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 mortality. 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 Greenville Hospital System from July 1, 1997 to June 30, 2000 was performed. Data were collected on patient demographics, admission information (date, admitting service, physical examination, and laboratory values), comorbidity, diagnostic studies, surgery date, operative findings, postoperative complications, operative mortality, and discharge date. Analysis of the data revealed 157 cases of presumed SBO of which 61 were managed nonoperatively and 96 required surgery. Acute SBO was diagnosed in 65 patients who constitute the basis for this review. Of these 65 patients 43 (66%) were admitted to the surgical service, 25 (38%) required small bowel resection, and 17 (26%) developed morbidity and/or mortality. When analyzed for morbidity and mortality the only characteristics that were statistically significant were the admitting service (P = 0.003) and length of stay (P = 0.003). On further analysis of admitting service and patient outcomes several factors were significant when we compared medical service admissions to surgical service admissions. These included days from admission to surgery (P = 0.003), length of stay (P = 0.019), morbidity (P = 0.004), mortality (P = 0.005), and combined morbidity and mortality (P = 0.003). Mortality of patients admitted to the medical service was 27 per cent compared with 2 per cent for the surgical service. There were no differences in morbidity and mortality when analyzed by the need for small bowel resection, patient age, etiology of obstruction, or presence of comorbidities. None of the factors studied were useful in predicting the need for small bowel resection. Our findings agree with those of previous investigators with regard to 1) lack of association between the preoperative evaluation and the need for small bowel resection and 2) the association between delay in diagnosis and increased morbidity and mortality. In addition we have found that one of the primary causes of delay in treatment for SBO was admission to the medical service. This delay led to significantly higher mortality in these patients. We recommend early surgical evaluation for any patient admitted with SBO as a differential diagnosis.