According to a study published in the Journal of the American College of Surgeons, Black patients are more likely than whites to have delayed surgical management of adhesive small-bowel obstruction (SBO).

The researchers corroborated previous guidelines that waiting more than 5 days for surgery for small-bowel obstruction leads to worse outcomes. However, surprisingly, black patients, even when controlled for patient comorbid conditions, were more likely to wait more than 5 days for surgery.

SBO, one of the most common surgical emergencies encountered by general surgeons.Guidelines for the Surgery of Trauma recommend that patients without clinical signs of deterioration can safely undergo a trial of expectant management for up to five days. Once the decision to operate is made, the guidelines also recommend a laparoscopic approach whenever feasible.

To investigate the impact of race in surgical decision-making in patients with SBO, the researchers grouped race into non-Hispanic white, non-Hispanic black, Hispanic and other. The team focused on the length of time from admission to surgery (5 days or less vs. >5 days) and the use of open surgery versus laparoscopy.

The mean time to surgery was 2.3 days, and 30-day mortality rates were significantly higher for patients waiting more than 5 days. Waiting longer than 5 days was associated with 61% greater odds of 30-day mortality and 56% greater odds of postoperative complications, the researchers, online November 20.

Compared with laparoscopy, open surgery had higher 30-day mortality rates and more postoperative complications. Mortality rates at 30 days were similar between black and white patients, but the complication rate was significantly higher for black patients than for white patients.

Dr Alexander L. Colonna who has evaluated the nonoperative management paradigm for adhesive SBO, said, “As a clinician, I'd like to think that I'm colour-blind, but the fact remains that African Americans are receiving interventions later and are having more complications than other groups. Further prospective research is needed to identify why African Americans are treated differently.”

There very well may be real differences in the management of small-bowel obstruction based on race. There may be inherent selection bias in this study, as black patients were more likely to have more comorbidities, higher ASA class, and worse functional status, which may be driving the delay in surgery.

The researchers also do not have information about individual surgeon case-mix and if this phenomenon is more a reflection of individual surgeon practice patterns and their baseline patient population. Therefore, it is hard to make conclusions if there is true racial bias present. The authors said further research required to investigate the influence of bias on surgical decision-making.

Finally, the choice of an open vs. laparoscopic approach remains controversial in the operative management of small-bowel obstruction. The current large, population-based study suggested that a laparoscopic approach for small-bowel obstruction might be linked to a higher risk of bowel injury compared to an open approach. Thus, a laparoscopic approach might not be an appropriate quality measure for small-bowel obstruction cases.