K. C. Brown1, D. Burneikis1, G. Morris-Stiff1, T. Capizzani1 1Cleveland Clinic,Digestive Disease & Surgery Institute,Cleveland, OH, USA
Introduction: This retrospective study evaluated the outcomes of an evidence-based protocol for management of adhesive small bowel obstruction (aSBO) at an academic, high-volume referral center.
Methods:
An evidence-based protocol for management of patients with aSBO was developed after thorough literature review. The protocol prescribed serial abdominal exams, nasogastric tube decompression, goal-directed maintenance fluid resuscitation, and electrolyte correction for patients without signs of bowel compromise. Patients failing to progress in the first 48 hours underwent contrasted small bowel follow through (SBFT) study. If SBFT demonstrated obstruction, patients were offered operative intervention; otherwise, they were continued to be observed until resolution of symptoms.
Between April 2014 and October 2015, patients admitted with aSBO were managed according to our evidence-based protocol. In October 2015, the Acute Care Surgery (ACS) service was restructured from a service run by 6 primary ACS surgeons to a service managed by 13 surgeons of varying specialties on a rotating schedule. This transition allowed for direct comparison of protocol-based and non-protocol management of aSBO. Our administrative database was queried for all ACS admissions assigned Diagnosis Related Group (DRG) codes associated with small bowel obstruction. Patients with incarcerated hernias, intraabdominal malignancy, and surgery within 30 days prior to admission were excluded. We compared the outcomes of the protocol-guided group to a non-protocol group admitted between April 2016 and October 2017. Primary outcomes of interest included length of stay, operative intervention rate, days from admission to operative intervention, and 90-day readmission rate.
Results: The protocol and non-protocol groups included 120 and 130 patients, respectively, who met strict inclusion criteria. Patients were well-matched in terms of age, gender, and severity of illness. There was no statistically significant difference between groups with respect to median length of stay (4 days [3-7] vs 4 days [3-7], p=0.781), operative intervention (21.7% vs 32.3%, p=0.081), days to operative intervention (2 days [0.25-3.75] vs 1 day [0-2], p=0.065), or 90-day readmission rate (9.2% vs 13.1%, p=0.436). Complication rates were comparable.
Conclusion: A protocol-guided approach to management of aSBO is safe and leads to a structured practice easily followed by surgical staff. While the use of the protocol resulted in increased utilization of SBFT studies, there was a trend towards a lower rate of operative intervention and fewer readmissions when the protocol was employed.