The first ever National Audit of Small Bowel Obstruction (NASBO) has published six key recommendations for improving standard care, the results will be a vital resource for the development of NHS guidelines and future research work. Small bowel obstruction is an enormous burden on NHS resources, accounting for up to 50% of emergency abdominal surgeries performed in the UK every year, with 13% of these patients dying within three months. NASBO’s findings showed average hospital stays of ten days, with 13% of discharged patients re-admitted within 30 days.
“What I really hope for NASBO is that it raises awareness of this really common condition and makes people focus on it a bit more, given that these patients are really, really sick – we just want to put a bit more focus on them,” said Matt Lee, a member of the South Yorkshire Surgical Research Collaborative which spearheaded the project.
People with SBO are very sick unable to eat and in extreme pain. The single biggest risk factor is age, and with people living longer lives than ever before while NHS resources are stretched increasingly thinly, the challenge of treating them will only become more urgent. Surgeons are desperate to find ways of treating SBO better because there are currently no standard protocols within the NHS.
Their biggest obstacle has been the fact that huge numbers of people are affected and many factors affect treatment, including levels of nutrition in the days leading up to hospital admission, old age and frailty, underlying medical conditions like Crohn’s disease, cancer, hernias and many more. The condition is extremely common and around 50% of patients admitted during the study had emergency surgery.
No one case is the same as the other, and evidence of what care strategies work better than others has been sparse, hence the need for a major national audit to provide a clearer look at the problem. BDRF granted funding for this hugely ambitious project in Spring 2016, and the results have enabled specialists to build a clearer picture of what is an enormous challenge.
Uptake was huge, with bowel specialists recognising the need to work together in tackling one of their most feared and complex conditions to treat. Surveying consultant surgeons around the UK, the team were able to get an idea of how individual specialists manage SBO and what variations there are between them. Overall, 131 hospitals signed up providing a network of 431 collaborators. These sites contributed data on the management of every patient over 16 years of age diagnosed with SBO at their hospital.
In just eight weeks the team logged data on the treatment journey of 2,434 patients compiling a uniquely broad set of data that can be the foundation of future work. While by no means definitive, the findings are of immense importance. They have enabled the team to identify ways to improve care right now, as well as posing questions that require more in-depth analysis in the form of new research projects.
The full recommendations are:
- Early CT scanning offers the best diagnostic & prognostic information, enabling surgeons to decide whether a patient can be managed without surgery or if they require an operation
- Water soluble contrast agent should be embedded in clinical management – for both prognostic and therapeutic purposes
- Nutritional support should be planned from the moment a diagnosis of SBO is made, and tailored to each individual patient’s needs and current nutritional status. Involvement of specialist nutritional services should be considered by surgeons for all patients.
- Surgery should be recommended and carried out within 72 hours in patients whose obstruction does not resolve through use of non-surgical treatments.
- Risk assessments should be carried out on all patients recommended for surgery, enabling those at high risk of complications or death to be admitted to critical care facilities.
- There may be a benefit to applying ‘enhanced recovery’ strategies to patients managed both surgically and non-surgically
Factors like pre-surgery nutrition were identified as under-recognised, despite the findings showing a statistically significant improvement in outcomes for patients where nutrition was prioritised. A lack of awareness of nutritional scoring procedures was highlighted, with many surgeons saying this would change the way they regard the issue.
“The beauty of NASBO is that we captured information on patients who do and don’t have surgery, and we now have high-quality information on what actually happens to these patients – what their pathways are, what the outcomes to their treatments are and where we can make differences for the future,” said Nicola Fearnhead, a consultant surgeon from Cambridge.
Other key factors were how quickly surgery is performed, early use of CT scanning and closer assessment of patients in the first 72 hours of care. One of the study’s other defining features was that it was entirely designed and delivered by junior doctors, via surgical research collaboratives around the country.
“NASBO is a real flagship project of BDRF, achieving our aims of saving and improving lives in the immediate future through a strategic approach to research. I would like to pay tribute to the research team and every collaborator on this project, whose dedication and willingness to do the hard yards of rigorously collecting and sifting through data on the management of thousands of patients will have real-world impacts and genuinely save lives,” said Peter Rowbottom, CEO of the Bowel Disease Research Foundation. “We couldn’t have achieved such a strong set of results without our close links to the membership of the ACPGBI – whose members form the bulk of collaborators and are on the front line of caring for these patients”.
The Stephen Gordon Catto Charitable Trust and the following organisations supported the costs of this audit – The Association of Coloproctology of Great Britain and Ireland, The Royal College of Surgeons of Edinburgh, The Royal College of Anaesthetists, The Royal College of Surgeons of England, South Yorkshire Surgical Research Group, West Midlands Research Collaborative, Association of Gastrointestinal Surgeons of Great Britain and Ireland, British Association of Parenteral and Enteral Nutritionists, Association of Surgeons of Great Britian and Ireland, National Emergency Laparotomy Audit, BRitish Society of Gastroenterology, Getting it Right First Time, BASO – The Association of Cancer Surgery and The University of Sheffield.
To download the report, please click here