia repair category with 3% in-hospital and 10% at one year.

Importantly, the patients receiving resection with lysis of adhesions also had the longest delay between admission and surgery. Comparing mortality and the time between admission and surgery, the team found delay could be deadly. Patients taken to the OR within one day of admission had a mortality rate close to 5% in the hospital and 14% at one year. By comparison, patients whose surgery was delayed for more than three days had a 10% hospital mortality rate and 28% one-year rate.

These data also correlated with increasing number of comorbidities. Patients with more comorbidities were less likely to have surgery, and if they did have surgery, it was a longer time after admission.

The data suggest that patient outcomes could be improved by getting patients into the operating room more quickly after admission, Dr. McGory said.

The work provides information into the natural history of the problem, said discussant Julio Garcia-Aguilar, M.D., Ph.D., chief of colorectal surgery at the University of California at San Francisco. However, he noted, that without clinical details, which cannot be gleaned from administrative records, it is hard to apply the data from the study to clinical decisions regarding individual patients.

Source: American College of Surgeon, Clinical Congress

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