Original article

Thirty-day mortality in patients undergoing laparotomy for small

bowel obstruction
O. Peacock1 , M. G. Bassett2 , A. Kuryba3 , K. Walker3,4 , E. Davies5 , I. Anderson6 and R. S. Vohra1 ,
on behalf of the National Emergency Laparotomy Audit (NELA) Project Team
1
Trent Oesophago-Gastric Unit, Nottingham City Hospital Campus, Nottingham University Hospitals NHS Trust, Nottingham, 2 NELA Research
Fellow, Royal College of Anaesthetists, 3 Clinical Effectiveness Unit, Royal College of Surgeons of England, and 4 Department of Health Services
Research and Policy, London School of Hygiene and Tropical Medicine, London, 5 Department of Surgery, Royal Lancaster Infirmary, University
Hospitals of Morecambe Bay NHS Foundation Trust, Lancaster, and 6 Colorectal Surgery Department, Salford Royal Hospitals NHS Trust, Salford, UK
Correspondence to: Mr R. S. Vohra, Trent Oesophago-Gastric Unit, Nottingham City Hospital Campus, Nottingham University Hospitals NHS Trust,
Hucknall Road, Nottingham NG5 1PB, UK (e-mail: ravinder.vohra@nuh.nhs.uk; @ravinder_vohra)

Background: Small bowel obstruction (SBO) is a common indication for emergency laparotomy. There
are currently variations in the timing of surgery for patients with SBO and limited evidence on whether
delayed surgery affects outcomes. The aim of this study was to evaluate the impact of time to operation
on 30-day mortality in patients requiring emergency laparotomy for SBO.
Methods: Data were collected from the National Emergency Laparotomy Audit (NELA) on all patients
aged 18 years or older who underwent emergency laparotomy for all forms of SBO between December
2013 and November 2015. The primary outcome measure was 30-day mortality, with date of death
obtained from the Office for National Statistics. Patients were grouped according to the time from
admission to surgery (less than 24 h, 24–72 h and more than 72 h). A multilevel logistic regression model
was used to explore the impact of patient factors, primarily delay to surgery, on 30-day mortality.
Results: Some 9991 patients underwent emergency laparotomy requiring adhesiolysis or small bowel
resection for SBO. The overall mortality rate was 7⋅2 per cent (722 patients). Within each time group,
30-day mortality rates were significantly worse with increasing age, ASA grade, Portsmouth POSSUM
score and level of contamination. Patients undergoing emergency laparotomy more than 72 h after
admission had a significantly higher risk-adjusted 30-day mortality rate (odds ratio 1⋅39, 95 per cent
c.i. 1⋅09 to 1⋅76).
Conclusion: In patients who require an emergency laparotomy with adhesiolysis or resection for SBO, a
delay to surgery of more than 72 h is associated with a higher 30-day postoperative mortality rate.

Presented to the International Surgical Congress of the Association of Surgeons of Great Britain and Ireland (ASGBI),
Glasgow, UK, May 2017, and to the ASGBI Emergency Laparotomy Meeting, Birmingham, UK, November 2017

Paper accepted 2 December 2017

Published online in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.10812

Introduction be managed with an observed period of expectant manage-

More than 30 000 patients undergo an emergency laparo-
tomy each year in National Health Service (NHS) hospi-
tals in England and Wales1,2 . Acute intestinal obstruction
is the most common indication, occurring in half of all
patients3 . Surgery is associated with a 30-day mortality rate
of 15 per cent1,4 – 6 . Abdominal adhesions following pre-
vious surgery account for 60–70 per cent of small bowel
obstruction (SBO)7 , and hernias account for the major-
ity of other cases8 . Some guidelines suggest that adhesive
SBO with no evidence of peritonitis or strangulation can
ment for 3–5 days9 , and that 65–80 per cent of patients
with adhesive SBO will avoid surgery10 – 14 . However, one
hypothesis is that unnecessary delay of more than 3 days in
patients who require surgery may worsen outcomes15 .
The National Emergency Laparotomy Audit (NELA)
is an ongoing national quality improvement programme
describing the processes of care and outcomes of patients
undergoing emergency bowel surgery in NHS hospitals in
England and Wales3 . The data set contains preoperative,
perioperative and postoperative demographic and outcome

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 O. Peacock, M. G. Bassett, A. Kuryba, K. Walker, E. Davies, I. Anderson and R. S. Vohra

data of more than 40 000 patients who have undergone Emergency laparotomy
emergency laparotomy since December 2013. n =43 574

The aim of this study was to report 30-day mortality in Excluded n =22 616
patients requiring emergency laparotomy for all forms of Elective admission n =3090
Primary indication not obstruction
acute SBO. In particular, the impact of surgical timing (less n = 19526
than 24 h, 24–72 h, or more than 72 h from admission to
Primary indication
surgery) and all-cause 30-day mortality for each group was bowel obstruction
investigated. n =20 958

Excluded (not small bowel

Methods
obstruction) n =10 195

Patients aged 18 years or over requiring an emergency

laparotomy for gastrointestinal surgery in an NHS hospi- Small bowel resection
tal in England and Wales between the 1 December 2013 or adhesiolysis
n =10 763
and 30 November 2015 were identified from the NELA
database. Those requiring an emergency laparotomy dur- Excluded n =772
ing an elective admission were excluded as their manage- Incomplete timings n= 420
Surgery more than 2 weeks
ment is unlikely to be representative of patients requiring after admission n =352
an emergency laparotomy as their index procedure within
an emergency admission. Eligible for final
analysis
Patients were included in the study if the recorded indi- n =9991
cation for surgery was obstruction, and the primary proce-
dure was recorded as small bowel resection or adhesiolysis. Fig. 1 Diagram showing the process of defining patients eligible
At the point of data collection, there was not an option for final analysis
within the NELA database to record an emergency laparo-
tomy performed for SBO. Therefore, patients were consid- perioperative (operative severity, procedure performed,
ered to have undergone an emergency laparotomy for SBO operative approach, intraoperative findings, level of con-
if the primary indication for surgery was obstruction and tamination, blood loss and postoperative destination)
the recorded primary procedure was either a small bowel factors were extracted. The total number of laparotomies
resection or adhesiolysis. All causes of SBO, such as adhe- performed at each hospital was also extracted from the
sions, malignancy and Crohn’s disease, were included in the NELA data set. Time from admission to surgery was
final analysis. defined in three groups: less than 24 h, 24–72 h or more
Time to surgery was calculated by subtracting the time of than 72 h.
admission to hospital from the time of entry into operating
theatre/anaesthetic room. Patients for whom this could not
be calculated were excluded (time of entry before time of Outcome
admission or time of entry not completed). Patients whose The primary outcome measure was (all-cause) 30-day post-
time to surgery was greater than 2 weeks after admission operative mortality in or out of hospital. Date of death
were also excluded as their disease process was assumed to was obtained by linking patient records to the Office for
be different from that of patients undergoing surgery more National Statistics mortality data.
promptly.

Data extraction
Demographic and preoperative (urgency of surgery, ECG
findings, number of operations within the admission,
previous cardiac and respiratory history, ASA fitness grade,
and Portsmouth (P) POSSUM16 -predicted mortality),
physiological (serum sodium, potassium, urea, creatinine,
haemoglobin, white cell count (WCC), lactate, pulse,
systolic BP and Glasgow Coma Scale (GCS) score) and
Statistical analysis
Data were analysed using Stata® SE v14.1 statistical soft-
ware (StataCorp, College Station, Texas, USA). The χ2 test
was used to test for differences between categorical demo-
graphic variables. A multilevel logistic regression model,
the NELA risk adjustment model, developed by the Clin-
ical Effectiveness Unit of the Royal College of Surgeons
of England, was used to determine whether there was any
influence of delay to surgery on postoperative mortality,

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Thirty-day mortality after laparotomy for small bowel obstruction

Table 1 Comparison of patient demographics across the different time groups

< 24 h (n = 3112) 24–72 h (n = 3895) > 72 h (n = 2984)

Age (years)
< 65 1182 (38⋅0) 1420 (36⋅5) 1081 (36⋅2)
65–80 1159 (37⋅2) 1472 (37⋅8) 1109 (37⋅2)
> 80 771 (24⋅8) 1003 (25⋅8) 794 (26⋅6)
Sex ratio (M : F) 1417 : 1695 1608 : 2287 1196 : 1788
ASA fitness grade
I 381 (12⋅2) 375 (9⋅6) 239 (8⋅0)
II 1185 (38⋅1) 1638 (42⋅1) 1035 (34⋅7)
III 1082 (34⋅8) 1446 (37⋅1) 1242 (41⋅6)
≥ IV 464 (14⋅9) 436 (11⋅2) 468 (15⋅7)
P-POSSUM score
< 10 2221 (71⋅4) 3013 (77⋅4) 2207 (74⋅0)
10–24⋅9 528 (17⋅0) 542 (13⋅9) 488 (16⋅4)
25–49⋅9 227 (7⋅3) 222 (5⋅7) 193 (6⋅5)
≥ 50 136 (4⋅4) 118 (3⋅0) 96 (3⋅2)
Procedure
Small bowel resection 1660 (53⋅3) 1384 (35⋅5) 1007 (33⋅7)
Adhesiolysis 1452 (46⋅7) 2511 (64⋅5) 1977 (66⋅3)
Approach
Open 2796 (89⋅8) 3465 (89⋅0) 2679 (89⋅8)
Laparoscopic 316 (10⋅2) 430 (11⋅0) 305 (10⋅2)
Findings
Malignancy 126 (4⋅0) 225 (5⋅8) 229 (7⋅7)
No malignancy 2986 (96⋅0) 3670 (94⋅2) 2755 (92⋅3)
Adhesions 1773 (57⋅0) 2953 (75⋅8) 2376 (79⋅6)
No adhesions 1339 (43⋅0) 942 (24⋅2) 608 (20⋅4)
Perforation 259 (8⋅3) 264 (6⋅8) 287 (9⋅6)
No perforation 2853 (91⋅7) 3631 (93⋅2) 2697 (90⋅4)
Contamination
None 2780 (89⋅3) 3534 (90⋅7) 2617 (87⋅7)
Free gas/enteric/pus 332 (10⋅7) 361 (9⋅3) 367 (12⋅3)
Blood loss (ml)
≤ 500 2986 (96⋅0) 3744 (96⋅1) 2841 (95⋅2)
> 500 83 (2⋅7) 102 (2⋅6) 109 (3⋅7)
Missing 43 (1⋅4) 49 (1⋅3) 34 (1⋅1)
Postoperative destination
Ward 1523 (48⋅9) 2004 (51⋅5) 1438 (48⋅2)
Level 2 HDU 926 (29⋅8) 1234 (31⋅7) 1002 (33⋅6)
Level 3 ICU 661 (21⋅2) 654 (16⋅8) 540 (18⋅1)
Died in theatre 2 (0⋅1) 3 (0⋅1) 4 (0⋅1)
ONS 30-day mortality
Alive 2892 (92⋅9) 3659 (93⋅9) 2718 (91⋅1)
Dead 220 (7⋅1) 236 (6⋅1) 266 (8⋅9)
Heart rate (b.p.m.)* 88⋅3 (87, 75–100) 86⋅4 (85, 75–95) 86⋅2 (85, 75–95)
Systolic BP (mmHg)* 131⋅3 (130, 115–145) 131⋅7 (130, 118–145) 131⋅7 (130, 117–145)
Haemoglobin (g/l)* 141⋅5 (143, 128–155) 134⋅5 (135, 121–149) 126 (126, 113–139)
WCC (× 109 /l)* 13⋅1 (12⋅0, 8⋅8–15⋅6) 11⋅5 (10, 7⋅3–13⋅5) 10⋅5 (8⋅7, 6⋅4–12)
Preoperative lactate (mmol/l)* 2⋅2 (1⋅6, 1⋅1–2⋅6) 1⋅7 (1⋅3, 1⋅0–1⋅9) 1⋅4 (1⋅2, 0⋅9–1⋅6)
Sodium (mmol/l)* 136⋅2 (137, 134–139) 136⋅8 (137, 134–140) 137⋅3 (138, 135–140)
Potassium (mmol/l)* 4⋅2 (4⋅2, 3⋅8–4⋅5) 4⋅1 (4⋅1, 3⋅8–4⋅4) 4⋅0 (3⋅9, 3⋅6–4⋅3)
Urea (mmol/l)* 10⋅0 (7⋅3, 5⋅2–11⋅8) 9⋅5 (7⋅1, 4⋅9–11) 8⋅0 (6⋅0, 3⋅9–9⋅2)
Creatinine (mmol/l)* 104⋅0 (83, 66–109) 92⋅9 (77, 62–103) 85⋅1 (69, 55–91)

Values in parentheses are percentages unless indicated otherwise; *values are mean (median, i.q.r.). P-POSSUM, Portsmouth POSSUM; HDU,
high-dependency unit; ONS, Office for National Statistics; b.p.m., beats per minute; WCC, white cell count.

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 O. Peacock, M. G. Bassett, A. Kuryba, K. Walker, E. Davies, I. Anderson and R. S. Vohra

10 was included to account for clustering of 30-day postoper-

9 ative mortality by hospital. The results are reported as odds
30-day mortality (%)

8
7 ratios (ORs) with 95 per cent confidence intervals.
6 Multiple imputation by chained equations with ten
5 imputed data sets was used to account for missing values
4
3 within the patient risk-adjustment variables16,18 . The
2 imputation model included the outcome variable, all vari-
1
0
ables included in the risk-adjustment model, and a number
<24 24–72 >72 of additional variables (NELA year and haemoglobin
Time from admission to surgery (h) level). Rubin’s rules were used to pool the regression
coefficients and estimate their standard errors.
Fig. 2 All-cause 30-day mortality in the three time groups

after adjusting for patient risk factors. Adjustment was car-
ried out using this model, a multivariable logistic regres-
sion model based on P-POSSUM variables, that was devel-
oped to provide risk-adjusted all-cause 30-day postoper-
ative mortality at hospital level17 . This model includes
the following variables: age, sex, audit year of procedure,
urgency of the surgery, ECG findings, number of opera-
tions within the admission, cardiac signs, respiratory his-
tory, ASA fitness grade, serum sodium, potassium, urea,
creatinine, haemoglobin, WCC, pulse, systolic BP, GCS,
operative severity, peritoneal soiling, intraoperative blood
loss and presence of malignancy, as well as interactions
between age and ASA grade, and age and respiratory his-
tory. The model has a C-index of 0⋅863 (95 per cent c.i.
0⋅858 to 0⋅868) and was chosen over P-POSSUM because
of better calibration in patients with a predicted risk of
death greater than 15 per cent17 . The year of the patient’s
procedure (2013–2014 or 2014–2015) was included as a
variable in the risk-adjustment model to allow for over-
all changes in postoperative mortality over time across all
hospitals. For this analysis, a random intercept for hospital
Results
The NELA database contained information for 43 574
patients who had an emergency laparotomy for bowel
surgery in 188 NHS hospitals in England and Wales
between 1 December 2013 and 30 November 2015
(Fig. 1). Of these, 10 763 (24⋅7 per cent) underwent an
emergency laparotomy with adhesiolysis or resection for
SBO during the study period. Patients were excluded if
the time of surgery could not be calculated (either time of
entry to theatre was not completed (419 patients) or time
of entry was before time of admission (1 patient)). Some
352 patients had an emergency laparotomy more than
2 weeks after admission and were also excluded. Thus,
during this 2-year interval, 9991 patients were considered
eligible for final analysis.
The majority of laparotomies (6879, 68⋅9 per cent) were
performed 24 h or more after admission (Table 1). The
majority of causes of SBO were adhesion-related (71⋅1 per
cent), and only 5⋅8 per cent were caused by malignancy and
2⋅9 per cent by inflammatory bowel disease. Mean lactate,
WCC and P-POSSUM values were higher in patients who

36
Mean
32 95% limits
99·8% limits
28
30-day mortality (%)

24

20

16

12

0
25 50 75 100 125 150 175 200
No. of operations

Fig. 3 Funnel plot of adjusted 30-day mortality in 188 hospitals that performed ten or more operations for small bowel obstruction

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Thirty-day mortality after laparotomy for small bowel obstruction

Table 2 Comparison of patient demographics versus all-cause 30-day mortality within each time group

< 24 h 24–72 h > 72 h

30-day 30-day 30-day

n Deaths mortality (%) P* n Deaths mortality (%) P* n Deaths mortality (%) P*

Overall 3112 220 7⋅1 3895 236 6⋅1 2984 266 8⋅9
Age (years) < 0⋅001 < 0⋅001 < 0⋅001
< 65 1182 23 2⋅0 1420 24 1⋅7 1081 27 2⋅5
65–80 1159 88 7⋅6 1472 91 6⋅2 1109 101 9⋅1
> 80 771 109 14⋅1 1003 121 12⋅1 794 138 17⋅4
Sex 0⋅386 0⋅064 0⋅136
M 1417 94 6⋅6 1608 111 6⋅9 1196 118 9⋅9
F 1695 126 7⋅4 2287 125 5⋅5 1788 148 8⋅3
ASA fitness grade < 0⋅001 < 0⋅001 < 0⋅001
I 381 1 0⋅3 375 2 0⋅5 239 0 0⋅0
II 1185 30 2⋅5 1638 25 1⋅5 1035 29 2⋅8
III 1082 80 7⋅4 1446 98 6⋅8 1242 103 8⋅3
≥ IV 464 109 23⋅5 436 111 25⋅5 468 134 28⋅6
P-POSSUM score < 0⋅001 < 0⋅001 < 0⋅001
< 10 2221 61 2⋅8 3013 81 2⋅7 2207 106 4⋅8
10–24⋅9 528 67 12⋅7 542 62 11⋅4 488 73 15⋅0
25-49⋅9 227 44 19⋅4 222 49 22⋅1 193 50 25⋅9
≥ 50 136 48 35⋅3 118 44 37⋅3 96 37 38⋅5
Procedure < 0⋅001 < 0⋅001 < 0⋅001
Small bowel resection 1660 146 8⋅8 1384 126 9⋅1 1007 124 12⋅3
Adhesiolysis 1452 74 5⋅1 2511 110 4⋅4 1977 142 7⋅2
Approach < 0⋅001 0⋅018 0⋅127
Open 2796 213 7⋅6 3465 221 6⋅4 2679 246 9⋅2
Laparoscopic 316 7 2⋅2 430 15 3⋅5 305 20 6⋅6
Findings
Malignancy 126 14 11⋅1 0⋅071 225 23 10⋅2 0⋅007 229 33 14⋅4 0⋅002
No malignancy 2986 206 6⋅9 3670 213 5⋅8 2755 233 8⋅5
Adhesions 1773 104 5⋅9 0⋅003 2953 160 5⋅4 0⋅003 2376 194 8⋅2 0⋅005
No adhesions 1339 116 8⋅7 942 76 8⋅1 608 72 11⋅8
Perforation 259 25 9⋅7 0⋅090 264 36 13⋅6 < 0⋅001 287 43 15⋅0 < 0⋅001
No perforation 2853 195 6⋅8 3631 200 5⋅5 2697 223 8⋅3
Contamination < 0⋅001 < 0⋅001 < 0⋅001
None 2780 177 6⋅4 3534 182 5⋅2 2617 197 7⋅5
Free gas/enteric/pus 332 43 13⋅0 361 54 15⋅0 367 69 18⋅8
Blood loss (ml) 0⋅099 0⋅001 0⋅002
≤ 500 2986 209 7⋅0 3744 218 5⋅8 2841 244 8⋅6
> 500 83 10 12⋅1 102 15 14⋅7 109 20 18⋅4
Missing 43 1 2⋅3 49 3 6⋅1 34 2 5⋅9
Postoperative destination < 0⋅001 < 0⋅001 < 0⋅001
Ward 1523 39 2⋅6 2004 37 1⋅9 1438 59 4⋅1
Level 2 HDU 926 58 6⋅3 1234 71 5⋅8 1002 86 8⋅6
Level 3 ICU 661 121 18⋅3 654 125 19⋅1 540 118 21⋅9

P-POSSUM, Portsmouth POSSUM; HDU, high-dependency unit. *χ2 test.

Table 3 Multivariable analysis of unadjusted and adjusted 30-day mortality rates according to stratified time group for operative
intervention

Odds ratio

< 24 h* 24–72 h > 72 h P

Unadjusted 30-day mortality 1⋅00 0⋅85 (0⋅70, 1⋅03) 1⋅29 (1⋅07, 1⋅55) < 0⋅001
NELA risk adjustment model 1⋅00 1⋅02 (0⋅81, 1⋅27) 1⋅38 (1⋅09, 1⋅75) 0⋅007
NELA risk adjustment model + random intercept 1⋅00 1⋅01 (0⋅81, 1⋅27) 1⋅39 (1⋅09, 1⋅76) 0⋅006

Values in parentheses are 95 per cent confidence intervals. All variables adjusted for are outlined in Table 4. *Reference. NELA, National Emergency
Laparotomy Audit.

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Table 4 Logistic regression table for the National Emergency Laparotomy Audit and hospital risk adjustment model for 30-day
mortality
Time to surgery (h)
Year of surgery
Sex
Surgical urgency (h)
No. of procedures
including this one in
previous 30 days
Operative severity
ECG findings
Cardiac signs/chest X-ray
appearance
GCS score
Presence of malignancy
Peritoneal soiling
Blood loss (ml)
Serum sodium (mmol/l)
Systolic BP (mmHg)
Serum WCC (× 109 /l)
Values in parentheses are 95 per cent confidence intervals. AF, atrial fibrillation; b.p.m., beats per minute; GCS, Glasgow Coma Scale; WCC, white cell
count.
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O. Peacock, M. G. Bassett, A. Kuryba, K. Walker, E. Davies, I. Anderson and R. S. Vohra
Odds ratio Odds ratio
< 24 1⋅00 (reference) Serum urea (mmol/l) 2 0⋅88 (0⋅45, 1⋅72)
24–72 1⋅02 (0⋅81, 1⋅27) 5 0⋅91 (0⋅74, 1⋅11)
> 72 1⋅39 (1⋅09, 1⋅76) 10 1⋅00 (reference)
2013–2014 1⋅00 (reference) 20 1⋅17 (1⋅03, 1⋅34)
2014–2015 0⋅82 (0⋅69, 0⋅98) 30 1⋅33 (1⋅05, 1⋅67)
M 1⋅00 (reference) Serum creatinine 40 1⋅24 (0⋅72, 2⋅11)
F 0⋅95 (0⋅79, 1⋅14) (mmol/l) 70 1⋅07 (0⋅84, 1⋅35)
> 18 1⋅00 (reference) 100 1⋅00 (reference)
6–18 1⋅11 (0⋅83, 1⋅47) 150 0⋅96 (0⋅84, 1⋅09)
2–6 1⋅18 (0⋅89, 1⋅57) 200 0⋅95 (0⋅78, 1⋅15)
<2 1⋅52 (1⋅02, 2⋅25) Serum potassium 3 1⋅06 (0⋅80, 1⋅41)
1 1⋅00 (reference) (mmol/l) 3⋅5 0⋅99 (0⋅88, 1⋅10)
2 1⋅00 (0⋅69, 1⋅46) 4 1⋅00 (reference)
>2 0⋅72 (0⋅19, 2⋅64) 4⋅5 1⋅11 (1⋅03, 1⋅19)
Major 1⋅00 (reference) 5 1⋅34 (1⋅13, 1⋅59)
Major+ 1⋅35 (1⋅08, 1⋅68) Pulse rate (b.p.m.) 60 0⋅58 (0⋅44, 0⋅76)
No abnormalities 1⋅00 (reference) 70 0⋅71 (0⋅61, 0⋅82)
AF rate 60–90 b.p.m. 1⋅18 (0⋅86, 1⋅64) 90 1⋅00 (reference)
AF rate > 90 b.p.m. or 1⋅01 (0⋅82, 1⋅25) 120 1⋅48 (1⋅23, 1⋅77)
abnormal
No cardiac failure 1⋅00 (reference) 140 1⋅75 (1⋅14, 2⋅70)
Antihypertensive therapy 1⋅25 (1⋅02, 1⋅54) Age (years) 50 0⋅26 (0⋅14, 0⋅44)
Borderline cardiomegaly 1⋅63 (1⋅20, 2⋅22) ASA grade I or II 60 0⋅48 (0⋅38, 0⋅59)
Cardiomegaly 1⋅48 (0⋅88, 2⋅48) 70 1⋅00 (reference)
13–15 1⋅00 (reference) 80 2⋅34 (1⋅88, 2⋅92)
9–12 2⋅86 (1⋅30, 6⋅28) 90 6⋅14 (3⋅51, 10⋅74)
3–8 3⋅71 (1⋅83, 7⋅53) Age (years) 50 0⋅31 (0⋅19, 0⋅52)
None 1⋅00 (reference) ASA grade III 60 0⋅57 (0⋅47, 0⋅69)
Primary 1⋅74 (1⋅06, 2⋅85) 70 1⋅00 (reference)
Nodal metastases 2⋅18 (1⋅22, 3⋅89) 80 1⋅70 (1⋅48, 1⋅95)
Distant 3⋅64 (2⋅51, 5⋅28) 90 2⋅78 (1⋅96, 3⋅95)
None 1⋅00 (reference) Age (years) 50 0⋅62 (0⋅48, 0⋅81)
Serous fluid 1⋅10 (0⋅91, 1⋅34) ASA grade IV 60 0⋅75 (0⋅67, 0⋅84)
Localized pus 1⋅14 (0⋅69, 1⋅90) 70 1⋅00 (reference)
Free bowel content, pus or 2⋅06 (1⋅58, 2⋅70) 80 1⋅70 (1⋅48, 1⋅95)
blood
< 100 1⋅00 (reference) 90 2⋅78 (1⋅96, 3⋅95)
101–500 1⋅20 (0⋅99, 1⋅44) Age (years) 50 0⋅62 (0⋅48, 0⋅81)
501–999 1⋅88 (1⋅20, 2⋅94) ASA grade V 60 0⋅75 (0⋅67, 0⋅84)
≥ 1000 2⋅64 (1⋅14, 6⋅12) 70 1⋅00 (reference)
125 1⋅19 (0⋅89, 1⋅59) 80 3⋅48 (1⋅50, 8⋅12)
130 1⋅13 (0⋅90, 1⋅42) 90 31⋅25 (3⋅03, 321⋅88)
140 1⋅00 (reference) Respiratory history None 1⋅00 (reference)
150 2⋅30 (1⋅06, 5⋅01) ASA grade I or II Mild dyspnoea 2⋅15 (1⋅22, 3⋅79)
80 1⋅74 (1⋅35, 2⋅25) Limiting and at rest 6⋅75 (3⋅14, 14⋅48)
100 1⋅24 (1⋅13, 1⋅37) Respiratory history None 1⋅00 (reference)
120 1⋅00 (reference) ASA grade III Mild dyspnoea 1⋅35 (0⋅99, 1⋅83)
150 0⋅91 (0⋅80, 1⋅03) Limiting and at rest 2⋅02 (1⋅45, 2⋅80)
180 1⋅08 (0⋅74, 1⋅59) Respiratory history None 1⋅00 (reference)
5 0⋅96 (0⋅86, 1⋅08) ASA grade IV Mild dyspnoea 1⋅60 (1⋅10, 2⋅35)
10 1⋅00 (reference) Limiting and at rest 2⋅17 (1⋅54, 3⋅05)
20 1⋅03 (0⋅89, 1⋅18) Respiratory history None 1⋅00 (reference)
30 0⋅99 (0⋅68, 1⋅44) ASA grade V Mild dyspnoea 0⋅83 (0⋅11, 6⋅25)
40 0⋅91 (0⋅39, 2⋅09) Limiting and at rest 5⋅09 (1⋅00, 25⋅79)
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Thirty-day mortality after laparotomy for small bowel obstruction
had surgery less than 24 h after admission, and a higher
proportion of small bowel resections was also performed
in this group.
The overall 30-day mortality rate was 7⋅2 per cent (722
of the 9991 patients). The unadjusted 30-day mortality rate
in the group of patients with inaccuracies of data entry for
surgical timing (420 of 10 763 patients, 3⋅9 per cent) was
5⋅7 per cent.
Despite patients treated within 24 h being the
highest-risk group, their unadjusted 30-day mortality
rate was only slightly higher than that in patients treated
in 24–72 h; the rate in the group of patients treated more
than 72 h after admission was substantially higher (Fig. 2).
The adjusted 30-day mortality rate by hospital perform-
ing ten or more laparotomies for SBO did not demonstrate
any greater variation between hospitals than would be
expected by chance alone (Fig. 3). Of the 188 hospitals
compared, nine (4⋅8 per cent) would be expected to fall
outside the inner funnel limits by chance alone, and only
six (3⋅2 per cent) were observed. There were no outlying
hospitals.
The unadjusted all-cause 30-day mortality rate was
significantly worse with increasing age, ASA grade,
P-POSSUM score, level of contamination, requirement
for small bowel resection and postoperative level of care
within each time group (Table 2). When most variables
were considered, 30-day mortality was generally higher in
the group that had surgery more than 72 h after admission.
Multilevel logistic regression model
Comparison of unadjusted 30-day mortality rates in the
groups of patients having surgery less than 24 h, 24–72 h
and more than 72 h after admission demonstrated a sig-
nificant increase in mortality proportional to the time
taken to perform the operation (P < 0⋅001) (Table 3). Using
patient demographic, surgical and physiological variables
in the NELA data set (Table 4), the NELA risk adjust-
ment model was used to derive the risk-adjusted hospital
30-day mortality rates for each time group (Table 3). There
were 1138 patients (11⋅4 per cent) missing one or more
risk-adjustment variables that were accounted for by multi-
ple imputation using chained equations with ten imputed
data sets.
There was strong statistical evidence of a difference
in 30-day mortality between the time groups (Table 3).
There was little difference in the adjusted 30-day mor-
tality between patients having surgery less than 24 h after
admission for SBO and those in the 24–72 h group, but
mortality was substantially higher when the operation was
done more than 72 h after admission (OR 1⋅39, 95 per cent
c.i. 1⋅09 to 1⋅76; P = 0⋅006).
© 2018 BJS Society Ltd
Published by John Wiley & Sons Ltd
Discussion
This study of the NELA database of emergency laparo-
tomy for all forms of SBO has shown that the timing of
laparotomy is an independent predictor of all-cause 30-day
mortality. Within each time group studied, increasing
mortality was associated with increasing age, ASA grade,
P-POSSUM score, level of contamination and whether a
small bowel resection was required as expected. Patients
who had surgery within 24 h represent a different cohort
of SBO, presenting with signs of strangulation or periton-
ism (or a cause of SBO unlikely to settle with conservative
management), as noted by the greater proportion requir-
ing a small bowel resection and higher mean lactate, WCC
and P-POSSUM values in this group. Patients who had an
operation more than 72 h after hospital admission had a 39
per cent higher mortality risk than those who had surgery
less than 24 h from admission, after adjustment for patient
demographics and physiological factors (OR 1⋅39, 95 per
cent c.i. 1⋅09 to 1⋅76). This increase in mortality was not
linked to hospital factors.
Previous studies have focused on patients with adhesive
SBO. In the present study, all forms of SBO requiring adhe-
siolysis or small bowel resection were included. Although
this produces a heterogeneous group, it is more represen-
tative of actual clinical practice for SBO. There are several
other limitations to this study, which must be considered.
This was a retrospective observational study, and the ret-
rospective nature probably accounts for the large number
of patients with missing values (11⋅4 per cent) within the
data set that were accounted for using multiple imputation
by chained equations to address the issue of bias. NELA
is reliant on data entry from multiple sources, and this is
another reason for the high number of missing variables.
The database included data only for patients who required
an emergency operative intervention for SBO (with adhe-
siolysis or small bowel resection), not for those with SBO
that settled with conservative management or required
another form of operative intervention. The study was not
designed to evaluate which patients actually required an
operation for SBO. The proportion of patients who were
turned down for surgery because of fitness or patient choice
is unknown. It is also possible that surgical delay reflects a
reluctance to intervene surgically with regard to particular
patient or institutional factors, which cannot be captured
by this database. However, the database collects a com-
prehensive list of patient variables, enabling risk-adjusted
outcomes and comparison of the study groups to reduce
selection bias. The prospective National Audit of Small
Bowel Obstruction (NASBO)3 may address some of the
limitations of this study.
www.bjs.co.uk BJS
 O. Peacock, M. G. Bassett, A. Kuryba, K. Walker, E. Davies, I. Anderson and R. S. Vohra
Currently, there are no UK guidelines for the manage-
ment of SBO. The World Society of Emergency Surgery
has produced guidelines9 for the management of adhesive
SBO, which advocate, in the absence of signs of strangu-
lation or peritonism, a period of non-operative manage-
ment for up to 72 h. However, there are variations in this
suggested non-operative management period, with other
guidelines and studies advocating up to 5 days for adhesive
SBO19,20 . In contrast, Teixeira and colleagues15 demon-
strated that patients with adhesive SBO whose operation
was delayed by 24 h or more after admission had signifi-
cantly higher risk-adjusted mortality than patients who had
early (at less than 24 h) surgical intervention.
Acknowledgements
O.P. and M.G.B. are joint first authors of this publication.
The authors thank all the members of the NELA project
team who prepared the first- and second-year NELA
reports for their contribution to this study: D. Cromwell,
N. Eugene, M. Grocott, C. Johnston, J. Lourtie, R.
Moonesinghe, D. Murray, D. Papadimitriou, C. Peden, T.
Poulton, M. Cripps, S. Drake and M. Oliver.
NELA was commissioned by the Healthcare Quality
Improvement Partnership (HQIP) and funded by NHS
England and the Welsh Government.
Disclosure: The authors declare no conflict of interest.
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