Surgeon attitudes and practice patterns in managing small bowel obstruction: a qualitative analysis

Abstract

INTRODUCTION Historical training instructs surgeons to, “never let the sun set on a small bowel obstruction (SBO)” due to concern for bowel ischemia. However, the routine use of CT scans for ruling out ischemia provides the opportunity for trial of non-operative management, allowing time for resolution of adhesive SBO. In light of advances in practice, little is known about how surgeons manage these patients, in particular, whether there is consistency in the stated duration for safe non-operative management. MATERIAL & METHODS Using a case vignette (a patient with CT-scan diagnosed complete SBO without bowel ischemia), we interviewed a purposive sample of general surgeons practicing in Washington State to understand stated approaches to clinical management. Interview questions addressed typical practice, preferred timing of surgery, and approach. We conducted a content analysis to understand current practice and attitudes. RESULTS We interviewed 15 surgeons practicing across Washington State. Surgical practice patterns for patients with SBO vary widely. The period of time that surgeons were willing to manage patients non-operatively ranged from 1–7 days. Interviews revealed insight into surgical decision making, the importance of patient preferences, variation in practice, and evidence gaps. All surgeons acknowledged a lack of evidence to support appropriate management of patients with SBO. CONCLUSIONS Interviews with practicing surgeons highlight a changing paradigm away from routine early surgery for patients with adhesive SBO. However, there is lack of consensus in the appropriate duration of non-operative management and practices vary considerably. These revealed attitudes inform the feasibility and design of future randomized studies of patients with adhesive SBO.

The Safety of Expectant Management for Adhesive Small Bowel Obstruction: A Systematic Review

“…However, for those patients that do not meet criteria to go to emergently to the operating room, previously identified surgeon practice variability in the timing and indications for operative interventions motivated a search for evidence to support the safety of this practice. 6 After a systematic review of the literature, we conclude that there are significant evidence gaps to support the safety and effectiveness of expectant management compared to early non-emergent surgery for aSBO. Washington State surgeons participating in the Surgical Care and Outcomes Assessment Program (SCOAP) network are now collecting data on expectant versus early operative management for SBO.…”

“…A third of surgeons interviewed wait 3 days or longer prior to operating. 6 Given the apparent frequency of expectant management and variation in the timing of non-emergent surgery, we aimed to evaluate the evidence supporting the safety and effectiveness of expectant management compared with usual care (early non-emergent surgery) for patients with aSBO.…”

National prospective cohort study of the burden of acute small bowel obstruction

“…This information was collected but is not reported in this patient‐level analysis. Survey work on decision‐making has been investigated as part of NASBO and by others. This may be particularly relevant where surgery was deliberately deferred in an effort to avoid operation in a particularly high‐risk patient.…”

“…Potential explanations for these observations are complex. Early intervention and source control in the immediate surgery group, deteriorating physiological and nutritional status in the delayed surgery group, and clinical bias in deferring surgery in unfit patients may all have contributed. This complexity has important implications for both surgical decision‐making and patient counselling, making a strong case for involvement of perioperative anaesthetic, critical care and elderly care clinicians in best advising high‐risk patients.…”

Fluoroscopy‑guided long intestinal tube placement for the treatment of malignant bowel obstruction

“…Nasogastric tube decompression is commonly used for MBO. While traditional nasogastric tube decompression can decompress and drain the gastral cavity fully, the location of the nasogastric tube makes it difficult to effectively drain small intestinal contents and relieve the symptoms of intestinal obstruction, including abdominal pain and abdominal bloating (17)(18)(19). More importantly, traditional nasogastric tube decompression may not achieve the restoration of early enteral nutrition (2).…”