Highlights from #AAST2014 - Protocolized Management of SBO

Interesting study from the Gainesville group - giving gastrograffin in SBO helps determine who needs to go to OR sooner.

PROTOCOLIZED MANAGEMENT OF ADHESIVE MECHANICAL SMALL BOWEL OBSTRUCTION: MOVING IT ALONG.

Janeen R. Jordan MD, Trina Bala RN, Scott Brakenridge MD, Chasen A. Croft MD, Lawrence Lottenberg* MD, Linda Atteberry* MD, Winston Richards MD, David Mozingo* MD, Alicia

Mohr* MD, Frederick A. Moore* MD, University of Florida - Gainesville Invited Discussant: Clay Cothren Burlew, MD

Introduction:Differentiating between a partial small bowel obstruction (SBO) likely to resolve with medical management and a complete obstruction requiring intervention remains elusive. For quality improvement, we implemented a standardized protocol for management of SBO and the purpose of this study is to evaluate its performance.

Methods:Patients with symptoms and X-ray findings of SBO were admitted for IV fluid resuscitation, bowel rest, nasogastric tube (ngt) decompression and exams every 4 hours. Labs and a CT scan of the abdomen and pelvis with IV contrast only were obtained. Patients with peritonitis or CT imaging findings suggestive of bowel compromise were taken to the operating room (OR) for exploration following resuscitation. All other patients were than given 120mL of diluted 2:1 gastrograffin (GG). KUBs were obtained at 4, 8, 12 and the 24th hour. If contrast did not reach the colon in 24 hours, then the patient was counseled and operative intervention was performed. Results:Over a year, 101 patients were admitted for SBO. 26 patients went directly to the OR due to imaging or clinical findings suggesting bowel compromise (49% required bowel resection). Seventy-five patients were enrolled in the GG protocol of which 45.3% of patients underwent surgery. The average time to surgery was within 1 day for those not on the protocol and 2 days for those treated with GG

Conclusion:Differentiating between patients with a partial bowel obstruction vs. complete obstruction remains arduous. Institution of the GG protocol standardized our management algorithm with the goal to identify those patients with complete obstructions early and intervene more rapidly. The protocol may have led to a more rapid resolution of a partial obstruction. The administration of GG did not comparatively increase the risk of bowel ischemia or significantly increase the rate of bowel resection.

	LOS	Time of GG to colon (min)
GG+no surgery(n=41)	3(p<0.0001)	300(p<0.0002)
GG+surgery(n=34)	14(p=1)	480(p=1)
no GG+surgery(n=26)	12(p=0.2)	N/A