L. W. Thornblade1, A. R. Truitt1, D. R. Flum1, D. C. Lavallee1 1University Of Washington,Department Of Surgery,Seattle, WA, USA
Introduction: Classic training instructs surgeons to, “never let the sun set on a small bowel obstruction (SBO)” for concern of bowel ischemia. However the routine use of CT scans for ruling out compromised bowel provides the opportunity for trial of non-operative management, allowing time for spontaneous resolution of adhesive SBO. In light of such advances in practice, little is known about how surgeons choose to manage these patients, in particular whether there is an agreed-upon time window for safe non-operative management.
Methods: Using a case scenario of a patient with CT-scan confirmed adhesive SBO without bowel ischemia, we interviewed a purposive sample of general surgeons practicing in Washington State to understand approaches to clinical management. Interview questions addressed typical practice, use of an oral contrast study, timing of surgery, and use of laparoscopy. We conducted a qualitative analysis to identify themes in practice and attitudes.
Results: Surgical practice patterns for patients with SBO vary widely. The importance of timely surgeon involvement and serial abdominal exams emerged as themes among most participants. Many participants identified themes of uncertainty about the diagnosis of a complete obstruction. The period of time that surgeons were willing to manage patients non-operatively ranged from 1-10 days. Most surgeons favored open surgery. All surgeons acknowledged a lack of clinical evidence to support appropriate management of patients with SBO.
Conclusion: Interviews with practicing surgeons across a range of practice sites illuminate a changing paradigm away from routine early operative management of patients with adhesive SBO. However, there is no established length for a trial of non-operative management. The surgeon attitudes and practice patterns identified will inform feasibility and design of future prospective randomized studies of patients with non-ischemic adhesive SBO.