Clinical Decisionmaking

Delaying treatment may increase the need for bowel resection in patients surgically treated for complete small bowel obstruction

Some patients with symptoms of complete small bowel obstruction, such as abdominal pain and distention, nausea, and vomiting, do not respond to conservative measures, such as bowel rest and decompression. Physicians may need to be cautious about postponing surgery beyond 24 hours on these patients, concludes a study supported by the Agency for Healthcare Research and Quality (HS09698), because patients with delayed surgery suffer higher complication rates such as wound infection, longer hospital stays, and death.

Nina A. Bickell, M.D., M.P.H. of the Mount Sinai School of Medicine, and colleagues studied the management and outcomes of 141 patients who were surgically treated for complete small bowel obstruction at two hospitals. They abstracted detailed clinical and time data from their medical records and calculated their risk of resection (surgical removal of the diseased portion of the bowel). They also determined factors affecting time to treatment. Of all patients treated surgically for obstruction, 45 percent underwent resection. Resected patients had longer (11 vs. 8 days) and more complicated (31 vs. 14 percent were in the intensive care unit) hospital stays.

Time to surgery, not clinical factors, was associated with risk of resection. Risk of resection was 4 percent among patients with 24 hours of unresponsive symptoms, but increased to 10 to 14 percent through 96 hours, then dropped slightly, but did not disappear. Patients treated first with a tube to drain gastrointestinal contents and decompress the bowel had longer times between first examination and operation (system-time of 40.6 vs. 10.2 hours), but this was not associated with an increased resection risk. System-times were shorter among patients seen first in the emergency department (median of 25.7 vs. 59.7 hours).

See "Influence of time on risk of bowel resection in complete small bowel obstruction," by Dr. Bickell, Alex D. Federman, M.D., M.P.H., and Arthur H. Aufses Jr., M.D., F.A.C.S., in the December 2005 Journal of the American College of Surgeons 201, pp. 847-854.

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