Water-soluble contrast in the management of adhesive small-bowel obstruction: a Canadian centre's experience with guideline development and implementation

Background: Orally administered water-soluble contrast (WSC) can track resolution of small-bowel obstruction (SBO), but no universal pathway for its use exists. We developed and implemented an evidence-based guideline for the use of WSC in the management of adhesive SBO, to be implemented across hospitals affiliated with the University of Toronto. Methods: We performed a systematic review and created a clinical practice guideline for WSC use in the management of adhesive SBO. The guideline was approved through consensus by an expert panel and implemented in 2018. We performed a prospective cohort study of guideline implementation at 1 pilot site (a large academic tertiary care centre), facilitated by the centre's acute care general surgery service. Primary outcomes included compliance with the guideline and hospital length of stay (LOS). Secondary outcomes included rates of failure of nonoperative management, morbidity, mortality and readmission for recurrence of SBO within 1 year. Patients with adhesive SBO admitted in 2016 served as a control cohort. Results: We analyzed the data for 152 patients with adhesive SBO admitted to the centre, 65 in 2016 (historical cohort), 56 in January-June 2018 (transitional cohort) and 31 in July-December 2018 (implementation cohort). There was a significant increase in compliance with the WSC protocol in 2018, with the proportion of patients receiving WSC increasing from 45% (n = 25) in the transitional cohort to 71% (n = 22) in the implementation cohort (p < 0.001). The median LOS did not differ across the cohorts (p = 0.06). There was a significantly lower readmission rate in the transitional and implementation cohorts (13 [23%] and 9 [29%], respectively) than in the historical cohort (29 [45%]) (p = 0.04). Among patients assigned to nonoperative management initially, a significantly higher proportion of those who received WSC than those who did not receive WSC went on to undergo surgery (14.6% v. 3.6%, p = 0.01), with no difference in median time to surgery (p = 0.2). Conclusion: An evidence-based guideline for WSC use in SBO management was successfully developed and implemented; no difference in LOS or time to surgery was seen after implementation, but rates of immediate operation increased and readmission rates decreased. Our experience shows that implementation of an evidencebased clinical practice guideline is feasible through multidisciplinary efforts and coordination. Contexte : La resolution de l'occlusion de l'intestin grele (OIG) peut etre surveillee par l'administration de produit de contraste hydrosoluble (PCH) par voie orale, mais il n'existe pas de protocole universel. Afin de pallier cette lacune, nous avons cree et mis en oeuvre une ligne directrice factuelle, destinee aux hopitaux afflies a l'Universite de Toronto, pour l'administration de PCH dans la prise en charge de l'OIG sur adherences. Methodes : Nous avons realise une revue systematique puis elabore un guide de pratique clinique, valide par consensus par un comite d'experts avant d'etre mis en oeuvre en 2018. Une etude de cohorte prospective sur sa mise en oeuvre a ete conduite au service de chirurgie generale d'urgence d'un etablissement pilote (grand centre universitaire de soins tertiaires). Les indicateurs de resultats principaux etaient l'adhesion au guide et la duree d'hospitalisation; les secondaires comprenaient le taux d'echec de la prise en charge conservatrice, la morbidite, la mortalite et le taux de readmission pour recidive d'OIG dans l'annee. La cohorte temoin se composait de patients hospitalises en 2016 pour une OIG sur adherences. Resultats : Nous avons analyse les donnees de 152 patients atteints d'OIG sur adherences admis au centre : 65 en 2016 (cohorte historique), 56 entre janvier et juin 2018 (cohorte de transition) et 31 entre juillet et decembre 2018 (cohorte d'appli cation). Le respect du protocole d'administration de PCH a largement augmente en 2018 : le pourcentage est passe de 45 % (n = 25) dans la cohorte de transition a 71 % (n = 22) dans la cohorte d'application (p < 0,001). La duree d'hospita lisation mediane est restee identique (p = 0,06), mais le taux de readmission etait beaucoup plus faible dans les cohortes de transition et d'application (13 [23 %] et 9 [29 %]) que dans la cohorte historique (29 [45 %]) (p = 0,04). L'administration de PCH dans le cadre de la prise en charge conservatrice de premiere intention est associee a une augmentation significative du taux de traitement chirurgical (14,6 % contre 3,6 % sans PCH; p = 0,01), sans variation du delai avant l'intervention (p = 0,2). Conclusion : Une ligne directrice factuelle sur l'administration de PCH dans la prise en charge de l'OIG a ete concue et mise en oeuvre. Aucune variation de la duree d'hospi talisation ou du delai avant l'intervention chirurgicale n'a ete observee apres l'application. Toutefois, le taux d'intervention chirurgicale a court terme a augmente tandis que le taux de readmission a diminue. Notre experience montre que les efforts et la coordination pluridisciplinaires permettent d'appliquer un guide de pratique clinique fonde sur des donnees probantes.
Adhesions after abdominal surgery are the most common cause of small-bowel obstruction (SBO). (1-3) Surgical intervention for SBO is sometimes necessary, and delays in treatment can lead to illness and [...]