Management of adhesive small bowel obstruction: The results of a large prospective trial

Abstract Background: Postoperative adhesive small bowel obstruction (SBO) is a frequent cause of hospital admission in a surgical department. Emergency surgery is needed in a majority of patients with bowel ischemia or peritonitis; most adhesive SBO can be managed nonoperatively. Many studies have investigated benefits of using oral water-soluble contrast to manage adhesive SBO. Treatment recommendations are still controversial. Methods: We conducted an observational prospective monocentric study to test our protocol of management of SBO using Gastrografin®, enrolling 661 patients from January 2008 and December 2021. An emergency surgery was performed in patients with abdominal tenderness, peritonitis, hemodynamic instability, major acute abdominal pain despite gastric decompression, or CT-scan findings of small bowel ischemia. Nonoperative management was proposed to patients who did not need emergency surgery. A gastric decompression with a nasogastric tube was immediately performed in the emergency room for four hours, then the nasogastric tube was clamped and 100 ml of nondiluted oral Gastrografin® was administered. The nasogastric tube remained clamped for eight hours and an abdominal plain radiograph was taken after that period. Emergency surgery was then performed in patients who had persistent abdominal pain, onset of abdominal tenderness or vomiting during the clamping test, or if the abdominal plain radiograph did not show contrast product in the colon or the rectum. In other cases, the nasogastric tube was removed and a progressive refeeding was introduced, starting with liquid diet. Results: 78% of patients with SBO were managed nonoperatively, including 183 (36%) who finally required surgery. Delayed surgery showed a complete small bowel obstruction in all patients who failed the conservative treatment, and a small bowel resection was necessary in 19 patients (10%): among them only 5 had intestinal ischemia. Conclusions: Our protocol is safe and it is a valuable strategy in order to accelerate the decisional making process for management of adhesive SBO, with a percentage of risk of late small bowel resection for ischemia esteemed at 0,1%.