B. Elsolh1, D. Naidu1, A. Nadler1 1University of Toronto,Division Of General Surgery,Toronto, Ontario, Canada
INTRODUCTION
Adhesions following abdominal surgery are the most common cause of small bowel obstruction (SBO). Surgical intervention for SBO is sometimes necessary, and delays in treatment can lead to morbidity and mortality. Determining which SBOs will resolve non-operatively is not standardized and relies on clinical acumen. Orally-administered water-soluble radiographic contrast (WSC) can be used diagnostically and therapeutically by tracking transit time to the cecum using X-rays in stable SBO patients. This more rapidly ascertains need for surgery and reduces length of stay (LOS). We review the outcomes of SBO patients following the implementation of a standardized SBO pathway at a Canadian tertiary care academic center.
METHODS
A WSC pathway for adhesive SBO management was created after a literature review. This was implemented by the General Surgery service at a large tertiary care academic center. The pathway (attached) was introduced gradually in 2018. Data prior to pathway implementation was gathered from 2016 (PRE group), and after implementation from the first half of 2018 (POST group). The primary outcome was LOS. Secondary outcomes included rates of failure of conservative management and subsequent need for surgery, in-hospital complications, mortality, and readmission rates for recurrent SBO. The hospital’s research ethics committee approved this study.
RESULTS
A total of 234 patients were admitted with SBO in the studied timeframe (102 PRE vs. 132 POST). Of these, 131 had adhesive SBO (66 vs. 65). 1 patient (2%) in the PRE group received WSC, compared to 26 (40%) in the POST group. The groups were matched in age, gender, and comorbidities. NG use was similar (77.3% vs. 80.0%, P=0.828). More POST patients required immediate surgery (6.1% vs. 24.6%, P<0.01) for either concerning CT findings (75%), clinical exam concerning for ischemia (12.5%), or other reasons (12.5%). There was no significant difference in failure of conservative therapy (3.1% vs. 6.2%, P=0.39). Median LOS (3 days vs. 4 days, P=0.259) was not significantly different. There was a higher rate of readmission in the PRE group (34.8% vs. 10.8%, P=0.001). There was 1 severe complication (Clavien-Dindo grade 3 or higher) in the PRE group, and 2 in the POST group. Mortality did not differ between groups (4.5% vs. 9.2%, P=0.29).
CONCLUSION
While LOS did not change following WSC pathway implementation, the number of patients undergoing immediate surgery increased and readmissions decreased. This may be a result of early operative decision making as a result of the pathway or may represent a change in management practices over time. Further evaluation is required to increase pathway compliance and ensure that outcomes are improved by the pathway.
