COMMENTARY

First Episode of Small Bowel Obstruction: Initially Observe or Operate?

Albert B. Lowenfels, MD

Disclosures

April 16, 2019

The aim of a recent study published in JAMA Surgery[1] was to examine the risk for recurrent adhesive small bowel obstruction after either initial operative intervention or initial observation. The results are based on administrative data from a longitudinal review of 27,904 Canadian patients with adhesive small bowel obstruction who were either initially observed (78%) or operated on (22%).

The authors then matched the two patient groups on characteristics such as age, sex, income, type of hospital, and so on. In the subsequent follow-up period, the overall and 5-year cumulative recurrence of small bowel obstruction differed between the two groups, at 13% for the operative group versus 21% for the nonoperative group (P < .001).

Where Does This Study Leave Us?

According to guidelines proposed by the World Society of Emergency Surgery,[2] unless there are signs of compromised bowel, the initial approach to adhesive small bowel obstruction should be observation, which can be continued for 72 hours unless there warning signs of impending deterioration. Surgeons are trained to follow this pathway.

But what is the long-term outcome of this strategy? Would results be improved with earlier surgery?

This current JAMA study[1] provides additional information on the long-term results, in which initial surgery seems to reduce the risk for subsequent recurrence when compared with initial observation. Despite an attempt at matching, key information about the duration of observation, the indication for surgery, and the number of patients needing bowel resection was not available.

It would be informative if, in future reports based on the same data, the authors were able to provide additional information about the effect of duration of observation on the long-term outcome. Perhaps the recommended 3-day period of observation needs to be modified.

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