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Role of Laparoscopy in Small Bowel Obstruction2018

Type: New Practice Management Guideline (PMG)
Category: Emergency General Surgery
Committee Liaison: Asanthi M. Ratnasekera, DO, FACS

Team leader(s)

With increasing comfort in laparoscopic surgery among emergency general surgeons, laparoscopic management of SBO has become increasingly common. While the 2012 guidelines do reference its use as an option for surgical management, only sparse data were available at the time of their publication, no definitive conclusions could be drawn (1) and the guidelines were published prior to the implementation of the GRADE methodology. At that time, the authors suggested that laparoscopic management was possible for complex SBO and carried a conversion rate of 29% with an enterotomy rate of 7%, but did result in earlier return of bowel function with shorter length of stay. No
clear recommendation for patient selection was proposed based on the available data at the time. Since the publication of these guidelines, more than 600 additional manuscripts with the keywords ‘Laparoscopic’ and ‘Small Bowel Obstruction’ have been published. While many of these are case reports and case series, several randomized
control trials have emerged and suggest continued improvement in patient outcomes from a laparoscopic approach (2,3). A 2015 meta-analysis including fourteen trials representing 38,000 patients demonstrated a reduction in length of stay, postoperative mortality and overall and infectious complication rates at the cost of an increased
operative time (4). We propose an a new practice management guideline regarding the decision making around laparoscopic vs open surgical management of Small Bowel Obstruction using the updated GRADE methodology (5), with the following initial PICO questions:

1. In adult patients with acute small bowel obstruction requiring operation(P), should laparoscopic adhesiolysis (I) be performed compared to laparotomy (C) to improve mortality, overall complication rate, time to return of bowel function or failure of operative management (O).

2. In adult patients with acute small bowel obstruction and Peritonitis (P), can laparoscopic exploration (I) be safely performed compared to laparotomy (C) to improve mortality and overall complications (O).

3. In adult patients with acute small bowel obstruction and multiple (>2 or >3) previous operations (P), can laparoscopic adhesiolysis (I) be performed compared to laparotomy (C) to improve mortality, overall complications, length of stay and time to return of bowel function(O). It is clear in the current literature that there is a role for the use of laparoscopy in small bowel obstruction, but many emergency general surgeons have been reluctant to incorporate it into their practice. Given the frequency the emergency general surgeon sees this condition, the development of practice management guidelines will encourage the use laparoscopy and its concomitant improvement in
patient outcomes.

Work Group Members
James Bogert, MD
Brad Dennis, MD
Nicole Fox, MD, MPH
Oliver Gunter, Jr., MD
Jaswin Sawhney, MD
Libby Schroeder, MD
D. Dante Yeh, MD
Jason B. Young, MD, PharmD

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