Thornblade Lucas W, Truitt Anjali R, Davidson Giana H, Flum David R, Lavallee Danielle C
Department of Surgery, Surgical Outcomes Research Center, University of Washington, Seattle, Washington.
Department of Surgery, Surgical Outcomes Research Center, University of Washington, Seattle, Washington.
J Surg Res. 2017 Nov;219:347-353. doi: 10.1016/j.jss.2017.06.052. Epub 2017 Jul 22.
Historical training instructs surgeons to, "never let the sun set on a small bowel obstruction (SBO)" due to concern for bowel ischemia. However, the routine use of computed tomography scans for ruling out ischemia provides the opportunity for trial of nonoperative management, allowing time for resolution of adhesive SBO. In light of advances in practice, little is known about how surgeons manage these patients, in particular, whether there is consistency in the stated duration for safe nonoperative management.
Using a case vignette (a patient with computed tomography scan diagnosed complete SBO without bowel ischemia), we interviewed a purposive sample of general surgeons practicing in Washington State to understand stated approaches to clinical management. Interview questions addressed typical practice, preferred timing of surgery, and approach. We conducted a content analysis to understand current practice and attitudes.
We interviewed 15 surgeons practicing across Washington State. Surgical practice patterns for patients with SBO varied widely. The period of time that surgeons were willing to manage patients nonoperatively ranged from 1-7 d. Interviews revealed insight into surgical decision-making, the importance of patient preferences, variation in practice, and evidence gaps. All surgeons acknowledged a lack of evidence to support appropriate management of patients with SBO.
Interviews with practicing surgeons highlight a changing paradigm away from routine early surgery for patients with adhesive SBO. However, there is lack of consensus in the appropriate duration of nonoperative management and practices vary considerably. These revealed attitudes inform the feasibility and design of future randomized studies of patients with adhesive SBO.
以往的培训指导外科医生，“绝不要让小肠梗阻（SBO）患者等到第二天”，原因是担心肠缺血。然而，常规使用计算机断层扫描来排除缺血为非手术治疗的试验提供了机会，从而有时间解决粘连性SBO。鉴于实践的进展，对于外科医生如何管理这些患者知之甚少，特别是在安全非手术治疗的规定持续时间方面是否存在一致性。
我们使用一个病例 vignette（一名经计算机断层扫描诊断为无肠缺血的完全性SBO患者），对华盛顿州执业的普通外科医生进行了有目的的抽样访谈，以了解他们所述的临床管理方法。访谈问题涉及典型实践、首选手术时机和方法。我们进行了内容分析以了解当前的实践和态度。
我们采访了华盛顿州各地执业的15名外科医生。SBO患者的手术实践模式差异很大。外科医生愿意对患者进行非手术治疗的时间范围为1至7天。访谈揭示了对外科决策、患者偏好的重要性、实践差异和证据差距的洞察。所有外科医生都承认缺乏支持SBO患者适当管理的证据。
对执业外科医生的访谈突出了一种从对粘连性SBO患者进行常规早期手术的模式转变。然而，在非手术治疗的适当持续时间方面缺乏共识，实践差异很大。这些揭示的态度为未来粘连性SBO患者随机研究的可行性和设计提供了信息。
