National survey on management practices for adhesional small bowel obstruction and nasogastric tube use among general surgeons in Australia

National survey on management practices for adhesional small bowel obstruction and nasogastric tube use among general surgeons in Australia | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article National survey on management practices for adhesional small bowel obstruction and nasogastric tube use among general surgeons in Australia Ali Al-Mashat, Anaan Fareed, Stephen Ridley Smith, Johnathan Gani This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7166930/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Background: The nasogastric tube (NGT) is recommended routinely by current guidelines in the non-operative management of adhesional small bowel obstruction (ASBO). However, several retrospective studies have reported poorer outcomes in ASBO patients managed with an NGT. We sought to examine current practices among Australian General Surgeons in managing ASBO and using NGTs, assess the presence of surgical equipoise for a potential randomised controlled trial (RCT), and evaluate interest in multi-centre collaboration. Methods: In October 2021, we conducted an online survey of all active members of General Surgeons Australia using a REDCap® questionnaire distributed via email. The survey included clinical scenarios of small bowel obstruction and questions on demographics, management practices, and clinical reasoning. Descriptive statistics were used to summarise all relevant variables. Results: Of the 893 emails sent, 181 responses were received (20%). Most respondents were from New South Wales (47%) and had subspecialty training (71%). An NGT was used in over 90% of ASBO cases by 42% of respondents. Sixty-four percent believed NGT use could prevent surgery, and 93% viewed it as having a therapeutic role. Vomiting was the most common indication for insertion, and 69% believed it reduces aspiration risk. Gastrografin® was used by 96% of surgeons. Forty-two percent expressed willingness to participate in an RCT evaluating NGT use. Conclusions: Current practice among Australian surgeons reflects a selective approach to NGT use in the management of ASBO. Given the variability in beliefs regarding its utility, a randomised controlled trial is needed to establish best practice in non-operative management of ASBO. Small bowel obstruction Adhesions Nasogastric tube Surgery Surveys and questionnaires Figures Figure 1 Background Adhesional small bowel obstruction (ASBO) is a common cause of hospital admissions, associated with significant morbidity and mortality. 1 Unlike other forms of small bowel obstruction (SBO), ASBO is the most common and is frequently managed non-operatively. 2 , 3 Traditionally, nasogastric tubes (NGTs) have been integral to the management of ASBO, as outlined in the Bologna guidelines from the World Journal of Emergency Surgery. 4 However, unlike other aspects of ASBO management, such as the Gastrograffin® challenge, which is supported by level one evidence, 5 the routine use of NGTs in ASBO remains a topic of debate. This is largely due to the limited and low-quality evidence supporting its efficacy, 6 , 7 , 8 as well as concerns regarding the potential discomfort and complications NGTs may cause patients. 9 The absence of standardised protocolised care for ASBO has led to significant variations and inconsistencies in clinical practice. Combined with the lack of robust evidence supporting NGT use, this highlights the need for a better understanding of how surgeons approach the management of ASBO. We conducted a survey to capture the current practices of Australian General Surgeons regarding ASBO management and their use of NGT decompression. Our objectives are to determine whether surgical equipoise exists for a randomised controlled trial (RCT) comparing NGT use against non-use in ASBO and gauge interest in a multicentre study. Methods A questionnaire survey (Appendix S1) was designed and distributed to all active members of General Surgeons Australia (GSA) via email through an attached web link. 10 GSA is a not-for profit governing body of practicing General Surgeons in Australia with membership granted to surgeons registered with the Royal Australian College of Surgeons (RACS). The survey was administered, and data were stored using the Research Electronic Data Capture (REDCap®) database. The study was conducted between October 2021 and March 2022. The questionnaire collected demographical data for each respondent, including level of experience, fellowship and subspecialty training, location and involvement in acute surgical on call practice. Respondents were presented with three clinical scenarios and questions designed to explore their self-reported management practices and beliefs in the care of ASBO and the use of NGTs. Multiple-choice questions were used, with some allowing for free text responses. The survey questionnaire did not seek identifiable information from the respondent except where the option for an expression of interest in a multicentre study was selected, in which their name and contact email was obtained. Descriptive statistics were reported for all relevant variables, including frequencies and percentages for categorical variables. Analysis was performed and figures were generated using Microsoft Excel. This research was approved by the Hunter New England Human Research Ethics Committee of the Hunter New England Local Health District (reference: 2021//ETH00724) with subsequent approval from GSA. Results Survey responses (including partially completed surveys) were received from 181 surgeons out of 893 emails sent (20% response rate). Demographical data is outlined in Table 1. The respondents were predominantly from metropolitan or regional hospitals (94%), practicing in the state of New South Wales (47%). Most of the surgeons identified as completing fellowship or subspecialty training (71%), with colorectal surgery being the most common subspecialty (26%). Respondents mainly reported having 1-5 years of specialist experience (39%). Almost all were engaged in acute surgical on-call duties at the time of the survey (94%), with approximately half managing 4 or more cases of ASBO per month (52%). Forty-two percent percent of respondents would advise the use of a NGT in more than 90% of ASBO cases. More than half of the respondents believed that a NGT can reduce the need for surgery in patients with ASBO (64%). Out of 133 surgeons who responded to whether an NGT could be therapeutic, 124 believed yes (93%). Of those, 121 selected that an NGT was therapeutic because it facilitated resolution (98%) and 44 selected that an NGT was therapeutic because it prevented surgery (35%); respondents could select both options. In ASBO requiring surgical intervention, 80% of respondents said they would insert an NGT pre-operatively. Most respondents believed that optimal NGT use reduces aspiration risk (69%), while some thought it increases it (9%) or did not change it (14%). Free text responses to aspiration risk were provided by some (8%), including that NGT reduces aspiration triggered by vomiting but may increase the risk of reflux-induced aspiration. Other responses included a lower risk in ASBO patients with persistent vomiting but a higher risk in those undergoing general anaesthesia or that are comatose. Some respondents stated that the risk varies among patients, stating it could reduce aspiration severity and volume while possibly increasing the risk of low-volume aspiration. For maintenance of an NGT, free drainage was preferred amongst surgeons (63%). Gastrograffin® was widely used in ASBO (96%), with 47% choosing either oral or NGT for administration. The optimal time frame for non-operative management was deemed to be 48-72 hours. However, 83% of respondents were willing to manage a patient with ASBO conservatively using a NGT for this timeframe, compared to only 68% without an NGT. Six percent of respondents would not manage an ASBO patient non-operatively without an NGT. Figure 1 illustrates factors influencing surgeons’ decisions for and against NGT insertion and Table 2 outlines the free text responses. When presented with a clinical scenario depicting a vomiting ASBO patient, 97% opted for NGT insertion compared to only 33% when vomiting was absent in the scenario. When the scenario depicted a closed loop bowel obstruction, the majority indicated they would insert an NGT (91%). Almost half of the respondents (42%) expressed willingness to participate in an RCT investigating NGT use. Survey response numbers and percentages are outlined in Table 3. Discussion Our study represents the first national survey of Australian General Surgeons that examines current management practices for ASBO and the use of NGTs. Our findings indicate a general adherence to established ASBO management guidelines. 4 The majority of surgeons reported frequent use of NGT decompression, and nearly all reported using Gastrograffin® in their practice. There was consensus on the belief that NGTs can facilitate resolution, along with agreement that the optimal duration for a trial of non-operative management is 48–72 hours. Despite guidelines advocating for universal NGT use in ASBO, 4 , 11 , 12 our findings suggest that Australian surgeons are taking a more selective approach. Only 42% reported routine use of NGTs (i.e. in > 90% of ASBO cases). Decisions to insert an NGT were primarily based on clinical indicators such as nausea and vomiting, abdominal distension, suspected closed loop obstruction, or the need for surgery. However, there are currently no protocols guiding patient selection for NGT use. Interestingly, vomiting was the most common reason for NGT insertion, whereas the absence of vomiting and lack of radiological gastric distention were the most common reasons for not inserting. Yet, our review of the literature does not support this practice. One study, which stratified patients by gastric volume to assess whether NGTs reduced vomiting in those with larger volumes, found no significant association. 8 Another study by Fonseca et al reported higher rates of pneumonia in patients managed with an NGT. 6 Given the lack of RCTs and the limited number of retrospective studies available, it appears that the selective use of NGTs reflects individual surgeon judgment and beliefs about their role in ASBO management. This may explain why retrospective comparisons often show poorer outcomes in the NGT group, 6 , 7 , 8 potentially because they are preferred for use in patients with greater disease severity. Our survey showed that surgeons preferred NGT use in patients needing operative intervention. This raises the question: if a patient appears unwell enough to require an NGT, should earlier operative management be considered instead? These findings suggest that the role of the NGT is poorly understood, with conflicting perspectives among surgeons regarding its clinical value and ability to prevent surgery. Such variation in beliefs, particularly in the absence of clear evidence, reinforces the uncertainty around whether the NGT itself influences outcomes. A RCT is therefore essential to define the true role of NGTs in ASBO and to guide future clinical practice. Limitations: The primary limitation of our study is the lower than anticipated response rate and the number of partially completed surveys returned, posing the threat of underrepresentation and respondent bias. While the length of the survey may have contributed to this, it is also important to consider the impact of longstanding surgical dogma, particularly regarding interventions like the NGT, which has been central to management of bowel obstructions for over a century. Furthermore, as with most survey-based studies, the reliance on predominantly structured, fixed-response questions may have constrained the ability to capture the full complexity of clinical reasoning and perspectives behind management choices. Nevertheless, despite the low response rate, which includes a sample population that predominantly believes in the therapeutic role of the NGT, our survey indicates that a discernible proportion of surgeons are still willing to participate in a clinical trial assessing its use. Conclusions Selective use of NGT decompression appears more common than its routine use in the management of ASBO in Australia. There is some variation among surgeons in their beliefs about its utility, with nearly half of the survey respondents indicating a willingness to participate in a prospective clinical trial. These findings highlight the need for further investigation through a RCT. Abbreviations NGT Nasogastric tube RCT Randomised controlled trial ASBO Adhesional small bowel obstruction GSA General Surgeons Australia REDCap® Research Electronic Data Capture. Declarations Ethics approval and consent to participate: This research was granted approval by the Hunter New England Human Research Ethics Committee (HREC), reference 2021//ETH00724. This study was conducted in accordance with the principles outlined in the Declaration of Helsinki. Informed consent was obtained from all participants. A cover letter distributed by General Surgeons Australia stated that completing the survey via the REDCap® platform indicated consent to participate, and that responses could be used in grouped form for this and future ethically approved projects. Consent for publication: Not applicable as no individual identifiable data is published in this study. Availability of data and materials: The datasets generated and analysed during the current study are available from the corresponding author on reasonable request. Competing Interests: None declared. Funding: None. Author contributions: SS and JG were involved in the conception, initiation and co-ordination of the study. SS is the corresponding author. AA was involved in the data analysis and formal write up of the manuscript. AF was involved in the manuscript write up, review of results and editing. All authors reviewed and approved the final manuscript. Acknowledgements: We acknowledge General Surgeons Australia for their support in distributing the survey to its members. References Duron JJ, du Montcel ST, Berger A, Muscari F, Hennet H, Veyrieres M, Hay JM. French Federation for Surgical Research. Prevalence and risk factors of mortality and morbidity after operation for adhesive postoperative small bowel obstruction. Am J Surg. 2008;195(6):726–34. https://doi.org/10.1016/j.amjsurg.2007.04.019 . Attard JAP, MacLean AR. Adhesive small bowel obstruction: epidemiology, biology and prevention. Can J Surg. 2007;50(4):291–300. Gutierrez Moreno O, Arredondo Mora N, Rincon Barbosa O, Gil Quintero F. Associated factors with nonoperative management failure in bowel obstruction. Surg Open Dig Adv. 2024;16:100185. https://doi.org/10.1016/j.soda.2024.100185 . ten Broek RPG, Krielen P, Di Saverio S, Coccolini F, Biffl WL, Ansaloni L, et al. Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2017 update of the evidence-based guidelines from the World Society of Emergency Surgery ASBO Working Group. World J Emerg Surg. 2018;13(1):24. https://doi.org/10.1186/s13017-018-0185-2 . Abbas SM, Bissett IP, Parry BR. Meta-analysis of oral water-soluble contrast agent in the management of adhesive small bowel obstruction. Br J Surg. 2007;94(4):404–11. https://doi.org/10.1002/bjs.5775 . Fonseca AL, Schuster KM, Maung AA, Kaplan LJ, Davis KA. Routine nasogastric decompression in small bowel obstruction: is it really necessary? Am Surg. 2013;79(4):422–8. PMID: 23574854. Berman DJ, Ijaz H, Alkhunaizi M, Kulie PE, Vaziri K, Richards LM, Meltzer AC. Nasogastric decompression not associated with a reduction in surgery or bowel ischemia for acute small bowel obstruction. Am J Emerg Med. 2017;35(12):1919–21. https://doi.org/10.1016/j.ajem.2017.08.029 . Shinohara K, Asaba Y, Ishida T, Maeta T, Suzuki M, Mizukami Y. Nonoperative management without nasogastric tube decompression for adhesive small bowel obstruction. Am J Surg. 2022;223(6):1179–82. https://doi.org/10.1016/j.amjsurg.2021.11.029 . Motta APG, Rigobello MCG, Silveira RCCP, Gimenes FRE. Nasogastric/nasoenteric tube-related adverse events: an integrative review. Rev Lat Am Enfermagem. 2021;29:e3400. https://doi.org/10.1590/1518-8345.3355.3400 . Al-Mashat A. National survey on management practices for adhesional small bowel obstruction and nasogastric tube use among general surgeons in Australia. Br J Surg. 2025;112(Suppl 1). https://doi.org/10.1093/bjs/znae318.014 . znae318.014. Köstenbauer J, Truskett PG. Current management of adhesive small bowel obstruction. ANZ J Surg. 2018;88(11):1117–22. https://doi.org/10.1111/ans.14526 . Diaz JJ Jr, Bokhari F, Mowery NT, Acosta JA, Block EFJ, Bromberg WJ, et al. Guidelines for management of small bowel obstruction. J Trauma. 2008;64(6):1651–64. https://doi.org/10.1097/TA.0b013e31816f709e . Tables Tables 1 to 3 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Appendix1Survey.pdf Appendix S1. REDCap® survey of nasogastric tube use for adhesional small bowel obstruction. Tables.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 23 Oct, 2025 Reviews received at journal 22 Oct, 2025 Reviews received at journal 19 Oct, 2025 Reviewers agreed at journal 26 Sep, 2025 Reviewers agreed at journal 26 Sep, 2025 Reviews received at journal 09 Sep, 2025 Reviewers agreed at journal 06 Sep, 2025 Reviewers invited by journal 07 Aug, 2025 Editor assigned by journal 07 Aug, 2025 Editor invited by journal 29 Jul, 2025 Submission checks completed at journal 29 Jul, 2025 First submitted to journal 29 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7166930","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":498588039,"identity":"6d8d4d4a-7e22-4ba6-8143-8ff16fb5b728","order_by":0,"name":"Ali Al-Mashat","email":"","orcid":"","institution":"John Hunter Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ali","middleName":"","lastName":"Al-Mashat","suffix":""},{"id":498588040,"identity":"86f9f2c5-510f-4bbe-82df-b1c42b489da3","order_by":1,"name":"Anaan Fareed","email":"","orcid":"","institution":"John Hunter Hospital","correspondingAuthor":false,"prefix":"","firstName":"Anaan","middleName":"","lastName":"Fareed","suffix":""},{"id":498588041,"identity":"cbf39784-cc98-41b8-a119-976265f94a14","order_by":2,"name":"Stephen Ridley Smith","email":"data:image/png;base64,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","orcid":"","institution":"Hunter Medical Research Institute","correspondingAuthor":true,"prefix":"","firstName":"Stephen","middleName":"Ridley","lastName":"Smith","suffix":""},{"id":498588042,"identity":"125dc8e9-f645-47a6-b313-e1f33a7965a6","order_by":3,"name":"Johnathan Gani","email":"","orcid":"","institution":"University of Newcastle","correspondingAuthor":false,"prefix":"","firstName":"Johnathan","middleName":"","lastName":"Gani","suffix":""}],"badges":[],"createdAt":"2025-07-20 01:08:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7166930/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7166930/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":88950147,"identity":"f2652c86-4b7d-490c-812c-60936f1e470e","added_by":"auto","created_at":"2025-08-13 05:45:25","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":34072,"visible":true,"origin":"","legend":"\u003cp\u003eBar graphs using absolute numbers, illustrating surgeon responses to indications for and against NGT use.\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7166930/v1/49f90e163cc8b3533387ae5e.png"},{"id":88950148,"identity":"1655dc17-cf96-45db-a788-34c1d59aada9","added_by":"auto","created_at":"2025-08-13 05:45:29","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":423517,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7166930/v1/5635b9f9-94f8-40f1-bbda-8024a46bd211.pdf"},{"id":88948929,"identity":"9b7c91ac-8511-41fe-9cc0-55e00677cbc6","added_by":"auto","created_at":"2025-08-13 05:37:25","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":63122,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAppendix S1.\u003c/strong\u003e REDCap® survey of nasogastric tube use for adhesional small bowel obstruction.\u003c/p\u003e","description":"","filename":"Appendix1Survey.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7166930/v1/3f27f0cd88371b64614c065f.pdf"},{"id":88948928,"identity":"9a9fa7cd-5d76-45ec-aa46-3dc17c4074a4","added_by":"auto","created_at":"2025-08-13 05:37:25","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":21141,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-7166930/v1/c3d912067d45713d71d0cace.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"National survey on management practices for adhesional small bowel obstruction and nasogastric tube use among general surgeons in Australia","fulltext":[{"header":"Background","content":"\u003cp\u003eAdhesional small bowel obstruction (ASBO) is a common cause of hospital admissions, associated with significant morbidity and mortality.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Unlike other forms of small bowel obstruction (SBO), ASBO is the most common and is frequently managed non-operatively.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Traditionally, nasogastric tubes (NGTs) have been integral to the management of ASBO, as outlined in the Bologna guidelines from the World Journal of Emergency Surgery.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e However, unlike other aspects of ASBO management, such as the Gastrograffin\u0026reg; challenge, which is supported by level one evidence,\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e the routine use of NGTs in ASBO remains a topic of debate. This is largely due to the limited and low-quality evidence supporting its efficacy,\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e as well as concerns regarding the potential discomfort and complications NGTs may cause patients.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThe absence of standardised protocolised care for ASBO has led to significant variations and inconsistencies in clinical practice. Combined with the lack of robust evidence supporting NGT use, this highlights the need for a better understanding of how surgeons approach the management of ASBO. We conducted a survey to capture the current practices of Australian General Surgeons regarding ASBO management and their use of NGT decompression. Our objectives are to determine whether surgical equipoise exists for a randomised controlled trial (RCT) comparing NGT use against non-use in ASBO and gauge interest in a multicentre study.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eA questionnaire survey (Appendix S1) was designed and distributed to all active members of General Surgeons Australia (GSA) via email through an attached web link.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e GSA is a not-for profit governing body of practicing General Surgeons in Australia with membership granted to surgeons registered with the Royal Australian College of Surgeons (RACS). The survey was administered, and data were stored using the Research Electronic Data Capture (REDCap\u0026reg;) database. The study was conducted between October 2021 and March 2022. The questionnaire collected demographical data for each respondent, including level of experience, fellowship and subspecialty training, location and involvement in acute surgical on call practice. Respondents were presented with three clinical scenarios and questions designed to explore their self-reported management practices and beliefs in the care of ASBO and the use of NGTs. Multiple-choice questions were used, with some allowing for free text responses. The survey questionnaire did not seek identifiable information from the respondent except where the option for an expression of interest in a multicentre study was selected, in which their name and contact email was obtained. Descriptive statistics were reported for all relevant variables, including frequencies and percentages for categorical variables. Analysis was performed and figures were generated using Microsoft Excel. This research was approved by the Hunter New England Human Research Ethics Committee of the Hunter New England Local Health District (reference: 2021//ETH00724) with subsequent approval from GSA.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eSurvey responses (including partially completed surveys) were received from 181 surgeons out of 893 emails sent (20% response rate). Demographical data is outlined in Table 1. The respondents were predominantly from metropolitan or regional hospitals (94%), practicing in the state of New South Wales (47%). Most of the surgeons identified as completing fellowship or subspecialty training (71%), with colorectal surgery being the most common subspecialty (26%). Respondents mainly reported having 1-5 years of specialist experience (39%). Almost all were engaged in acute surgical on-call duties at the time of the survey (94%), with approximately half managing 4 or more cases of ASBO per month (52%).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eForty-two percent percent of respondents would advise the use of a NGT in more than 90% of ASBO cases. More than half of the respondents believed that a NGT can reduce the need for surgery in patients with ASBO (64%). Out of 133 surgeons who responded to whether an NGT could be therapeutic, 124 believed yes (93%). Of those, 121 selected that an NGT was therapeutic because it facilitated resolution (98%) and 44 selected that an NGT was therapeutic because it prevented surgery (35%); respondents could select both options. In ASBO requiring surgical intervention, 80% of respondents said they would insert an NGT pre-operatively. Most respondents believed that optimal NGT use reduces aspiration risk (69%), while some thought it increases it (9%) or did not change it (14%). Free text responses to aspiration risk were provided by some (8%), including that NGT reduces aspiration triggered by vomiting but may increase the risk of reflux-induced aspiration. Other responses included a lower risk in ASBO patients with persistent vomiting but a higher risk in those undergoing general anaesthesia or that are comatose. Some respondents stated that the risk varies among patients, stating it could reduce aspiration severity and volume while possibly increasing the risk of low-volume aspiration.\u003c/p\u003e\n\u003cp\u003eFor maintenance of an NGT, free drainage was preferred amongst surgeons (63%). Gastrograffin\u0026reg; was widely used in ASBO (96%), with 47% choosing either oral or NGT for administration. The optimal time frame for non-operative management was deemed to be 48-72 hours. However, 83% of respondents were willing to manage a patient with ASBO conservatively using a NGT for this timeframe, compared to only 68% without an NGT. Six percent of respondents would not manage an ASBO patient non-operatively without an NGT. Figure 1 illustrates factors influencing surgeons\u0026rsquo; decisions for and against NGT insertion and Table 2 outlines the free text responses. When presented with a clinical scenario depicting a vomiting ASBO patient, 97% opted for NGT insertion compared to only 33% when vomiting was absent in the scenario. When the scenario depicted a closed loop bowel obstruction, the majority indicated they would insert an NGT (91%). Almost half of the respondents (42%) expressed willingness to participate in an RCT investigating NGT use. Survey response numbers and percentages are outlined in Table 3.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur study represents the first national survey of Australian General Surgeons that examines current management practices for ASBO and the use of NGTs. Our findings indicate a general adherence to established ASBO management guidelines.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e The majority of surgeons reported frequent use of NGT decompression, and nearly all reported using Gastrograffin\u0026reg; in their practice. There was consensus on the belief that NGTs can facilitate resolution, along with agreement that the optimal duration for a trial of non-operative management is 48\u0026ndash;72 hours.\u003c/p\u003e\u003cp\u003eDespite guidelines advocating for universal NGT use in ASBO,\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e our findings suggest that Australian surgeons are taking a more selective approach. Only 42% reported routine use of NGTs (i.e. in \u0026gt;\u0026thinsp;90% of ASBO cases). Decisions to insert an NGT were primarily based on clinical indicators such as nausea and vomiting, abdominal distension, suspected closed loop obstruction, or the need for surgery. However, there are currently no protocols guiding patient selection for NGT use. Interestingly, vomiting was the most common reason for NGT insertion, whereas the absence of vomiting and lack of radiological gastric distention were the most common reasons for not inserting. Yet, our review of the literature does not support this practice. One study, which stratified patients by gastric volume to assess whether NGTs reduced vomiting in those with larger volumes, found no significant association.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Another study by Fonseca et al reported higher rates of pneumonia in patients managed with an NGT.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eGiven the lack of RCTs and the limited number of retrospective studies available, it appears that the selective use of NGTs reflects individual surgeon judgment and beliefs about their role in ASBO management. This may explain why retrospective comparisons often show poorer outcomes in the NGT group,\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e potentially because they are preferred for use in patients with greater disease severity. Our survey showed that surgeons preferred NGT use in patients needing operative intervention. This raises the question: if a patient appears unwell enough to require an NGT, should earlier operative management be considered instead? These findings suggest that the role of the NGT is poorly understood, with conflicting perspectives among surgeons regarding its clinical value and ability to prevent surgery. Such variation in beliefs, particularly in the absence of clear evidence, reinforces the uncertainty around whether the NGT itself influences outcomes. A RCT is therefore essential to define the true role of NGTs in ASBO and to guide future clinical practice.\u003c/p\u003e\u003cp\u003eLimitations:\u003c/p\u003e\u003cp\u003eThe primary limitation of our study is the lower than anticipated response rate and the number of partially completed surveys returned, posing the threat of underrepresentation and respondent bias. While the length of the survey may have contributed to this, it is also important to consider the impact of longstanding surgical dogma, particularly regarding interventions like the NGT, which has been central to management of bowel obstructions for over a century. Furthermore, as with most survey-based studies, the reliance on predominantly structured, fixed-response questions may have constrained the ability to capture the full complexity of clinical reasoning and perspectives behind management choices. Nevertheless, despite the low response rate, which includes a sample population that predominantly believes in the therapeutic role of the NGT, our survey indicates that a discernible proportion of surgeons are still willing to participate in a clinical trial assessing its use.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eSelective use of NGT decompression appears more common than its routine use in the management of ASBO in Australia. There is some variation among surgeons in their beliefs about its utility, with nearly half of the survey respondents indicating a willingness to participate in a prospective clinical trial. These findings highlight the need for further investigation through a RCT.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eNGT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNasogastric tube\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eRCT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eRandomised controlled trial\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eASBO\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAdhesional small bowel obstruction\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eGSA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eGeneral Surgeons Australia\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eREDCap\u0026reg;\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eResearch Electronic Data Capture.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was granted approval by the Hunter New England Human Research Ethics Committee (HREC), reference 2021//ETH00724. This study was conducted in accordance with the principles outlined in the Declaration of Helsinki. Informed consent was obtained from all participants. A cover letter distributed by General Surgeons Australia stated that completing the survey via the REDCap\u0026reg; platform indicated consent to participate, and that responses could be used in grouped form for this and future ethically approved projects.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable as no individual identifiable data is published in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone declared.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSS and JG were involved in the conception, initiation and co-ordination of the study. SS is the corresponding author. AA was involved in the data analysis and formal write up of the manuscript. AF was involved in the manuscript write up, review of results and editing. All authors reviewed and approved the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe acknowledge General Surgeons Australia for their support in distributing the survey to its members.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDuron JJ, du Montcel ST, Berger A, Muscari F, Hennet H, Veyrieres M, Hay JM. French Federation for Surgical Research. Prevalence and risk factors of mortality and morbidity after operation for adhesive postoperative small bowel obstruction. Am J Surg. 2008;195(6):726\u0026ndash;34. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.amjsurg.2007.04.019\u003c/span\u003e\u003cspan address=\"10.1016/j.amjsurg.2007.04.019\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAttard JAP, MacLean AR. Adhesive small bowel obstruction: epidemiology, biology and prevention. Can J Surg. 2007;50(4):291\u0026ndash;300.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGutierrez Moreno O, Arredondo Mora N, Rincon Barbosa O, Gil Quintero F. Associated factors with nonoperative management failure in bowel obstruction. Surg Open Dig Adv. 2024;16:100185. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.soda.2024.100185\u003c/span\u003e\u003cspan address=\"10.1016/j.soda.2024.100185\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eten Broek RPG, Krielen P, Di Saverio S, Coccolini F, Biffl WL, Ansaloni L, et al. Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2017 update of the evidence-based guidelines from the World Society of Emergency Surgery ASBO Working Group. World J Emerg Surg. 2018;13(1):24. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s13017-018-0185-2\u003c/span\u003e\u003cspan address=\"10.1186/s13017-018-0185-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAbbas SM, Bissett IP, Parry BR. Meta-analysis of oral water-soluble contrast agent in the management of adhesive small bowel obstruction. Br J Surg. 2007;94(4):404\u0026ndash;11. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/bjs.5775\u003c/span\u003e\u003cspan address=\"10.1002/bjs.5775\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFonseca AL, Schuster KM, Maung AA, Kaplan LJ, Davis KA. Routine nasogastric decompression in small bowel obstruction: is it really necessary? Am Surg. 2013;79(4):422\u0026ndash;8. PMID: 23574854.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBerman DJ, Ijaz H, Alkhunaizi M, Kulie PE, Vaziri K, Richards LM, Meltzer AC. Nasogastric decompression not associated with a reduction in surgery or bowel ischemia for acute small bowel obstruction. Am J Emerg Med. 2017;35(12):1919\u0026ndash;21. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ajem.2017.08.029\u003c/span\u003e\u003cspan address=\"10.1016/j.ajem.2017.08.029\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShinohara K, Asaba Y, Ishida T, Maeta T, Suzuki M, Mizukami Y. Nonoperative management without nasogastric tube decompression for adhesive small bowel obstruction. Am J Surg. 2022;223(6):1179\u0026ndash;82. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.amjsurg.2021.11.029\u003c/span\u003e\u003cspan address=\"10.1016/j.amjsurg.2021.11.029\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMotta APG, Rigobello MCG, Silveira RCCP, Gimenes FRE. Nasogastric/nasoenteric tube-related adverse events: an integrative review. Rev Lat Am Enfermagem. 2021;29:e3400. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1590/1518-8345.3355.3400\u003c/span\u003e\u003cspan address=\"10.1590/1518-8345.3355.3400\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAl-Mashat A. National survey on management practices for adhesional small bowel obstruction and nasogastric tube use among general surgeons in Australia. Br J Surg. 2025;112(Suppl 1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/bjs/znae318.014\u003c/span\u003e\u003cspan address=\"10.1093/bjs/znae318.014\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. znae318.014.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eK\u0026ouml;stenbauer J, Truskett PG. Current management of adhesive small bowel obstruction. ANZ J Surg. 2018;88(11):1117\u0026ndash;22. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/ans.14526\u003c/span\u003e\u003cspan address=\"10.1111/ans.14526\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDiaz JJ Jr, Bokhari F, Mowery NT, Acosta JA, Block EFJ, Bromberg WJ, et al. Guidelines for management of small bowel obstruction. J Trauma. 2008;64(6):1651\u0026ndash;64. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/TA.0b013e31816f709e\u003c/span\u003e\u003cspan address=\"10.1097/TA.0b013e31816f709e\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 3 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Small bowel obstruction, Adhesions, Nasogastric tube, Surgery, Surveys and questionnaires","lastPublishedDoi":"10.21203/rs.3.rs-7166930/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7166930/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e\u003cp\u003e The nasogastric tube (NGT) is recommended routinely by current guidelines in the non-operative management of adhesional small bowel obstruction (ASBO). However, several retrospective studies have reported poorer outcomes in ASBO patients managed with an NGT. We sought to examine current practices among Australian General Surgeons in managing ASBO and using NGTs, assess the presence of surgical equipoise for a potential randomised controlled trial (RCT), and evaluate interest in multi-centre collaboration.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e\u003cp\u003eIn October 2021, we conducted an online survey of all active members of General Surgeons Australia using a REDCap\u0026reg; questionnaire distributed via email. The survey included clinical scenarios of small bowel obstruction and questions on demographics, management practices, and clinical reasoning. Descriptive statistics were used to summarise all relevant variables.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e\u003cp\u003eOf the 893 emails sent, 181 responses were received (20%). Most respondents were from New South Wales (47%) and had subspecialty training (71%). An NGT was used in over 90% of ASBO cases by 42% of respondents. Sixty-four percent believed NGT use could prevent surgery, and 93% viewed it as having a therapeutic role. Vomiting was the most common indication for insertion, and 69% believed it reduces aspiration risk. Gastrografin\u0026reg; was used by 96% of surgeons. Forty-two percent expressed willingness to participate in an RCT evaluating NGT use.\u003c/p\u003e\u003ch2\u003eConclusions:\u003c/h2\u003e\u003cp\u003eCurrent practice among Australian surgeons reflects a selective approach to NGT use in the management of ASBO. Given the variability in beliefs regarding its utility, a randomised controlled trial is needed to establish best practice in non-operative management of ASBO.\u003c/p\u003e","manuscriptTitle":"National survey on management practices for adhesional small bowel obstruction and nasogastric tube use among general surgeons in Australia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-13 05:37:20","doi":"10.21203/rs.3.rs-7166930/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-24T01:40:24+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-22T11:38:22+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-19T13:20:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"193616915941803728022768478509158976184","date":"2025-09-27T01:41:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"105418655505361098142959612153130339378","date":"2025-09-26T11:19:22+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-10T03:46:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"177265701788674726180027129690399658690","date":"2025-09-06T22:35:15+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-07T07:38:06+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-07T07:37:14+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-29T14:33:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-29T11:58:01+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Surgery","date":"2025-07-29T11:22:03+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a19fb341-ec45-4043-aeba-c67651678321","owner":[],"postedDate":"August 13th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-05T17:39:00+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-13 05:37:20","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7166930","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7166930","identity":"rs-7166930","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}