BTK Team MIZZOU_ SBO Journal Review Final 1.2 ===

Alright guys, welcome back to Behind The Knife for the EGST at Tiger Country at the University of Missouri, I'm rash dev and I'm one of the acute care surgeons at Mizzou. Today we're gonna be tackling one of the most common EGS consults across the country, small bowel obstruction. But we're not just gonna be talking about management here. We're gonna be going into and providing a good journal review on the global evolution of small bowel obstruction. And some of the predictive models that are out there dating from 2011 through their current practice in 2025. We're also gonna talk about how some of these international studies can apply to North American, uh, acute care models across the nation. But before we get started, let's go ahead and do some quick team introductions. Right. Hi, I am Raymond, OK. I'm the a CS at SCM Fellow. My name's Dera Fletcher. I'm a third year general surgery resident. I'm Bryson Radcliffe. I'm a fourth year general surgery resident. I'm Regina Miff. I one of the PGY fives at the University of Missouri. Awesome. So we're surrounded by a bunch of budding acute care surgeons who are nerds in their field. So let's go ahead and talk talk about the lineup.

So we're gonna walk through five major papers that influence how we can diagnose. Risk stratify and manage small bowel obstruction in 2025. So the first paper is gonna be the impact of operative management on recurrent on recurrence of adhesive small bowel obstruction published in 2020 and the general of American College of Surgeons. Second paper is gonna be the risk and NOFA scores for predicting immediate surgery or failure of non-operative management published in 25 by the Oxford University in the British Journal of Surgery. That third paper we're gonna talk about is evidence-based. Cost-effective a CS algorithm for SBO Management. This one was published in the Journal of Trauma and Acute Care Surgery most recently in 2025. The fourth paper will be discussing the perspective validation of a multi-variate model for predicting operative needs published in 2011 by the Journal of American College of Surgeons. And then the final paper will be the new clinical severity score for Predicting Bowel Ischemia, which was published in 2023. By the International Journey journal of

Surgery from the University Hospitals of Geneva. Quite a bit of papers that we're gonna go through. We're gonna do our best to keep it brief and get through the salient major points. Okay. So, Dr. Fletcher, why don't you go ahead and start us off with the 2023 new clinical severity score, what's essentially the essence of this 12 year Swiss core? Yeah, absolutely. Okay. So this was a S single center prospective cohort study. They kind of compared this new data with old data from within their same institution. Um, so this looked at 492 patients with adhesive small bowel obstruction from the years of 2008, 2016. Basically 70% were managed surgically in 20. 9% were managed conservatively. They compared this with previous years from 2004 to 2007 and come up with this six item score. Basically, the main outcome that they looked at was small bowel resection as a surrogate for ischemia and necrosis. We're gonna talk about eight predictors that they kind of focused on. So age greater than or equal to

70. The first episode of a small bowel obstruction, no bowel movement, oration within, uh, or equal to three days guarding on exam CRP greater than or equal to 50 transition point on the CT scan, and then lack of enhancement on the CT scan. And then also about 500 mils of free fluid. Seen on the scan to score these, they, each variable was worth one point. They used a threshold score greater than or equal to four to define high risk. This showed a sensitivity of about 65%, um, with a specificity of about 88%. So why does this matter? How does this apply to clinical application? So scores greater five through seven had a hundred percent resection rate. A score of four had about a 70% resection rate, and then if you scored zero to one, it was negligible at about a zero to 6% resection rate. Also in contrast to this, they kind of took into consideration different patients, uh, that were unable to receive IV contrast. So they created the seven

item, no contrast score, which is basically the above the, uh, points that I listed minus a ct contrast enhancements. Study the threshold again, greater than four, corresponded to it greater than 70%. Predicted risk, the same sensitivity, a higher specificity. Also I think that especially applicable for residents 'cause we don't have a lot of time to walk around and remember, um, all eight items, they kind of made a brief four item score, age greater than 70 abdominal guarding. On exam, you see a clear transition point on the CT scan and then also that greater than 500 mils of free fluid on the CT as well. If a patient had a high risk threshold, which is greater score, greater than two, um, out of this four point score, they had a greater than 70% predicted risk of resection. That's insane. So, uh, when you finished doing all this and reading this paper, what are some of the key clinical findings beyond the score that you thought about? Yeah, for sure. So I think we can talk about operative versus non-operative strategy. So

70% approximately of the index small bowel obstructions were managed surgically. Um, which was higher than many North American, uh, series as this was performed in Geneva, about 30% of all small obstructions underwent resection recurrence. For these, it was highest in the conservatively managed group, about 30% versus 15% in surgically treated without resection, and about 8% in those treated with resection. Interestingly, a prior small bowel obstruction doubled the risk of recurrence and then the surgical treatment of the index episode, half the recurrence risk. To talk about complications with this, the overall post-op complication rate, uh, was about 35%. Complications were more frequent and severe with resection versus no resection, which is kind of common sense. And then. For me, most interesting. The traditional go-to labs that everyone loves to talk about when we talk about bowel ischemia or small bowel obstruction, lactate, leukocytosis, creatinine and platelets were not independent factors of resection and these were actually dropped from the study, the CRP number that they got that I mentioned

earlier that was greater than 50. It was an independent predictor, but it was actually, I, it was acknowledged as non-specific and we don't use it here, so it's not routinely used everywhere. It's cool listening to you talk about this and kind of, you know, reading ahead and. Uh, for the listeners, um, we're gonna be hitting a lot of points and a lot of things you said are gonna be mentioned multiple times in all the different studies. So it kind of actually gets goosebumps going on the back of my neck, or maybe that's just the nerdiness in me. Um, but I'm looking forward to kind of, you know, tying it all together at the end here. So why don't you tell us some of the strengths of this study? Yep. So I think for this study in particular, uh, it was a prospective data collection in the developmental cohort. There were clear clinical meaning, meaningful outcome, meaning that we know what small bowel resection means. It's a hard endpoint for surgeons. It correlates with clinically significant ischemia, even if it's imperfect. There was both internal and external, uh, validate validation. So they used a red, relatively large cohorts, about 500 patients validated. Based on their internal reflections from the previous

years they did use multiple usable score versions. So they have an eight or a seven or a four. These are more applicable depending on real life constraints. So renal insufficiency limits your ability to get IV contrast. Sometimes also the exclusion of malignancy, hernia, radiation, it creates a more homogenous population. Um, so this was true adhesive, small bowel obstruction, and then they contextualized within the existing guidelines, so they compared their score to the bologna WSES guidance. And double A ST Small bowel obstruction severity classification. So authors explicitly compared their scores to Bologna and the WSES guidance and as well as double A STA small bowel obstruction severity classification. And then the data supports that timely surgical management for adhesive small bowel obstructions actually reduces recurrence as well. That's crazy. You got way too many strengths, man. So why don't you tell us some of the weaknesses. Yep. So single center, uh, just one place. Their operative threshold for adhesive small bowel obstruction is actually higher than North America, and a

CS center is about 70%. Which, why does this matter? This can inflate the prevalence of ischemic bowel and actually overestimate the score performance when transported to lower intervention environments. Cool. Alright, well. I don't know if this is a good spot to say it, but this podcast might be a little bit longer, but I think it's worth delving into some of these topics. So I'm just going to, you know, preview the readers about the next few papers that we're gonna go into. But regarding this last paper you talked about, overall great framework not really a full plug and play kind of system to adopt at the US acute care surgery model because of the CRP and the, and that routine use of enhanced CT protocols. But still. The common points are that lack of that transition point, lack of small bowel enhancement and free fluid has universal red flags. So with that being said, let's just go ahead and dive into our next paper, the STRs and NOFA score model. Dr. Oge, why don't you get us going? Right. So, uh, this finished multicenter perspective study looked at, uh,

481 patients and actually produced two models. The risk is the risk score that predicts strangulation. While the NOFA predicts non-operative failure, they had two clinical questions that they wanted to look at. So the first one was in adults with CT confirmed that adhesive small bowel obstruction, can we actually predict strangulation and admission? And then amongst patients initially treated non-operatively, can we predict failure of non-operative management within 30 days? The study was a prospective observational multicenter cohort two. Both have both internal and external validation. And then, uh, they were stratified into two cohorts development and external validation cohorts. The patients that were included were adults with CT confirmed adhesive small bowel obstruction, as well as any relative clinically relevant labs of day obtained presentation. For patients who had surgery within 30 days, who had IBD, intraluminal obstruction, peritoneal carcinomatosis, paralytic, ileus, or were younger than 18 years of

age, they were excluded from this study. If strangulation was suspected at any time, emergency surgery was pursued. Otherwise, patients got NG tube decompression, IV fluids, a water soluble contrast challenge with failure or new strangulation signs triggering surgery. The goal of this is important to mention was not to make another fancy score, but rather something that was clinically usable, well calibrated, and had real world reliability. So, starting off with drisk, it looked at six variables. One of them was number of prior small bowel obstruction episodes that abdominal guarding neutrophil to white blood cell count ratio, small bowel feces sign the presence of mesentary edema or free peritoneal fluid. And then a closed loop configuration on ct. I like to talk performance here because I think it's good to show that this is a very outstanding prediction model. So the development and external validation came out at 0.86 and 0.91. And if we look at one as a sign of perfect

discrimination, this is actually pretty good for a prediction model. Well, that's a lot of stats, man. So what does it actually mean clinically, right? Thanks for asking that. So, stress essentially. Listen, I, I like being nice. It's okay. Swiss essentially tells you, so how worried should I be that this patient is strangulated right now? And then they did more stats here and they created an online calculator of which you can find in our show notes if you want to access that. But the patients was stratified into four groups based on risks. So you have a low, which is less than 5%, moderate, five to 20% high, 20 to 50%, and very high, which is greater than 50%. So in this very high group. Most of them ended up in the OR and required resection. So this is the patient you don't want to leave on NGD compression overnight. Now speaking of nofa, it actually reuses the same exact six variables just to keep it simple. But instead, the question here, the outcome was will this patient fail non-operative management within 30 days? Also had pretty good discrimination

here and uh, it's actually pretty valid in itself. NOFA answers the question that we have when patients present on day one or day two. So is this patient actually gonna get better with non-op management or are we just delaying the inevitable so it helps reduce prolonged, unproductive, you know, multi-day, uh, non-operative trials. Yeah, so does that, that actually, that's probably probably one of the best parts of the paper that I enjoyed the most. Uh, seeing how they were able to, uh, create that model with the same scoring system. Um, that dovetails pretty nicely with. Going into the strengths of this paper. So why don't you tell us a little bit about that? Right, so strengths of this paper are its perspective, it's multi-institutional, it's externally validated adhesive, small bowel obstruction was the only population study, so that's clear. It employed high quality blinded CT review. It had good strong calibration and a good discrimination. And again, there is the presence of the web-based calculator online that's about as rigorous. As EGS literature gets, yeah, that's pretty cool.

I've already made it a home screen app on my phone. Then again, I have everything as a home screen app. Tell us about the weaknesses. So, unfortunately, this study was conducted in Finland, so practice patterns may differ from the us. CT interpretations here whereby expert radiologists, not surgeons. Only small bowel adhesive, small bowel obstruction was studied, so it doesn't apply to malignant hernia or post-op obstruction. And it's very important to mention here that prediction is not the same as a mandate. So even though drisk and NOFA can help guide decisions, they should not and do not replace surgical judgment. There's a slight over prediction in the high risk groups, but again, none of these things invalidate its clinical usefulness. Yeah. I really liked the paper. I thought this one was more applicable than some of the older models because the inputs are things that the US hospital systems routinely kind of collect already, and the CT based variables match modern radiology practices. So kind of very reproducible actually. But anyway, let's go ahead and move on with the next paper

with Dr. Ismal. Why don't you go ahead and, uh, talk to us about the impact of operative management on recurrence adhesive small bowel obstruction. Sounds great. We've been talking a lot about dead and dying bowel, so let's talk recurrence. This current study says that, you know, adhesive SBO as we all know, is a pretty much one of the most frequent things we see in the emergency department, in the middle of the night, in the middle of the day, and any and all hours. Historically the dogma has been that if you operate on a small bowel obstruction, your risk developing more adhesions, potentially developing further episodes of SBO. Versus if you don't operate and you're able to manage the patient non-operatively this will be safe for long term. But until recently we haven't really had much data on this, and the subject has been rather poorly understood. The current study of presenting leverages a unique statewide data set in Tennessee that links patients across every hospital in the state. So if somebody were to recur later at a different institution, they would still be captured in this data set, which I think is huge. The authors took adults with first ever adhesive related

small bowel obstruction between the years of 2007 and 2009, and followed them all the way to 2016 to watch for recurrences. They had about 6,000 patients and 70% of those were managed non-operatively. The median follow-up was about 10 years in each group, which is pretty good timeframe I would say. They used the, pretty much a gold standard model called the Anderson Gill Model for analyzing recurrent events, uh, to see how the small bowel obstruction episodes and its management affected future episodes. They found a couple of things that I think are important and important takeaways from this. First and foremost, they found that operative management actually reduces risk of recurrence. So if you operate on a small bowel obstruction at its initial occurrence. You significantly reduced the chance of the patient developing another episode down the line. Skipping some of the math here, about 70% reduction rate in future recurrences compared to patients that were managed conservatively. The second big thing that they did

find is that surgery actually delays the next episode of recurrence by many years. The operative index episode median was about 729 days to recurrence compared to five 50 for a non-operatively managed patient. So just over two years, right? Yeah, that's, that's crazy. It's quite a bit of, quite a bit of a difference for sure. However, some negative things about operating as much as we all like operating on small bowel obstructions recurrence begets recurrence whether treated surgically or nonsurgically. Once a patient has a recurrence, their future risk rises with each episode. And the hazard ratio is here for non-op recurrence is 1.18. And for an upper occurrence is 2.3, meaning if you're on your third small bowel obstruction, regardless of which treatment you received previously, you're much more likely to have a fourth. Uh, and then finally, as we all know, surgery does come higher does come, I'm sorry, with higher risks in the immediate postoperative period. Uh, one of 'em being mortality for operative is 3.7 for non-operative patients is 2.6, I

imagine. This is during their admission with said small bowel obstruction. And the complications are higher across the board. So whether we're talking about cardiac ischemia, pulmonary emboli, pneumonias, kidney injury, or wound infection. So ultimately the reason why we're all in surgical residency is to make clinical decisions. And the trade-off is, is ultimately real based on this study that surgery does lower future small bowel obstruction episodes, but it does increase short-term morbidity and mortality. So we, so tell us about the strengths of the study. Yeah, so there's quite a few. The first one is that it's large, it's statewide, and it being all a linked hospital system, we were able to, the, the authors were able to capture recurrences across multiple institutions within the state. Uh, long term follow up, approaching close to a decade appropriate current events, statistics, not just the first recurrence of SBO. They continued to follow these patients for this, uh, period of time. And they looked at clinical outcomes that we're all on a lookout for. So recurrence time to recurrence mortality, and then the associated complications that we've discussed. And then

ultimately, this was in Tennessee, so I think this has high applicability for a CS practices across North America. Yeah. And then those are great strengths, but clueing into the limitations. There's one big limitation that I was listening to or kind of picking up on, and that's the complications associated with the operative cases. Why don't you. Dive in and tell us a little bit about those limitations. So I think, you know, the biggest limitation here is that all this is administrative data. We don't have CT findings, we don't have lactates, there's no clinical severity markers. We ultimately don't know why the patients that got an operation were operated on, which adhesions were encountered, whether the operations were laparoscopic or open, whether there was any bowel ischemia found at the time of the operation. Also confounding by the indication is huge, sicker patients are more likely to be operated on and more likely to have complications and mortality. This inflates the observed operative mortality as you would expect. And finally, the data are from 2007 and 2016, which I think with the developments in the radiology

world, I think the modern CT based scoring systems, the standardized gastro graft and protocols and as well as laparoscopy, ultimately were in, is widespread. Nice. Nice. Good job wrapping up that paper. Let's move on. We're almost at the end. Okay. So, hey Bryson, are you ready to go? Yes, sir. Alright, man. Let's, uh, finish off and wrap us up with the jtac EGS algorithm. Yeah. So, uh, general trauma acute cancer surgery algorithm is the most North American document in the group. It pushes a structured approach. This patient answer or this paper answers the questions we all have of what's an evidence-based, cost-effective way to manage small bowel obstruction actually works in real life, a CS practice. All right, so this synthesizes moderate evidence including CT predictors, previous guidelines, including E guideline, other meta-analyses. This algorithm starts by emphasizing the CT scan as the central decision making tool. Like Eugene had said, we moved beyond the era of relying on plain films, non-specific labs, white blood cell count, lactate CT tells you that need anatomy, the transition points, most importantly, the early signs of ischemia.

So importantly, this paper lists the features that are strongly predict the need for urgent surgery. Most importantly, like Desiree talked about previously, mesenteric edema free in sha peritoneal fluid, a closed loop obstruction, lack of small bowel feces, sign and ball, bowel wall hypo enhancements, like I said, same findings they found in zelensky ST. Risk and nofa scoring systems earlier. The message is clear. Uh, the CT is predictive, it's reproducible, and it should just guide your decision making. All right, so according to this algorithm, about 20% of small bowel obstructs need emergency surgery right at presentation. These CRE key triggers are peritonitis, hemodynamic instability, CT signs of ischemia, and a closed loop bowel obstruction. The authors are crystal clear on this. If you have one of these, uh, that you should not delay surgery for a gastro challenge or prolonged observation, you need to go straight to the operating room. The important part is the non-operative management of adhesive small bowel obstructions without emergency surgical indications that we talked about. The algorithm supports an initial

trial of non-operative management. Uh, this includes your N-P-O-N-G-D compression, your fluids, and your early CT reassessment. Uh, they shifted away from the old document that the virgin abdomen always needs surgery. This paper shows and cites multiple places of evidence that the adhesions are the most common cause. With no prior surgery, many can still be managed conservatively, uh, this is a huge point for the residents. The author strongly recommend using a water soluble contrast study Gastrografin challenge within six to 24 hours after NGD compression for these stable patients with adhesive obstructions. Why? The evidence consistently shows that lengthen or it shortens the length of stay. It predicts failure, not operative management. It provides diagnostic clarity and it avoids prolonged pointless non-operative trials. Alright, cool. Um, good job, man. So, what do you think the algorithm's biggest clinical pushes here? Yeah, this algorithm talked all about the gastro grin challenge. They strongly recomme recommended using a water-soluble contrast study between six and 24 hours after

NGD compression in stable patients with adhesive obstructions. Why? Uh, the evidence consistently shows that it shortens the length of stay. It predicts failure of non-operative management, it provides diagnostic clarity and it avoids prolonged pointless non-operative trials. So why don't you tell us a little bit about the important nuances of it? Yeah. The. Real value is predictive. If contrast reaches the colon, then it's a good sign. If not, then your patient likely to fail. Non-operative management, the authors emphasize, uh, you should not delay the gastro graft and challenge beyond 72 hours. That's when we see the morbidity of delayed surgery that goes up. Nice. Alright, so, while we just dive, uh, dive into the biggest point that I know all of you guys as budding acute care surgeons wanna talk about. So what about the role of laparoscopy? Yeah, so this is one of the strongest contributions of the paper. Uh, it analyzed the modern role of minimally invasive surgery and bowel obstructions. They used randomized trials, meta-analyses, and quip data that shows the laparoscopy is safe, it's effective, and it's associated with shorter length of stay. And it's definitely

best for single band or simple adhesive obstructions, but only in the right patient. Uh, the ideal candidates are less than two prior laparotomies, uh, single band obstruction, no diffuse peritonitis, and the bowel diameters less than four centimeters. Uh, this mirrors current North American minimally invasive surgery practice, especially at high volume centers, uh, for laparoscopic and robotic acute care surgery teams. Nice man. Good analysis, good review. Great job going over that. Um, it's the current standard to build from everywhere in acute care surgery services nationwide. It should be building local protocols, in my opinion, to mirror this kind of information that marries the CT findings, nasogastric tube decompression, water soluble contrast. And these timing based red flag triggers we've gone through quite a bit. Um, it's been, it's been a bit of a journal club. I think all of you guys have done a great job, but I think we should probably start bringing it all together. Yeah. So I wanna remind everyone a lot of what we have heard today and gone over actually started way back in 2011 with, uh, Dr.

Zelensky perspective multivariate model. One of the papers that we didn't fully discuss, but I want to clue into a little bit, 'cause it sets the framework. Or helps tie in everything that we've discussed today. It was the first serious attempt to bring objective CT driven structure to by the notoriously murky disease process we have. And after reviewing these papers from Switzerland, Finland, the new US models and these consensus algorithms, it's remarkable just to see how much has changed, but also kind of to realize how much has really stayed the same, looking at the same things, just with different models. And you can see across every era, and with every healthcare system, there's just. One key message that to me, I think keeps resurfacing. It's the surgeon's job to identify strangulation early and before the bowel declares itself and not after. I think that's one of the key points, right? Zelensky original work showed that just four features, OB observation, mesenteric edema, free fluid, and the absence of feces signs could meaningfully stratify patients, which

were heading towards the, or. Which I think we've done a pretty good job. Fast forwarding now into 2023 and 2025 with the Geneva score that expanded the concept by integrating clinical labs and TT findings. This finish Drisk and NOFA model in 2025 that returned to mesentary changes like free fluid, the fe feces sign, or lack thereof. Uh, and the number of prior small bowel episodes as most reliable predictors. And then. This all got tied together with that Jtax algorithm that just came out right, and it kind of talks about the same features and the foundational knowledge of those red flags on the CT scan that determine whether or not you should be proceeding for early operative intervention. For me, you sit back and you listen to these journal clubs and you ask ourselves, what does it all tell us? Despite more complex stats, multivariate modeling, all this bootstrapping and external validation, the same core imaging features that mattered in 2011. Still matter today, our tools have just only gotten better. Right?

Um, we have better cts, higher quality imaging. Our methodologies are tighter. Our access to laboratory data and quick access point of care evals are much more improved. But the biology of strangulation hasn't changed. It's the same, it's the same biology, right? Yeah. So there are three big shift we've seen now which are pretty interesting. So we've gone from operating. Operating early to operating selectively, but earlier when you should. So the old mantra of don't let the sun rise or set on a small bowel obstruction is actually given way to a more modern mantra, which is don't delay when high risk features are present. Also we've seen that there's no single lab, no single CT cut, no single vital sign will save you modern scoring systems. Acknowledge what seasoned surgeons already know. Small bowel obstruction severity emerges from patterns, not isolated findings. So it's whether it's alinsky's, uh, three feature or four feature model Geneva's eight item score, or

the STR NOFA six predictors. The shift is towards integrated clinical models that reflect real world decision making. And then finally, the long game is important, recurrence matters. So again, operative management at the first episode. Decreases long-term recurrence. Non-operative management has lower perioperative morbidity, but earlier and more recurrent more frequent recurrence in each episode. Operative or non-operative raises the risk for future recurrence. Alright, dude, so what does this all leave us in the tight country and across North America? After 15 years of models, validation studies and international data sets, I'm pretty sure we can distill, listen to four clinical routes that surgeons can bank on. Um, so number one, CT predictors are at the heart of SBO decision making. I know that kind of burns a couple of my senior partners, but I'm gonna say it across every paper and every country. The strongest predictors of needing surgery include mesenteric, edema and

or stranding free inter peral fluid, closed loop transition points, lack of small ball enhancement, and or the absence of a feces sign. Number two. The physical exam, which honestly in my humble opinion is the most important, still matters, especially ing and the delineation of an observation. History. Guardian and observation appear repeatedly and repeatedly has significant predictors in, in all the studies from Geneva Zelensky to JTA. Everyone talked about it. And if a patient has both objective CT red flags and or guarding with persistent pain and no bowel movements or flats. You should seriously consider expediting the OR and not another gastro challenge or another day with the NG tube because you may aspirate. Number three, failure of non-operative management is predictable and or preventable, right? The stress and NOVA or NOFA score reminds us that non-operative failure failure doesn't occur randomly. It's predictable

and you can, uh, get an idea from when these patients arrive in the er. Those with high neutrophil lymphocyte ratios, multiple prior SPOs mesentary changes. And there it is again. The fecal sign being present or absent in the setting of guarding and constipation gives you these predicting, uh, predictive models. And if the patient arrives like this and they have those elevated scores, and you use that calculator that's on your home screen, I hope it's on your home screen, the odds of non-operative success dropped dramatically. So instead of repeating imaging and prolonging that N GT decompression. These are the patients where early operative intervention improves outcomes, decreases costs, and decreases the length of stay. So, um, all these things, right? At the end of the day, these are the contributions that we never had in 2011 at Zelensky first framework, which I think is pretty cool. Um, moving at the end above else, remember that SPO isn't just one disease, it's a spectrum. I think that's one of the biggest things we could take home from. This,

your job is to figure out where on that spectrum your patient's gonna lie before the bowel makes the decision for you. So from all of us here at Tiger Country and in Mizzou, this is behind the Knife Acute Care Surgery team signing off and reminding you to trust your exam. Trust the ct, trust the red flags, and when in doubt, operate before the bowel asks you to. So until next time, stay sharp and dominate the day.