Factors Predicting the Need for Early Surgical Intervention for Small Bowel Obstruction

Predictive factors for operative intervention and ideal length of non-operative trial in adhesive small bowel obstruction

BACKGROUND

Small bowel obstruction (SBO) is responsible for 350,000 U.S. hospitalizations and costs ~ $2.3 billion annually. The current standard of care for SBO is to trial 3 to 5 days of non-operative management. This study evaluated the factors associated with operative management.

METHODS

This retrospective cohort study included adult patients admitted with adhesive SBO. Exclusions were for operative intervention within 24 h or death.

RESULTS

At baseline (N = 360), mean age was 65.9 years, 57.8% female, 72.3% white, mean BMI 26.1, 38.7% with history of SBO and 98.1% had history of abdominal surgery. Symptom onset prior to hospitalization was 1-2 days. 55.6% had successful non-operative management at discharge (median length of stay 3 days) vs. 44.4% operative conversion. In univariate analyses, BMI, SBO history, surgical history, days symptom onset, vitals, abdominal pain, obstipation, acute kidney injury, and lack of small bowel feces sign on CT scan were significantly associated with operative management. In a multivariable logistic regression, after controlling all other variables, a lack of small bowel feces sign (adjusted odds ratio, aOR = 2.25, 95% CI 1.06-4.77, p = 0.04) and history of exploratory laparotomy (aOR = 0.44, 95% CI 0.21-0.90, p = 0.03) were significantly associated with operative management. Time from admission to surgery averaged 3.89 days: small bowel resection (55/160) was 4.9 days (median = 4), compared to patients without resection (3.4 days, median = 2; p = 0.00; OR = 1.2, 95% CI 1.07-1.35).

CONCLUSIONS

A lack of small bowel feces sign can be a potential indicator for operative management and should be further explored. Since the median resolution of symptoms in the non-operative management group was ~ 2 days and a 20% higher odds for bowel resection each day surgery is delayed, the conservative trial period for adhesive SBO should not exceed 3 days.

Surgical management of adhesive small bowel obstruction: Is it still mandatory to wait? - An update

Small bowel obstruction syndromes (SBO) represent one of the main causes of emergency admission for surgical abdominal pain. The 2018 Bologna Guidelines (Ten Broek et al. 2018) recommend non-operative management at the outset if there are no signs of severity; surgery is proposed after 72h for the 20-30% of patients who fail medical management. However, these recommendations were based on old studies published at a time when laparoscopic surgery was not commonplace and when diagnostic capabilities (particularly for establishing etiology) were less developed than they are today. Additionally, the advent and development of laparoscopy and enhanced rehabilitation after surgery have led to a decrease in surgical morbidity. These guidelines are therefore now debated and several recent publications have encouraged urgent or semi-urgent surgical management for patients presenting for SBO in order to reduce morbidity, mortality, duration of hospitalization and costs, and to improve the feasibility of therapeutic laparoscopy. Prompt surgical management could also reduce the risk of recurrent small bowel obstructions. This model for early surgical management probably cannot be applied to all patients. It therefore seems important to select those patients at risk for failure of medical treatment and to identify those in whom the probability of successful laparoscopy is high. New radiological tools should allow better selection in the future. At the present time, the indications for early surgery "within 24h" should be emphasized.