Adhesive Small Bowel Obstruction: Early Operative versus Observational Management

Abstract

We assessed the nonoperative and operative management of adhesive small bowel obstruction (ASBO) and compared complication rates and surgical outcomes. ASBO is a common complication of abdominopelvic surgery. Although patients may respond to nonoperative management, many require surgery. We retrospectively studied patients admitted to Mount Sinai Hospital with a diagnosis of complete ASBO to determine outcomes of nonoperative management. Patients admitted with complete ASBO from 2001 to 2011 were included. Patients with no previous abdominopelvic surgery, surgery within the six weeks preceding admission and obstruction due to other identifiable causes, such as incarcerated hernia, were excluded. Complication rates and outcomes were compared between patients managed with immediate surgery and those managed initially with non-operative strategies. Of 460 patients admitted with complete ASBO, 106 (23.0%) had surgery within 24 hours of admission. At surgery, 20 (18.9%) had ischemic bowel and 8 (7.5%) had perforations. The remaining 354 patients had a trial of nonoperative management lasting at least 24 hours. Of 354 patients managed initially without surgery, 100 (28.2%) patients were discharged without operative intervention during their index admissions. Among the patients having surgery more than 24 hours after admission, indications for surgery were generally failure to resolve, worsening clinical status, and change in imaging findings. Of those patients observed for at least 24 hours, 40 (15.7%) were found to have ischemic bowel and 5 (2.0%) had perforation at surgery. Rates of bowel resection, stoma creation and postoperative complications were similar for the immediate and delayed surgery groups. Among the delayed surgery group, 71 (28.0%) required a bowel resection and 11 (4.3%) stoma creation. Twenty one per cent had postoperative complications, most commonly ileus. There were no statistically significant differences in the outcomes between immediate and delayed groups regardless of duration of delay. Among patients observed with complete ASBO, 24.6 per cent of patients with adhesive obstruction resolved without surgery or readmission. Delaying operative management did not affect surgical findings or complication rates.

Mechanisms of adhesive small bowel obstruction and outcome of surgery; a population-based study

“…An elderly patient with co-morbidity and not requiring emergency surgery will probably start with a conservative regimen to avoid the surgical trauma. In our study, about 20% of patients needed same-day surgery, which is about equal to the rate reported by Bauer et al [20]. Overall mean time to surgery was 3.4 days (including outliers).…”

Optimal time of surgery for acute adhesive small bowel obstruction

“…О пациентах, нуждавшихся в экстренной операции из-за ишемии кишки, которым, однако, проводилось длительное консервативное лечение, сообщается в зарубежных и отечественных публикациях [9,17,19]. В Болонских рекомендациях выделены следующие группы пациентов, у которых исключается консервативное лечение ОСТКН:…”

Management of Intestinal Obstruction

“…In summary, clinically stable patients with partial obstruction can be treated by conservative management [50].…”

“…There are high success rates in the stable patients with incomplete obstruction [53,54]. Among the patients with adhesive small bowel obstruction, 24.6% of patients are treated with nonoperative management, without surgery or readmission [55]. On the other hand, high rates of recurrence and the risk of complications including vascular impairment were reported [47].…”