Surgical Resident’s Research Challenges Dogma of Small Bowel Obstruction Management

PSI Spotlights Cover photo with Dr. Ramy Behman's headshot Posted: November 8, 2019

A potentially practice-changing study led by a PSI Foundation-funded surgical resident has challenged long-held beliefs about care for small bowel obstructions (SBOs).

SBO, a blockage in the intestine often cause by scar tissue (or “adhesions”) from previous surgery, is a common condition, representing about 20% of all hospital admissions for abdominal pain. A small number of patients whose conditions don’t resolve with usual treatment receive surgery, but most patients, about 80%, recover from SBO through treatment with bowel rest, IV fluids and gastric decompression. These patients are considered to be successfully treated and released from hospital, yet many of them will return – sometimes as often as every few months – with a recurrence.

Dr. Ramy Behman, a surgical resident with the University of Toronto, wanted to study the long-term natural history of SBO and potentially improve treatment. “We’ve been treating SBO the same way for a long time. Some people bounce back from an SBO, but then they’re dealing with it every few months,” says Dr. Behman. “SBOs aren’t very well studied, so a better understanding of the natural history could be helpful to improve treatment.”

Dr. Behman applied for and received PSI Foundation funding, which he says was crucial to the research, especially so early in his career. “I don’t know how we would have done the study without the funding,” he says. “And having people outside of your research committee think that the research is worthwhile is very encouraging when you’re just starting off.”

With a Resident Research Grant, Dr. Behman looked at 10 years of health administrative data, identifying nearly 40,000 patients in Ontario admitted to hospital for their first SBO during that time period. They then followed how the patients were treated on that occasion and any following recurrences and tracked the outcomes. The large dataset allowed them to examine the different ways that SBOs are managed and how outcomes are affected.

“We were one of the first groups to really step back and look at the long-term disease course,” he says. “And what we found was challenging to the dogma.”

Physicians have long believed that surgery for SBO would increase the risk of recurrence by creating new adhesions and usually don’t recommended surgery for SBO unless other treatments are unsuccessful. But Dr. Behman’s research suggested that this actually isn’t the case – in fact, surgery could reduce the risk of recurrence. According to their results, patients with SBO treated with surgery – whether on the first or subsequent occurrences – cut the risk of recurrence by about half.

“Operating can take patients off the recurrence cycle. It can really change the trajectory of disease for patients,” says Dr. Behman.

Surgery does have its own risks, namely the risk of complications that could potentially have been avoided, as well as a greater upfront cost than standard treatment. Dr. Behman and his team are analyzing the cost-utility to examine whether the greater upfront costs are offset by fewer hospital readmissions due to recurrences, and he is hoping to publish the results soon.

He notes that the study may influence guidelines for SBO management and help physicians make informed decisions about how the condition can be managed.

“This isn’t a uniform prescription for every patient with SBO, but it adds to our understanding of the disease and facilitates informed decision making,” he says. “The optimal practice will be the right intervention for the right patient.”

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