Journal Review in Emergency General Surgery: Small Bowel Obstruction - What 15 Years of Data Teach Us in Tiger Country

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Now, enjoy the episode and dominate the day. - All right, guys, welcome back to Behind the Knife with the EGS team at Tiger Country at the University of Missouri. I'm Richard Devon. I'm one of the acute care surgeons at Missouri. Today, we're gonna be tackling with the most common EGS consults across the country, small bowel obstruction. We're not just gonna be talking about management here. We're gonna be going into and providing a good general review on the global evolution of small bowel obstruction and some of the predictive models that are out there dating from 2011 through the current practice in 2025. We're also gonna talk about how some of these international studies can apply to North American acute care models across the nation. But before we get started, let's go ahead and do some quick team introductions. - All right, hi, I'm Raymond O'Kake. I'm the ACS and SEC, I'm fellow. - My name's Deszre Plectrum. I'm a third-year general surgery resident. - I'm Bryce O'Reckle. I'm a fourth-year general surgery resident. - I'm Eugene Asmila. If I want to talk about PGY-5s at the University of Missouri. - Awesome. So we're surrounded by a bunch of budding acute care surgeons who are nerds in their fields. So let's go and talk about the lineup. So we're gonna walk through five major papers that influence how we can diagnose, risk stratify, and manage small bowel obstruction in 2025. So the first paper is gonna be the impact of operative management on recurrence of adhesive small bowel obstruction published in 2020 in the journal of American College of Surgeons. Second paper is gonna be the Strisk and NoFA scores for predicting immediate surgery or failure of non-operative management, published in 25 by the Oxford University in the British Journal of Surgery. That third paper we're gonna talk about is Evans-based, cost-effective ACS algorithm for SBO management. This one was published in the journal of trauma and acute care surgery most recently in 2025. - The fourth paper will be discussing the perspective validation of a multivariate model for predicting operative needs published in 2011 by the Journal of American College of Surgeons. And then the final paper will be the new clinical severity score for predicting bowel leukemia, which was published in 2023 by the International Journal of Surgery from the University Hospitals of Geneva. - Quite a bit of papers that we're gonna go through. We're gonna do our best to keep it brief and get through the salient major points, okay? So Dr. Fletcher, why don't you go ahead and start us off with the 2023 new clinical severity score. What's essentially the essence of this 12 year Swiss goal? - Yeah, absolutely. - Okay, so this was a single center prospective cohort study. They kind of compared this new data with old data from within their same institution. So this looked at 492 patients with adhesive small bowel obstruction from the years of 2008 to 2016. Basically 70% were managed surgically and 29% were managed conservatively. They compared this with previous years from 2004 to 2007 and come up with this six item score. Basically, the main outcome that they looked at was a small bowel resection as a surrogate for ischemia and necrosis. We're gonna talk about eight predictors that they kind of focused on. So age greater than or equal to 70, the first episode of a small bowel obstruction, no bowel movement or obstapation within or equal to three days, guarding on exam, CRP greater than or equal to 50, transition point on the CT scan and then lack of enhancement on the CT scan, and then also about 500 mils of free fluid seen on the scan. To score these, they each variable was worth one point. They used a threshold score greater than or equal to four to define, quote, high risk. This showed a sensitivity of about 65% with a specificity of about 88%. So why does this matter? How does this apply to clinical application? So scores greater five through seven had a hundred percent resection rate. A score of four had about a 70% resection rate and then if you scored zero to one, it was negligible at about a zero to six percent resection rate. Also in contrast to this, they kind of took into consideration different patients that were unable to receive IV contrast. So they created the seven item, no contrast score, which is basically the above the points that I listed minus a CT contrast enhancement study. The threshold again greater than four corresponded to it greater than 70% predicted risk. The same sensitivity, a higher specificity. Also, I think especially applicable for residents, 'cause we don't have a lot of time to walk around and remember all eight items. They kind of made a brief four item score. Age greater than 70, abdominal guarding on exam. You see a clear transition point on the CT scan and then also that greater than 500 mills of free fluid on the CT as well. If a patient had a high risk threshold, which is greater score greater than two, out of this four point score, that had a greater than 70% predicted risk of resection. - That's insane. So when you finish doing all this and reading this paper, what are some of the key clinical findings beyond the score that you've thought about? - Yeah, for sure. So I think we can talk about operative versus nonoperative strategy. So 70% approximately of the index, small bowel obstructions were managed surgically, which was higher than many North American series as this was performed in Geneva. About 30% of all small levels of obstructions underwent resection. Recurrence for these, it was highest in the conservatively managed group. About 30% versus 15% insurgically treated without resection and about 8% in those treated with resection. Interestingly, a higher small bowel obstruction doubled the risk of recurrence and then the surgical treatment of the index episode half the recurrence risk. To talk about complications with this, the overall post-op complication rate was about 35%. Complications were more frequent and severe with resection versus no resection, which is kind of common sense. And then for me, most interesting, the traditional go-to labs that everyone loves to talk about when we talk about ballaschemia or small bowel obstruction, lactate, lucocytosis, creatinine and platelets were not independent factors of resection and these were actually dropped from the study. The CRP number that they got that I mentioned earlier that was greater than 50, it wasn't independent predictor, but it was actually, it was acknowledged as non-specific and we don't use it here. So it's not routinely used everywhere. It's great listening to you talk about this and reading ahead and for the listeners, we're going to be hitting a lot of points and a lot of things you said are going to be mentioned multiple times in all the different studies. So it actually gets goosebumps going on the back of my neck or maybe that's just the nerdiness in me, but I'm looking forward to tying it all together at the end here. So I'll let you tell us some of the strengths of this study. - Yep, so I think for this study in particular, it was a prospective data collection in the developmental cohort. There were clear clinical meaningful outcome, meaning that we know what small-virus section means. It's a hard endpoint for surgeons. It correlates with clinically significant ischemia, even if it's imperfect. There was both internal and external validation. So they used a relatively large cohort, about 500 patients validated based on their internal reflections from the previous years. They did use multiple usable score versions. So they have an eight or seven or a four. These are more applicable depending on real life constraints. So renal and sufficiency limits your ability to get IV contrast sometimes. Also, the exclusion of malignancy, hernia, radiation, it creates a more homogenous population. So this was true adhesive small bowel obstruction. And then they contextualized within the existing guidelines so they compared their score to the Bologna WSES guidance and double AST small bowel obstruction severity classification. So authors explicitly compared their scores to Bologna and the WSES guidance and as well as double AST, a small bowel obstruction severity classification. And then the data supports that timely surgical management for adhesive small bowel obstructions actually reduces recurrence as well. - That's crazy, you've got a week to many strikes, man. So why don't you tell us some of the weaknesses? - Yep, so single center, just one place. Their operative threshold for adhesive small bowel obstruction is actually higher than North America and ACS centers about 70%, which why does this matter? This can inflate the prevalence of the schematic bowel and actually overestimate the score performance when transported to lower intervention environments. - Cool. All right, well, I don't know if this is a good spot to say it, but this podcast might be a little bit longer, but I think it's worth delving into some of these topics. So I'm just wanting to preview the readers about the next few papers that we're gonna go into. But regarding this last paper you talked about, an overall great framework, not really a full plug-in play kind of system to adopt if the US acute care surgery model because of the CRP, then that routine use of enhanced CT protocols, but still, the common points are that transition point, lack of small bowel enhancement and free fluid as universal red flags. So with that being said, let's just go ahead and dive into our next paper, the Strisk and Nofus Core model. Dr. O'Keeke, why don't you get us going on it? - Right, so this Finnish multi-center perspective study looked at 481 patients and actually produced two models. The Strisk is the risk core that predicts triangulation while the Nofus predicts nonoperative failure. They add two clinical questions that they wanted to look at. So the first one was, "In adults with CT confirmed adhesive small bowel obstruction, can we actually predict strangulation and admission?" And then amongst patients initially treated nonoperatively, can we predict failure of nonoperative management within 30 days. The study was a prospective observational multi-center cohort to both have both internal and external validation and then they would stratify it to two cohorts, development and external validation cohorts. The patients that were included were adults with CT confirmed adhesive small bowel obstruction, as well as any relatively clinically relevant labs, updated presentation. For patients who had surgery within 30 days, who had IBD, interluminal obstruction, paternal conservatosis, paralytic ilias, or were younger than 18 years of age, they were excluded from this study. If strangulation was suspected at any time, emergency surgery was pursued, otherwise patients got NG2 decompression, IV fluids, a water soluble contrast challenge, with failure or new strangulation science triggering surgery. The goal of this is important to mention was not to make another fancy score, but rather something that was clinically usable, well calibrated and had real world reliability. So starting off with strisk, it looked at six variables. One of them was number of prior small bowel obstruction episodes that abdominal guarding, neutrophil to y-blood cell count ratio, small bowel feces sign, the presence of mesenteric edema or free partennial fluid, and then a closed loop configuration on CT. I like to talk performance here because I think it's good to show that this is a very outstanding prediction model. So the development and external validation came out at 0.86 and 0.91, and if we look at one as a sign of perfect discrimination, this is actually pretty good for a prediction model. - Well, that's a lot of stats, man. So what does it actually mean clinically? - Very thanks for asking that. So strisk essentially, listen, I like being nice. It's okay. Strisk essentially tells you, so how worried should I be that this patient is regulated right now? And then they did more stats here and they created a non-like calculator, which you can find in our show notes, if you wanna access that. But the patients were stratified into four groups based on risk. So you have a low, it's just less than 5%, moderate, five to 20%, high, 20 to 50%, and very high, which is greater than 50%. So in this very high group, most of them ended up in the OR and required resection. So this is the patient you don't want to leave on NGD compression overnight. Now, speaking of NOFA, it actually reuses the same exact six variables, this to keep it simple. But instead, the question here, the outcome was, will this patient fail non-operative management within 30 days? Also had pretty good discrimination here and it's actually pretty valid in itself. NOFA answers the question that we have when patients present on day one or day two. So is this patient actually gonna get better with non-op management, or are we just delaying the inevitable? So it helps reduce prolonged, unproductive, multi-day non-operative trials. - Yeah, so does that, actually, that's probably one of the best parts of the paper that I enjoyed the most, seeing how they were able to create that model with the same scoring system. That dovetails pretty nicely with going to this trace of this paper. So why don't you tell us a little bit about that? - Right. So, trends of this paper are it's perspective, it's multi-institutional, it's externally validated. Adhesive small bowel obstruction was the only population studied, so that's clear. It employed high quality blinded CT review. It had good strong calibration and a good discrimination. And again, there is the presence of the web-based calculator online. That's about as rigorous as EGS literature gets. - Yeah, it's pretty cool. I've already made a home screen app on my phone. Then again, I have everything as a home screen app, but tell us about the weaknesses. - So unfortunately, this study was conducted in Finland. So practice patterns may differ from the US. CT interpretations here were by expert radiologist not surgeons. Only small bowel, adhesive small bowel obstruction was studied. So it doesn't apply to malignant, hernia, or post-op obstruction. And it's very important to mention here that prediction is not the same as they mandate. So even though strisking NOFA can help guide decisions, they should not and do not replace surgical judgment. There's a slight over prediction in the high risk routes, but again, none of these things in validity, it's clinical usefulness. - Yeah, I really liked the paper. I thought this one was more applicable than some of the older models because they can put things at the US hospital systems routinely kind of collect already. And the CT base variables match modern radiology practices. So kind of very reproducible actually. - Behind the knife would like to thank our partner, Jomi, with over 300 high quality, expertly narrated surgical videos. Jomi is an indispensable resource for residents and students to prep for the OR. Attendees and residents from Stanford, Harvard, and Johns Hopkins depend on Jomi's up-to-date peer review cases. Virtually scrub in at jomi.com to improve your OR prep today. - But anyway, let's go ahead and move on with the next paper with Dr. Ismalov. Aren't you going ahead and talk to us about the impact of operative management on recurrence piece of small bowel obstruction? - Sounds great. We've been talking a lot about dead and dying bowel, so let's stop recurrence. This current study says that, you know, adhesive SBO, as we all know, is pretty much one of the most frequent things we see in the emergency department, in the middle of the night, in the middle of the day, in any and all hours. Historically, the dogma has been that, if you operate on a small bowel obstruction, you risk developing more adhesions, potentially developing further episodes of SBO. Versus, if you don't operate and you're able to manage the patient not operation, this will be safe for long term. But until recently, we haven't really had much data on this and the subject has been rather poorly understood. The current study of presenting leverages a unique statewide data set in Tennessee that links patients across every hospital in the state. So if somebody were to recur later to a different institution, they would still be captured in this data set, which I think is huge. The authors took adults with first ever adhesive, related small bowel obstruction, between the years of 2007 and in 2009, and followed them all the way to 2016 to watch for recurrences. They had about 6,000 patients, and 70% of those were managed not operatively. A medium followup was about 10 years in each group, which is a pretty good timeframe, I would say. They used the pretty much a gold standard model, called the Anderson Gale Model, for analyzing recurrent events to see how the small bowel obstruction episodes and its management affected future episodes. They found a couple of things that I think are important and important takeaways from this. First and foremost, they found that operative management actually reduces risk of recurrence. So if you operate on a small bowel obstruction at its initial occurrence, you significantly reduce the chance of the patient developing another episode down the line. Skipping some of the math here, about 70% reduction rate in future recurrences compared to patients that were managed conservatively. The second big thing that they did find is that surgery actually delays the next episode of recurrence by many years. The operative index episode median was about 729 days to recurrence compared to 550 for a nonoperatively managed patient. So just over two years, right? Yeah, that's crazy. It's quite a bit of a difference for sure. However, some negative things about operating, as much as we all like operating on small bowel obstructions, recurrence begets recurrence. Whether treated surgically or non surgically, once a patient has a recurrence, their future risk rises with each episode and the hazard ratios here for a nonopercurrence is 1.1A and for an operative recurrence is 2.3. Meaning, if you're on your third small bowel obstruction regardless of which treatment you receive previously, you're much more likely to have a fourth. And then finally, as we all know, surgery does come with higher risks in immediate post-operative period. One of them being mortality for operative is 3.7. For nonoperative patients is 2.6. I imagine this is during their admission with sense mobile obstruction. And complications are higher across the board. So whether we're talking about cardiac ischemia, pulmonary embolite, pneumonia is kidney injury, or lume infection. So ultimately, the reason why we're all in surgical residency is to make clinical decisions. And the tradeoff is ultimately real based on this study that surgery does lower future small bowel obstruction episodes, but it does increase short-term morbidity and mortality. So we'd tell us about the strengths of the study. Yeah, so there's quite a few. The first one is that it's large, it's statewide, and it being all a linked hospital system, we were able to. The authors were able to capture recurrences across multiple institutions within the state. The long-term follow-up approaching close to a decade. Appropriate recurrent events statistics, not just the first recurrence of SBO, they continue to follow these patients for this period of time. And they looked at clinical outcomes that we're all on a lookout for. So recurrence, time to recurrence, mortality, and then the associated complications that we've discussed. And then ultimately, this was in Tennessee. So I think this has high applicability for ACS practices across North America. Yeah, and then those are great strengths, but clueing into limitations, there's one big limitation that I was listening to or kind of picking up on, and that's the complications associated with the operative cases. Why don't you dive in and tell us a little bit about those limitations? So I think the biggest limitation here is that all this is administrative data. We don't have CT findings, we don't have lactates, there's no clinical severity markers. We ultimately don't know why the patients that got an operation were operated on, which adhesions were encountered, whether the operations were laparoscopic or open, whether there was any bowel ischemia found at the time of the operation. Also, come founding by the indication is huge. Cycropatients are more likely to be operated on and more likely to have complications and mortality. This inflates the observed operative mortality as you would expect. And finally, the data are from 2007 and 2016, which I think were the developments in the radiology world. I think the modern CT base scoring systems, the standardized gastrograph from protocols, and as well as laparoscopy, ultimately were in his white spread. - Nice, nice. Good job wrapping up that paper. - Let's move on, we're almost at the end, okay? So, hey, Bryson, are you ready to go? - Yes, sir. - How are we, man? Let's finish off and wrap us up with the JTAC's EGS algorithm. - Yeah, so, Journal of Trauma and KK surgery algorithm is the most North American document in the group. It pushes a structured approach. This patient, or this paper, answers the questions we all have of what's an evidence-based, cost-effective way to manage small bowel destruction actually works in real life ACS practice. - All right, so this is the size of moderate evidence, including CT predictors, previous guidelines, including East guideline, other meta-analyses. This algorithm starts by emphasizing the CT scans, the central decision-making tool. Like Eugene had said, we moved beyond the air ever learning on playing films, non-specific labs, white blood cell count, lactate. CT tells you you need an anatomy, the transition points, and most importantly, the early signs of ischemia. So, importantly, this paper lists the features that are strongly predict the need for urgent surgery. Most importantly, like Desiard talked about previously, mesenteric edema, free-insured peritoneal fluid, a closed-loop obstruction, lack of small bowel feces sign, and bowel-wall hypoenhancement. Like I said, same findings as they found in Zalinsky, Strisk, and Nofo scoring systems earlier. The message is clear. The CT is predictive, it's reproducible, and it should get the guided decision-making. All right, so according to this algorithm, about 20% of the small bowel structures need emergency surgery, right at presentation. These key triggers are parotonitis, hemodynamic instability, CT signs of ischemia, and a closed-loop bowel obstruction. The authors are crystal clear on this if you have one of these. You should not delay surgery for a gastrographic challenge or prolonged observation, you need to go straight to the operating room. The important part is the non-operative management of adhesive with small bowel obstructions. Without emergency surgical indications that we talked about, the outer of the supports and initial trial of non-operative management. This includes your NPO, NGD compression, your fluids and your early theory assessment. They shifted away from the old dog with the Virgin Adamin always needs surgery. This paper shows and sites multiple places of evidence that the adhesions are the most common cause with no prior surgery, many can still be managed conservatively. This is a huge point for the residents. The authors strongly recommend using a water soluble contrast study, gastrographic challenge within six to 24 hours after NGD compression for these stable patients with adhesive obstructions. Why the evidence consistently shows that shortens the length of stay, it predicts failure and not operative management. It provides diagnostic clarity and avoids prolonged pointless non-operative trial. All right, cool. Vid job man, so what do you think the algorithm is the biggest clinical push is here? And as I've ever talked all about the gastrographic challenge, they strongly recommended using a water soluble contrast study between six and 24 hours after NGD compression and stable patients with adhesive obstructions. Why the evidence consistently shows that it shortens the length of stay, it predicts failure of non-operative management, it provides diagnostic clarity and it avoids prolonged pointless non-operative trials. So watch this a little bit about the important nuances of it. Yeah, the real value is predictive. If contrast reaches the cold and it's a good sign, if not, then you're patient likely to fail non-operative management. The authors emphasize you should not delay the gastrographic challenge beyond 72 hours. That's when you see the morbidity of delayed surgery that goes up. Nice. All right, so while we just dive into the biggest point that I know all of you guys is budding acute care surgeons who want to talk about, so what about the role of laparoscopy? Yeah, so this is one of the strongest contributions of the paper. It an analyzed the modern role of minimally invasive surgery in bowel obstructions. They used randomized trials, metanalyses, and this quick data that shows the laparoscopy is safe. It's effective and associated with shorter length of stay. And it's definitely best for single band or simple adhesive obstructions, but only in the right patient. The ideal candidates are less than two prior laparotomies, single band obstruction, no diffuse paratonitis, and the bowel diameter is less than four centimeters. This mirror's current North American, minimally invasive surgery practice, especially at high volume centers for laparoscoping robotic acute care surgery teams. Nice, man. That analysis, good review. Great job going over that. It's the current standard to build from everywhere in acute care surgery services nationwide. It should be building local protocols, in my opinion, to mirror this kind of information that marries the CT findings, nasogastric tube decompression, water soluble contrast, and these timing-based red flag triggers. We've gone through quite a bit. It's been a bit of a journal club. I think all of you guys have done a great job, but I think we should probably start bringing it all together. So I want to remind everyone a lot of what we have hurt today and gone over. I should start way back to 2011 with Dr. Zelensky's perspective multivariate model. One of the papers that we didn't fully discuss, but I want to clue into a little bit, because it sets the framework. It helps tie in everything that we've discussed today. It was the first series attempt to bring objective CT-driven structure to archive this notoriously murky disease process we have. And after reviewing these papers from Switzerland, Finland, the new US models, and these consensus algorithms, they're remarkable just to see how much has changed, but also kind of to realize how much has really stayed the same, looking at the same things just with different models. And you can see across every era and with every healthcare system, there's just one key message that to me, I think keeps resurfacing. It's the surgeon's job to identify strangulation early and before the battle declares itself and not after. I think that's one of the key points, right? Zelensky's original work showed that just four features, obstapation, mesenteric, adiba, free fluid, and the absence of PC signs, could meaningfully stratify patients, which were heading towards the OR, which I think we've done a pretty good job fast-forwarding now into 2023 and 2025 with the Geneva score that expanded the concept by integrating clinical labs and CT findings, this finish, strisk, and nofo model, in 2025 that returned to mesenteric changes like free fluid, the PC sign, or lack thereof, the number of prior small ball episodes as most reliable predictors, and then this all got tied together with that J-Tax algorithm that just came out, right? And it kind of talks about the same features and the foundational knowledge of those red flags on the CT scan that determine whether or not you should be proceeding for early operative intervention. For me, you sit back and be listening to these journal clubs and ask ourselves, what does it all tell us? Despite more complex stats, multivariate modeling, all this bootstrapping and external validation, the same core imaging features that mattered in 2011, still matter today. Our tools have just only gotten better, right? We have better CTs, higher quality imaging. Our methodologies are tighter, our access to laboratory data, and quick access point of care evals are much more improved, but the biology of strangulation hasn't changed. It's the same biology, right? Yeah, so there are three big shifts we've seen now, which are pretty interesting. So we've gone from operating early to operating selectively, but earlier when you should. So the old mantra of don't let the sunrise or set on a small bowel obstruction is actually given way to a more modern mantra, which is don't delay when high risk features are present. Also, we've seen that there's no single lab, no single CT cut, no single vital sign will save you. Modern scoring systems acknowledge what season surgeons already know. Small bowel obstruction severity emerges from patterns, not isolated findings. So it's whether it's Celine's he's a three feature, four feature model, Geneva's eight item score, or the strict NOFA six predictors, the shift is towards integrated clinical models that reflect real world decision making. And then finally, the long game is important, recurrence matters. So again, operative management at the first episode decreases long term recurrence. An operative management has lower perioperative morbidity, but earlier and more recurrent, more frequent recurrence. And each episode operative and nonoperative raises the risk for future recurrence. - All right, dude, so what does this all leave us in the tight country and across North America? After 15 years of models, validation studies, and international data sets, I'm pretty sure we can just still listen to four clinical roots that surgeons can bake on. So number one, CT predictors are at the heart of HESPIR decision making. I know that kind of burns a couple of my senior partners, but I'm gonna say across every paper in every country, the strongest predictors of needing surgery include mesenteric edema, endorphs grinding, free interpretal fluid, closed loop transition points, a lack of small bowel enhancement, and/or the absence of a fecesine. And number two, the physical exam, which honestly, in my humble opinion, is the most important, still matters, especially guardian and the delineation of an obstapation history. Guarding an obstapation appear repeatedly and repeatedly as significant predictors in all the studies from Geneva, Zelinsky, to JTACS, everyone talked about. And if a patient has both objective CT red flags, endorph guarding with persistent pain and no bowel movements or flattas, you should seriously consider expediting the OR and not another gastrographic challenge or another day with the NGTube because you may ask for it. Number three, failure of nonoperative management is predictable and/or preventable, right? The strisk and no-fa score reminds us that nonoperative failure doesn't occur randomly. It's predictable and you can get an idea from when these patients arrive in the ER. Those with high Neutrophil to lymphocyte ratios, multiple prior SBOs, mesenter changes, and there it is again, the fecal sign being present drops in in the setting of guarding an obstapation gives you these predictive models. And if the patient arrives like this and they have those elevated scores and you use that calculator that's on your home screen, I hope it's on your home screen, the odds of nonoperative success drop dramatically. So instead of repeating imaging and prolonging that NGTube decompression, these are the patients who are early operative intervention improves outcomes, decreases costs, and decreases linked to state. So all these things, right? At the end of the day, these are the contributions that we never had in 2011 at Zelensky's first framework, which I think is pretty cool. Moving at the end, above all else, remember that SBO isn't just one disease, it's a spectrum. I think that's one of the biggest things we could take home from this. Your job is to figure out where on that spectrum your patient's going to lie before the bowel makes the decision for you. So from all of us here at Tiger Country in Abazoo, this is behind the knife, acute your surgery team, signing off and reminding you to trust your exam, trust the CT, trust the red flags, and when in doubt, operate before the bowel asks you to. So until next time, stay sure and-- - Thrombinate the day. - Be sure to check out our website at www.behindtheknife.org. 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