How can small bowel obstruction be prevented?

Prevention of Small Bowel Obstruction

Small bowel obstruction can be prevented primarily through minimally invasive surgical techniques and the use of adhesion barriers, particularly in younger patients who have a higher lifetime risk for recurrent adhesive small bowel obstruction (ASBO). 1

Primary Prevention Strategies

Surgical Techniques

• Minimally invasive approaches: Laparoscopic surgery should be preferred over open procedures whenever feasible, as it results in less adhesion formation 1, 2
• Good surgical technique: Meticulous handling of tissues during surgery with principles including:
  • Careful tissue handling to minimize trauma
  • Thorough hemostasis to prevent blood collection
  • Avoiding unnecessary dissection of tissue planes
  • Minimizing use of foreign materials (sutures, mesh) when possible
  • Preventing contamination with foreign bodies (glove powder, lint)

Adhesion Barriers

• Application timing: Should be used during the initial surgery in high-risk patients, particularly younger individuals who face a higher lifetime risk of ASBO 1
• Types of barriers: Several FDA-approved adhesion barriers are available and should be considered during abdominal or pelvic surgeries, especially in patients undergoing extensive procedures

Secondary Prevention (After First ASBO Episode)

• Adhesion barriers: Should be applied during surgical treatment of ASBO, especially in younger patients who have higher recurrence risk 1
• Surgical approach: When operative treatment is required for ASBO, a laparoscopic approach may be beneficial for selected cases of simple obstruction 1, 2
• Complete adhesiolysis: During surgery for ASBO, consider complete rather than partial adhesiolysis when feasible to reduce recurrence risk

Management of ASBO to Prevent Complications

Non-operative Management

• Initial approach: Non-operative treatment is effective for most patients with ASBO and should be attempted first unless contraindications are present 1
• Contraindications: Peritonitis, strangulation, and intestinal ischemia require immediate surgical intervention 1
• Components of non-operative treatment:
  • Nil per os (NPO)
  • Nasogastric or long-tube decompression
  • Intravenous fluid and electrolyte supplementation 1

Diagnostic Approach

• CT scan: When adhesive etiology is uncertain or when contraindications for non-operative management might be present, CT is the diagnostic technique of choice 1
• Water-soluble contrast: Administration can both diagnose and potentially treat ASBO 1
  • If contrast reaches the colon within 24 hours, this predicts successful non-operative management
  • The contrast itself may have a therapeutic effect in resolving partial obstructions

Special Considerations

High-Risk Patients

• Pregnant women: Diagnostic laparoscopy for SBO is effective with good maternal and fetal outcomes; ultrasound and MRI are preferred over CT 2
• Post-bariatric surgery patients: Require specialized evaluation and approach for NG tube placement 2
• Pediatric patients: May not require routine NG decompression; consider potential complications of NG tubes 2

Pitfalls and Caveats

• Timing of surgical intervention: Delaying surgery beyond 12-24 hours in patients with complete obstruction or signs of strangulation significantly increases morbidity and mortality 2, 3
• Contrast administration risks: Water-soluble contrast can cause aspiration pneumonia and dehydration; ensure adequate stomach decompression before administration and appropriate hydration 1
• Recurrence risk: Despite preventive measures, ASBO has a recurrence rate of approximately 8% at 1 year after surgical management 2

By implementing these preventive strategies, the incidence and recurrence of small bowel obstruction can be significantly reduced, leading to decreased morbidity, mortality, and healthcare costs associated with this common surgical emergency.