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Open Access

Current management of malignant bowel obstructions: a survey of acute care surgeons and surgical oncologists

Josh Bleicher, Laura A Lambert, Courtney L Scaife, Alexander Colonna
DOI: 10.1136/tsaco-2021-000755 Published 16 June 2021
Josh Bleicher
1General Surgery, University of Utah Health, Salt Lake City, Utah, USA
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Laura A Lambert
1General Surgery, University of Utah Health, Salt Lake City, Utah, USA
2Surgical Oncology, Huntsman Cancer Institute at the University of Utah, Salt Lake City, Utah, USA
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Courtney L Scaife
1General Surgery, University of Utah Health, Salt Lake City, Utah, USA
2Surgical Oncology, Huntsman Cancer Institute at the University of Utah, Salt Lake City, Utah, USA
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Alexander Colonna
1General Surgery, University of Utah Health, Salt Lake City, Utah, USA
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    Figure 1

    Adjusted rates of participants selecting they would be ‘likely’ or ‘very likely’ to offer an operation to the patient in each case, by surgeon specialty. ACS, acute care surgeon; SO, surgical oncologist.

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  • Table 1

    Characteristics of the surgeon respondents and their current practices, reported as n (%)

    VariableCategoryAll participants n (%)Acute care surgeons (n=197)Surgical oncologists (n=119)P value
    Age, years (median, IQR) 45 (39–53)43 (38–52)48 (42–57)<0.01
    GenderFemale78 (24.7)54 (27.4)24 (20.2)0.25
     Male237 (75.0)142 (72.1)95 (79.8)
     Other1 (0.3)1 (0.5)0
    Fellowship trainingNone26 (8.2)22 (11.2)4 (3.4)<0.01
     Surgical oncology107 (33.9)3 (1.5)104 (87.4)
     Trauma/acute care171 (54.1)170 (86.3)1 (0.8)
     Other12 (3.8)2 (1.0)10 (8.4)
    Current practiceSurgical oncology97 (30.7)–97 (81.5)–
     Trauma and/or acute care197 (62.3)197 (100)–
     Peritoneal surface malignancy22 (7.0)–22 (18.5)
    Years in practice<583 (26.3)64 (32.5)19 (16.0)<0.01
     5–1079 (25.0)52 (26,4)27 (22.7)
     11–1542 (13.3)19 (9.6)23 (19.3)
     16–2040 (12.7)24 (12.2)16 (13.5)
     21–2532 (10.1)18 (9.1)14 (11.8)
     >2540 (12.7)20 (10.2)20 (16.8)
    Type of practiceAcademic187 (59.2)102 (51.8)85 (71.4)<0.01
     Private50 (15.8)37 (18.8)13 (10.9)
     Both private and academic64 (20.3)47 (23.9)17 (14.3)
     Other15 (4.8)11 (5.6)4 (3.4)
    LocationNortheast71 (22.5)37 (18.8)34 (28.6)0.07
     Southeast85 (26.9)48 (24.4)37 (31.1)
     Midwest80 (25.3)56 (28.4)24 (20.2)
     Southern24 (7.6)15 (7.6)9 (7.6)
     Mountain West25 (7.9)20 (10.2)5 (4.2)
     Pacific31 (9.8)21 (10.7)10 (8.4)
    RuralityUrban188 (59.5)113 (57.4)75 (63.0)0.28
     Suburban89 (28.2)57 (28.9)32 (26.9)
     Rural32 (10.1)24 (12.2)8 (6.7)
     Other7 (2.2)3 (1.5)4 (3.4)
  • Table 2

    Univariable analysis of factors predictive of participants selecting they would be ‘likely’ or ‘very likely’ to offer an operation to the patient in each case

     
     
    Case 1 (n=316)Case 2 (n=290)Case 3 (n=273)
    LikelyP valueLikelyP valueLikelyP value
    Gender
     Female57 (73.1)0.32429 (41.4)0.52528 (42.4)0.351
     Male191 (80.6) 95 (43.4) 102 (49.5) 
    Fellowship training
     Surgical oncology94 (87.9)0.00252 (51.5)0.02261 (61.0)0.002
     Trauma/acute care124 (72.5) 57 (37.0) 57 (40.4) 
    Current practice
     Surgical oncology103 (86.6)0.00957 (50.9)0.03466 (59.5)0.002
     Trauma/acute care146 (74.1) 68 (38.2) 65 (40.1) 
    Years in practice
     <561 (73.5)0.06820 (28.6)0.04025 (38.5)0.228
     5–1058 (73.4) 30 (40.0) 34 (47.2) 
     11–1532 (76.2) 21 (55.3) 19 (54.3) 
     16–2034 (85.0) 18 (46.2) 17 (44.7) 
     21–2526 (81.3) 15 (50.0) 14 (48.3) 
     >2538 (95.0) 21 (55.3) 22 (64.7) 
    Type of practice
     Academic151 (80.8)0.45876 (44.2)0.92479 (47.9)0.775
     Private38 (76.0) 20 (40.8) 20 (45.5) 
    Location
     Northeast61 (85.9)0.05134 (54.0)0.09430 (51.7)0.416
     Southeast70 (82.4) 34 (44.2) 36 (49.3) 
     Midwest64 (80.0) 35 (46.7) 37 (52.8) 
     Southern14 (58.3) 7 (31.8) 7 (33.3) 
     Mountain West17 (68.0) 6 (26.1) 11 (50.0) 
     Pacific23 (74.2) 9 (30.0) 10 (34.5) 
    Rurality
     Urban144 (76.6)0.46168 (38.9)0.10378 (47.6)0.478
     Suburban74 (83.2) 39 (48.8) 36 (46.8) 
     Rural25 (78.1) 16 (57.1) 15 (60.0) 
    • Individual cases were analyzed separately. Participant selections were averaged across all scenarios within each case.

  • Table 3

    Univariable and multivariable analysis of factors predictive of participants selecting they would be ‘likely’ or ‘very likely’ to offer an operation to the patient in each case; participant selections were averaged across all scenarios across all cases

     
     
    UnivariableMultivariable*
    n (%)P valueIncidence rate ratio (95% CI)P value
    Gender
     Female30 (45.5)0.241
     Male114 (55.3)  
    Fellowship training
     Surgical oncology73 (73.0)<0.001Excluded†
     Trauma/acute care55 (39.0)  
    Current practice
     Surgical oncology78 (70.3)<0.001Reference–
     Trauma/acute care67 (41.4) 0.61 (0.49 to 0.76)<0.001
    Years in practice
     <527 (41.5)0.0010.66 (0.47 to 0.91)0.011
     5–1032 (44.4) 0.65 (0.48 to 0.89)0.008
     11–1525 (71.4) 0.90 (0.68 to 1.19)0.462
     16–2017 (44.7) 0.61 (0.42 to 0.88)0.009
     21–2517 (58.6) 0.78 (0.56 to 1.09)0.150
     >2527 (79.4) Reference–
    Type of practice
     Academic87 (52.7)0.452
     Private26 (59.1)  
    Location
     Northeast38 (65.5)0.101Reference–
     Southeast39 (53.4) 0.93 (0.70 to 1.22)0.586
     Midwest39 (55.7) 1.02 (0.79 to 1.32)0.880
     Southern7 (33.3) 0.59 (0.32 to 1.08)0.087
     Mountain West10 (45.5) 1.06 (0.66 to 1.71)0.818
     Pacific12 (41.4) 0.79 (0.51 to 1.23)0.301
    Rurality
     Urban77 (47.0)0.017Reference–
     Suburban49 (63.6) 1.34 (1.06 to 1.70)0.014
     Rural17 (68.0) 1.56 (1.14 to 2.13)0.006
    • *All variables with p<0.20 on univariable analysis included in multivariable analysis.

    • †Fellowship training excluded from multivariable analysis as this variable is confounding with the variable describing current practice.

  • Table 4

    Responses to individual case scenarios by practice type

    TotalSurgical oncologistsAcute care surgeonsP value
    Case 1: a 50-year-old man with colon cancer 36 months from resection and adjuvant chemotherapy with a single point of obstruction in the terminal ileum. He has a single, 3 cm metastatic lesion in his liver, but no other metastatic disease.
     Base scenario94.94 (4.70±0.64)95.80 (4.83±0.48)94.42 (4.62±0.71)0.587
     Multiple hepatic metastases82.91 (4.16±0.97)91.60 (4.48±0.72)77.66 (3.97±1.04)0.001
     Pulmonary metastases71.84 (3.87±1.16)84.87 (4.31±0.83)63.96 (3.60±1.24)<0.001
     Shorter disease-free interval86.08 (4.29±0.84)87.39 (4.39±0.78)85.28 (4.23±0.87)0.599
     Omental metastases63.92 (3.68±1.11)78.15 (4.05±0.95)55.33 (3.46±1.15)<0.001
     Pancreatic adenocarcinoma46.84 (3.22±1.24)47.06 (3.24±1.22)46.70 (3.22±1.26)0.951
    Case 2: a 45-year-old woman with epithelial ovarian cancer 36 months from optimal debulking and adjuvant chemotherapy with a single point of obstruction in the small bowel from carcinomatosis. She has three peritoneal implants, but no other metastatic disease.
     Base scenario74.48 (3.97±1.12)90.18 (4.29±0.86)64.61 (3.60±1.19)<0.001
     Ascites present57.24 (3.41±1.19)74.11 (3.81±1.04)46.63 (3.16±1.21)<0.001
     Multiple areas of obstruction22.76 (2.54±1.17)26.79 (2.65±1.13)20.22 (2.48±1.18)0.194
     2nd episode of obstruction24.48 (2.63±1.14)25.00 (2.63±1.07)24.16 (2.65±1.18)0.871
     Shorter disease-free interval47.59 (3.24±1.13)50.00 (3.29±1.03)46.07 (3.22±1.18)0.514
     Melanoma73.10 (3.88±1.15)87.50 (4.27±0.99)64.04 (3.63±1.19)<0.001
    Case 3: a 62-year-old woman with a carcinoid tumor 48 months from resection of an isolated mesenteric mass with a single point of obstruction in the jejunum from an unresectable central mesenteric mass.
     Base scenario83.88 (4.21±0.93)90.99 (4.50±0.74)79.01 (4.01±0.99)0.008
     Stable hepatic metastases75.09 (3.94±1.00)87.39 (4.33±0.81)66.67 (3.67±1.03)<0.001
     2nd episode of obstruction44.69 (3.22±1.11)54.95 (3.41±1.03)37.65 (3.08±1.15)0.005
     Shorter disease-free interval32.97 (2.82±1.23)36.94 (2.91±1.25)30.25 (2.76±1.21)0.248
     Multiple areas of obstruction32.60 (2.90±1.15)39.64 (3.09±1.12)27.78 (2.78±1.15)0.04
    • All patients were described as being otherwise healthy with good functional status. Patients had no signs of peritonitis or other indications for emergent surgery, although participants were informed that the obstruction would not resolve with conservative management. Responses reported as percent responding ‘likely’ or ‘very likely’ to offer an operation (mean response on the 5-point Likert scale±SD). Full case scenarios are shown in online supplemental file 1.

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    [tsaco-2021-000755supp001.pdf]

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    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

    • Data supplement 1
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Current management of malignant bowel obstructions: a survey of acute care surgeons and surgical oncologists
Josh Bleicher, Laura A Lambert, Courtney L Scaife, Alexander Colonna
Trauma Surg Acute Care Open Jun 2021, 6 (1) e000755; DOI: 10.1136/tsaco-2021-000755

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Current management of malignant bowel obstructions: a survey of acute care surgeons and surgical oncologists
Josh Bleicher, Laura A Lambert, Courtney L Scaife, Alexander Colonna
Trauma Surg Acute Care Open Jun 2021, 6 (1) e000755; DOI: 10.1136/tsaco-2021-000755
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Current management of malignant bowel obstructions: a survey of acute care surgeons and surgical oncologists
Josh Bleicher, Laura A Lambert, Courtney L Scaife, Alexander Colonna
Trauma Surgery & Acute Care Open Jun 2021, 6 (1) e000755; DOI: 10.1136/tsaco-2021-000755
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