2023 General Surgery Presentations

Fred Kobylarz, MD1; Maeghan Ciampa, DO1; Michael Lustik, MS2; Andrew Schlussel, DO1; Carly Richards, MD3; 1Eisenhower Army Medical Center; 2Tripler Army Medical Center; 3Martin Army Community Hospital

Introduction: The management of a small bowel obstruction (SBO) remains a challenge for general surgeons. The majority of SBOs can be treated conservatively; however, when surgery is required, the timing of operative intervention remains uncertain. Utilizing a large national database, we sought to evaluate the optimal timeframe for surgical intervention following hospital admission with a diagnosis of SBO.

Methods: This was a retrospective review utilizing the Nationwide Inpatient Sample (NIS; 2006-2015). ICD-9-CM diagnosis and procedural coding was utilized to identify and compare outcomes following surgery for SBO. Demographics, comorbidities, and postoperative outcomes were identified. All Patients Refined Diagnosis Related Groups (APR DRG) and Elixhauser comorbidity index (ECI) were utilized to determine severity of illness. Patients were stratified into four day groups based on time from admission to surgery. A propensity score model was created to predict surgery >6 days following admission. Multivariate regression analysis was then performed to determine risk adjusted postoperative outcomes.

Results: We identified 109,820 cases of non-elective SBO, 48% underwent adhesiolysis, and the majority of operative cases occurred between day 1-2 (36%; p<0.01). The overall mortality rate was 4.7%. The most common complications included gastrointestinal (18%), pulmonary (9.2%), and infectious (5.3%). After adjusting for propensity score, surgery on days 3-5 compared to day 0 was associated with the lowest rate of mortality (OR=0.87; p<0.05). A longer pre-operative length of stay (LOS) (≥6 days) was associated with a significantly greater number of wound (OR 1.47; p<0.01) and procedural (OR=1.22; p<0.01) complications compared to day 0; however, this did not increase the risk of death (OR=0.98; p=0.69). Surgical intervention ≥6 days was protective for cardiac complications when compared to patients operated on day 0 (OR=0.8; p<0.01) and days 1-2 (OR 0.74; p<0.01).

Conclusion: After adjusting for comorbidities and age, a pre-operative hospital stay of at least 3-5 days was associated with a decreased risk of mortality. In addition, increasing pre-operative LOS minimized cardiac complications. However, there was an increased risk of procedural and wound complications suggesting a surgery during this time period may be more technically challenging.