Clinical and CT-Guided Decision Making in Adhesive Small Bowel Obstruction: A Single Center Prospective Study

Abstract

Background: Adhesive small bowel obstruction (ASBO) is one of the common causes of readmission after any abdominal surgery in adults. While current guidelines suggest an initial conservative management trial, the value of computed tomography (CT) findings to predict the failure of nonoperative treatment is still unclear. Methods: This prospective, single-center cohort study included 41 adult patients with ASBO. All patients underwent standardized clinical assessment, CT imaging, and initial conservative management unless immediate surgery was indicated. CT variables, including mesenteric edema, small bowel feces sign, and intraperitoneal free fluid, were recorded. The outcomes of interest were the success or failure of conservative therapy, the need for surgery, intraoperative adhesion grade according to the Zühlke classification, postoperative complications, and length of hospital stay. Results: 30 patients (73.2%) were treated conservatively and 11 patients (26.8%) had early surgery. A total of 17 patients (41.5%) had to be operated on after the initial period of conservative treatment, and this was successful in 13 (31.7%). Mesenteric edema, small-bowel feces sign and intraperitoneal free fluid were not significantly associated with failure of conservative management or need for surgery in classical CT. Mean hospital stay was less in the patients in whom conservative treatment was successful than in the patients who underwent surgery. The predominant intraoperative adhesions were localized and single band, especially following midline laparotomy and laparotomy of the pelvis, while postoperative complications (mainly wound infection and pneumonia) were found in a significant number of the surgical patients. Conclusion: In this prospective cohort of patients with ASBO, commonly evaluated CT features were not useful for predicting the failure of conservative management and/or the need for surgery. Most patients eventually require surgical treatment after a period of nonoperative treatment, with considerable morbidity. This study suggests a multicenter approach with quantitative radiological scoring systems to define the optimal timing of surgery for ASBO and the pitfalls of CT-based decision-making.