Operative acute small bowel obstruction: Admitting service impacts outcome

Early surgical intervention in acute small bowel obstruction (SBO) has long been recognized as an important factor in preventing morbidity and mortali ty. Factors associated with surgically managed acute SBO were analyzed for delay in intervention and impact on outcome. A retrospective review of all patients evaluated for SBO on the surgical teaching service of the Greenvil le Hospital System from July 1, 1997 to June 30, 2000 was performed. Data w ere collected on patient demographics, admission information (date, admitti ng service, physical examination, and laboratory values), comorbidity, diag nostic studies, surgery date, operative findings, postoperative complicatio ns, operative mortality, and discharge date. Analysis of the data revealed 157 cases of presumed SBO of which 61 were managed nonoperatively and 96 re quired surgery. Acute SBO was diagnosed in 65 patients who constitute the b asis for this review. Of these 65 patients 43 (66%) were admitted to the su rgical service, 25 (38%) required small bowel resection, and 17 (26%) devel oped morbidity and/or mortality. When analyzed for morbidity and mortality the only characteristics that were statistically significant were the admit ting service (P = 0.003) and length of stay (P = 0.003). On further analysi s of admitting service and patient outcomes several factors were significan t when we compared medical service admissions to surgical service admission s. These included days from admission to surgery (P = 0.003), length of sta y (P = 0.019), morbidity (P = 0.004), mortality (P = 0.005), and combined m orbidity and mortality (P = 0.003). Mortality of patients admitted to the m edical service was 27 per cent compared with 2 per cent for the surgical se rvice. There were no differences in morbidity and mortality when analyzed b y the need for small bowel resection, patient age, etiology of obstruction, or presence of comorbidities. None of the factors studied were useful in p redicting the need for small bowel resection. Our findings agree with those of previous investigators with regard to 1) lack of association between th e preoperative evaluation and the need for small bowel resection and 2) the association between delay in diagnosis and increased morbidity and mortali ty. In addition we have found that one of the primary causes of delay in tr eatment for SBO was admission to the medical service. This delay led to sig nificantly higher mortality in these patients. We recommend early surgical evaluation for any patient admitted with SBO as a differential diagnosis.