The Safety of Expectant Management for Adhesive Small Bowel Obstruction: A Systematic Review

Abstract

Background: Surgical training has long been to "never let the sun set on a bowel obstruction" without an operation to rule out and/or treat compromised bowel. However, advances in diagnostics have called into question the appropriate timing of non-emergent operations and expectant management is increasingly used. We performed a systematic review to evaluate the safety and effectiveness of expectant management for adhesive small bowel obstruction (aSBO) compared to early, non-emergent operation. Materials & Methods: We queried PubMed, EMBASE, and Cochrane databases for studies (1990-present) comparing early, nonemergent operations and expectant management for aSBO (PROSPERO #CRD42017057676). Results: Of 4873 studies, 29 cohort studies were included for full-text review. Four studies directly compared early surgery with expectant management, but none excluded patients who underwent emergent operations from those having early non-emergent surgery, precluding a direct comparison of the two treatment types of interest. When aggregated, the rate of bowel resection was 29% in patients undergoing early operation vs. 10% in those undergoing expectant management. The rate of successful, nonoperative management in the expectant group was 58%. There was a 1.3-day difference in LOS favoring expectant management (LOS 9.7 vs. 8.4 days), and the rate of death was 2% in both groups. Conclusion: Despite the shift towards expectant management of aSBO, no published studies have yet compared early, nonemergent operation and expectant management. A major limitation in evaluating the outcomes of these approaches using existing studies is confounding by indication related to including patients with emergent indications for surgery on admission in the early

Clinicopathological spectrum of small bowel obstruction and management outcomes in adults - experience at a regional academic hospital complex

“…Thus nine patients (20.5%) in the early presentation group and 52 (46.4%) in the delayed group underwent resection (p = 0.003). Other interventions were hernia repair (25) and appendicectomy (3). A stoma was deemed necessary in 12 patients undergoing bowel resection.…”

“…Fifty-four per cent of patients underwent resection in this study, which is higher than the 36% (range 9-51%) reported in the literature. 25,26 In a study by Meier et al, resection was necessary in 32.4% and there was a longer hospital stay for the OM group, and nine deaths (6.6%) were observed, all from the OM group. 26 The complication rate for the whole group was 35% (25% and 37% for the early presentation and delayed presentation groups, respectively).…”

Diagnostics and Complex Treatment of Adghesive Intestinal Obstruction

“…Спайкова хвороба очеревини та її ускладнення у вигляді гострої спайкової тонкокишкової непрохідністі (ГСТКН), незважаючи на досягнення сучасної клінічної хірургії, залишається актуальною проблемою сьогодення. Актуальність проблеми, перш за все, обумовлена повсюдним зростанням планових та ургентних оперативних втручань на органах черевної порожнини, а поступовий перехід сучасної абдомінальної хірургії до менш інвазивних лапароскопічних втручань достеменно не вирішив питання розвитку СХО та ГСТКН [2,13,14,15].…”

Non-Emergent Early Surgical Management for Adhesive Small Bowel Obstruction

“…Before the advent of cross-sectional imaging, standard surgical training was to "never let the sun rise or set on small bowel obstruction." Since then, the increasing availability of computed tomography (CT) has supplanted the requirement of emergent surgical exploration to rule out compromised bowel, permitting a trial of conservative management [1]. In view of high morbidity and mortality associated with emergency surgery in the setting of adhesive small bowel obstruction (ASBO), it should be only considered when signs of strangulation, peritonitis, or bowel ischemia are present [2].…”