A Danish Audit of Small Bowel Obstruction
Conditions: Bowel Obstruction Small
Sponsor: Danish Small Bowel Obstruction Collaborative

 
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Project title 
A Danish Audit of Small Bowel 
Obstruction 
 
Participating Centres  
Bispebjerg Hospital; 
Herlev Hospital; 
Hillerod Hospital; 
Hvidovre Hospital; 
Slagelse Hospital; 
Zealand University Hospital, Køge; 
Principal Investigator 
Henry G Smith 
Abdominal Center K, Bispebjerg Hospital 
Henry.george.smith@regionh.dk 
 
Local Investigators 
Bispebjerg Hospital 
Liv Bjerre Nielsen 
liv.bjerre.nielsen@regionh.dk  
Herlev Hospital 
Thomas Korgaard Jensen 
Thomas.korgaard.jensen@regionh.dk 
Hillerod Hospital 
Anders Peter Skovsen 
Anders.Peter.Skovesen@regionh.dk 
Hvidovre Hospital 
Ida Lolle 
Ida.lolle.01@regionh.dk 
Slagelse Hospital 
Kenneth Rütz 
keru@regionsjaelland.dk 
Zealand University 
Hospital, Køge 
Mette Astrup Tolver 
meam@regionsjaelland.dk 
 
 
 
 
 

 
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1. Background 
Small bowel obstruction (SBO) is a common and potentially life-threatening acute 
surgical condition. A minority of patients present with a clear indication for urgent 
surgical intervention, either on the basis of clinical or radiological assessment 
(clinical signs of peritonitis/sepsis; suspicion of bowel ischaemia; closed loop 
obstructions; irreducible herniae etc.). However, the optimal management of the 
remaining patients, the majority of whom present with SBO caused by abdominal 
adhesions, remains a topic of international debate.  
 
In the United Kingdom, the majority of patients with adhesional SBO are managed 
non-operatively unless a clear indication for acute surgery is found. This approach 
is based on both the rationale that the acute presentation may resolve with non-
operative management and that surgical intervention may lead to the 
development of further adhesions, leading to further episodes of SBO in the future 
[1]. The management of adhesional SBO in Denmark is more surgically aggressive, 
where the majority of patients tend to undergo an acute or urgent operation 
unless there is a clear contraindication to surgery. The rationale for this approach 
is that the patient has been admitted with clinically significant adhesions, which 
will continue to cause intermittent obstruction unless divided. Although there is 
some evidence to support a more aggressive approach, with a recent retrospective 
study from Canada demonstrating fewer future episodes of SBO in patients 
undergoing operative management, the benefit of the acute surgical intervention 
must be balanced with the risks of peri-operative morbidity [2]. 
 

 
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In 2017, a snapshot audit of the outcomes of patients admitted with SBO in the UK 
was 
performed, 
including 
over 
2,400 
patients 
(https://www.acpgbi.org.uk/content/uploads/2017/12/NASBO-REPORT-
2017.pdf) [3]. This audit not only identified variations in the management of 
patients with SBO but also identified several key recommendations to improve the 
outcomes of this patient group including earlier use of CT scanning, a more 
standardised approach to non-operative management, a greater focus on 
nutritional status and optimisation of peri- and post-operative care.  
 
Standardised acute care bundles are now commonplace in Denmark. With a focus 
on early identification of high-risk surgical patients, these pathways facilitate 
early radiological diagnoses, pre/peri-operative patient optimisation and early, 
appropriate surgical intervention. Although one of the key patient groups 
identified by these pathways, the outcomes of patients admitted with SBO are not 
routinely audited, which limits further optimisation of patient care. 
 
This quality assessment study aims to provide robust data on the outcomes of 
patients admitted with SBO in Region Øst in order to identify areas in need of 
improvement and further research. 
 
 

 
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2. Objectives 
To perform a prospective quality assessment study of the outcomes of 
management of patients admitted with SBO in Region Øst. 
 
Primary objective 
• 30-day morbidity and mortality rates of patients admitted with SBO 
 
Secondary objectives 
• 90-day mortality rates of patients admitted with SBO  
• To identify the most common causes of SBO in this patient cohort 
• To investigate potential variability in the diagnosis and peri-operative 
management of these patients 
• To determine what proportion of patients undergo non-operative vs 
operative management of SBO 
• To determine the success rate of non-operative management in patients 
with SBO and identify predictors of success/failure 
• To determine the incidence and consequence of acute kidney injury in 
patients with SBO 
• To determine the incidence and consequence of malnourishment in 
patients with SBO 
 
Tertiary objectives 
• To identify areas of management of patients with SBO requiring 
optimisation 

 
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• To determine the incidence of recurrent SBO at 1-year, 3-year and 5-year 
follow-up. 
 
 
3. Methods  
This is a prospective quality assessment study that will be performed across 6 
acute general surgical hospitals in Region Øst (Bispebjerg, Herlev, Hillerød, 
Hvidovre, Køge, Slagelse). Consecutive consenting patients admitted with a 
diagnosis with SBO will be included from each site over a 3-month period.  
 
Eligible patients will be identified using the following methods during the study 
period: 
• Screening of acute theatre lists 
• A data extraction of all diagnoses of ileus (DK567) or subileus (DK566C) 
from the emergency department and inpatient wards 
• A data extraction of from the radiology department of all patients 
undergoing a small bowel follow-through with water soluble contrast 
 
In the initial study phase, each patient will be followed for 90 days after diagnosis. 
Relevant clinicopathological variables will be extracted from electronic patient 
records, which will be entered in a pseudo-anonymised form into a purpose-built 
REDCap database using a site-specific study number that is individual for each 
patient. Patient CPR numbers will be stored on secure folders at each site to allow 
data validation as necessary. The first analysis of the dataset will be performed 

 
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once all included patients have reached 90 days follow-up. Patient journals will be 
accessed again at 1, 3 and 5 years after diagnosis to investigate the tertiary 
objectives outlined above. 
 
As this study is purely observational, no alterations to standard patient care will 
be made. The study will be run by a steering committee including senior surgeons 
acting as local principal investigators from each of the participating centres. An 
additional collaborator from each centre will be responsible for patient 
identification and data collection. It is estimated that each centre will identify 
between 20-30 eligible patients each month, giving a final cohort size of 360-540 
patients. 
 
4. Patients 
Inclusion criteria 
• Age ≥ 18 years old 
• Radiological or clinical diagnosis of mechanical SBO made from 00:00 on 
22/02/2021 until 23:59 on 21/05/2021 
• Admitted to one of the 6 participating centres 
 
Exclusion criteria 
• SBO presenting within 30 days of a previous abdominal operation 
 

 
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5. Risks and side effects of study 
This is a prospective observational study of patient outcomes. As such, there are 
no risks or potential side effects for the patients that will be included. 
 
6. Access to patient journals 
Patient journals will be accessed in order to extract relevant clinicopathological 
data. The local principal investigators are responsible for the relevant study 
approvals, which should be made as a quality assessment project. As described 
above, patient journals will be accessed at 4 timepoints during this study: 
• Period 1 – from diagnosis until 90 days follow-up 
• Period 2 – 1 year after diagnosis 
• Period 3 – 3 years after diagnosis 
• Period 4 – 5 years after diagnosis 
 
7. Data storage and security 
Patient identifiable data will be stored in a secure folder at each specific site. The 
local principal investigators will be responsible for establishing and maintaining 
these folders. Only those directly involved with the study will have access to these 
files. Relevant clinicopathological variables will be entered into a purpose-built 
REDCap database in an anonymised form. Each site will have a specific REDCap 
login with site-specific patient study numbers. 
Any patient identifiable data will be permanently deleted within 5 years of the 
study start (i.e. 31/12/2026). 
 

 
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8. Publication of results 
This study is registered on www.clinicaltrials.gov – NCT04750811. The results of 
the study will be published in scientific journals and presented at international 
conferences.  
 
 
 

 
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9. References 
[1] Lee MJ, Sayers AE, Wilson TR, Acheson AG, Anderson ID, Fearnhead NS, et al. 
Current management of small bowel obstruction in the UK: results from the 
National Audit of Small Bowel Obstruction clinical practice survey. Colorectal Dis. 
2018;20:623-30. 
[2] Behman R, Nathens AB, Mason S, Byrne JP, Hong NL, Pechlivanoglou P, et al. 
Association of Surgical Intervention for Adhesive Small-Bowel Obstruction With 
the Risk of Recurrence. JAMA Surg. 2019;154:413-20. 
[3] Lee MJ, Sayers AE, Drake TM, Marriott PJ, Anderson ID, Bach SP, et al. National 
prospective cohort study of the burden of acute small bowel obstruction. BJS 
Open. 2019;3:354-66.