May 2023 - Emergency General Surgery
May 2023
EAST Monthly Literature Review
"Keeping You Up-to-Date with Current Literature"
Brought to you by the EAST Manuscript and Literature Review Committee
This issue was prepared by EAST Emergency General Surgery Committee Member Jill Streams, MD.
Thank you to Haemonetics for supporting the EAST Monthly Literature Review.
In This Issue: Emergency General Surgery
Scroll down to see summaries of these articles
Article 1 reviewed by Jill Streams, MD
Geographic Variation in Operative Management of Adhesive Small Bowel Obstruction. Carmichael SP 2nd, Kline DM, Mowery NT, Miller PR 3rd, Meredith JW, Hanchate AD. J Surg Res. 2023 Jun;286:57-64.
Article 2 reviewed by Jill Streams, MD
Surgery for adhesive small-bowel obstruction is associated with improved long-term survival mediated through recurrence prevention: A population-based, propensity-matched analysis. Behman R, Nathens AB, Haas B, Look Hong N, Pechlivanoglou P, Karanicolas P. J Trauma Acute Care Surg. 2019 Sep;87(3):636-644.
Article 1
Geographic Variation in Operative Management of Adhesive Small Bowel Obstruction. Carmichael SP 2nd, Kline DM, Mowery NT, Miller PR 3rd, Meredith JW, Hanchate AD. J Surg Res. 2023 Jun;286:57-64.
Clinical management of adhesive small bowel obstruction (aSBO) can vary widely amongst surgeons. This study utilized a national database of commercial insurance claims to retrospectively analyze the management of patients admitted with aSBO. The authors hypothesized that there is state level variation in the operative management of aSBO. The database was examined for a 2-year period of 2017- 2019, which identified 2145 patients admitted with aSBO. Patients with SBO due to a non-adhesive etiology such as hernia or malignancy and those patients >65 years of age were not included in the study cohort.
The primary outcome of this study was to describe the rate of operative versus non-operative management of adhesive small bowel obstructions among the continental US states. In the cohort, 23% of patients with aSBO were managed with operative intervention, which is consistent with historic data on aSBO. In the cohort, patients who were younger and of female gender were more likely to receive an operation. Compared to a national baseline, Missouri had a higher rate of operative intervention while patients cared for in Florida had lower than expected rates of operative management. Importantly, this study also investigated the impact of operative management on readmissions for aSBO in the following year. The 90 patients who had operations for aSBO in 2018 had a 77% reduction in the odds of readmission in the next calendar year. Given that aSBO is one of the most common conditions cared for by Acute Care Surgeons, this study lends evidence to support a need for standardization and/or consensus national guidelines for recommended aSBO management.
Article 2
Surgery for adhesive small-bowel obstruction is associated with improved long-term survival mediated through recurrence prevention: A population-based, propensity-matched analysis. Behman R, Nathens AB, Haas B, Look Hong N, Pechlivanoglou P, Karanicolas P. J Trauma Acute Care Surg. 2019 Sep;87(3):636-644.
Adhesive small bowel obstruction (aSBO) can present as an acute and a chronic surgical pathology. Current guidelines advocate a trial of non-operative management, and this has been found to be successful in approximately 70% of aSBOs. This study sought to investigate the impact of operative versus non-operative management of first occurrence of aSBO on long term survival. This was accomplished with a retrospective analysis of healthcare administrative databases in Ontario, Canada over a 10-year period. A cohort of 27,904 patients were admitted with a first-time occurrence of aSBO during the study period, of which 22% underwent operative intervention. There was 19.6% rate of aSBO recurrence during the study period, consistent with prior studies on SBO recurrence rates. Propensity matched groups of patients managed non-operatively versus operatively were used for the primary and secondary outcome measures.
The primary outcome of survival was shown to be significantly higher in patients undergoing operative treatment during their index admission for aSBO. Immediate mortality rate of 4% was the same between groups, however there was significantly lower odds of mortality at 1, 3 and 5-years in the operative cohort. For secondary outcomes, the incidence of aSBO recurrence was significantly lower in patients who underwent an operation. This is one of a number of recent studies demonstrating a clear benefit to operative intervention for adhesive small bowel obstruction in terms of risk of recurrence. This investigation was also able to demonstrate a clear survival benefit for patients managed operatively. Despite the success of non-operative management for aSBO for a single occurrence, Acute Care Surgeons should consider pursuing more operative intervention for aSBOs given the current data.