From the Guidelines
Surgical Management of Small Bowel Obstruction
Surgical treatment of small bowel obstruction is manageable and often necessary, requiring careful patient selection and individualized management 1.
Key Considerations
- Surgical intervention involves relieving the obstruction, resecting any non-viable bowel, and restoring intestinal continuity, often via a laparoscopic or open approach 1.
- Preoperative management may include bowel rest, nasogastric decompression, and fluid resuscitation with intravenous crystalloids, such as 0.9% saline or lactated Ringer's solution, at a rate of 100-200 mL/hour, and administration of broad-spectrum antibiotics, such as cefoxitin 2 grams intravenously every 8 hours, for a duration of 24-48 hours 1.
- Postoperative care typically involves gradual advancement of oral intake and monitoring for complications, with pain management using medications such as acetaminophen 650-1000 mg orally every 4-6 hours, as needed 1.
Surgical Approach
- Laparotomy is the surgical approach of choice in patients with small bowel obstruction, although laparoscopic surgery may be considered in selected cases 1.
- The use of adhesion barriers can reduce recurrence rates in case of small bowel obstruction caused by adhesions 1.
Non-Operative Management
- Non-operative management is effective in approximately 70-90% of patients with adhesive small bowel obstruction, and involves nil per os, decompression with naso-gastric suction or long intestinal tube, and fluid resuscitation 1.
- The ideal duration of non-operative management is lacking, but most authors consider a 72-hour cutoff safe and appropriate 1.
Complications and Recurrence
- The risk of intestinal injuries is higher in laparoscopic surgery for adhesive small bowel obstruction, and careful selection of patients for laparoscopic surgery is mandatory 1.
- The risk of recurrence is slightly lower after operative treatment compared to non-operative treatment: 8% after 1 year and 16% after 5 years 1.
From the Research
Surgical Management of Small Bowel Obstruction
- Small bowel obstruction can be surgically managed, with studies showing that laparoscopic approach is feasible, effective, and safe 2, 3.
- Laparoscopic management of adhesive small bowel obstruction (ASBO) has been shown to improve postoperative outcomes and functional recovery compared to open surgery 2.
- A retrospective study found that patients who underwent laparoscopic adhesiolysis had a lower overall complication rate, lower mortality, earlier oral intake, and shorter hospital stay compared to those who underwent open surgery 2.
- Another study found that laparoscopic intervention for the operative management of small bowel obstruction may provide superior clinical outcomes, shorter return of bowel function, and length of stay compared to open operation 3.
Patient Selection and Outcomes
- Patient selection is a key factor in the success of laparoscopic management of ASBO, with factors such as age, previous abdominal operations, and complexity of adhesions influencing the decision to use a laparoscopic approach 2, 3.
- Studies have shown that patients who undergo laparoscopic intervention have shorter return of bowel function and length of stay compared to those who undergo open surgery 2, 3.
- A protocol for the management of ASBO using a water-soluble contrast agent has been shown to facilitate early recognition of complete obstruction and reduce hospital length of stay 4.
Diagnostic and Therapeutic Approaches
- Imaging modalities such as computer tomography (CT) and small bowel follow-through (SBFT) are widely used for the diagnosis and management of small bowel obstruction 5.
- The use of water-soluble contrast (WSC) has been shown to stimulate bowel function and may reduce hospital length of stay 6.
- A systematic review found that treatment of ASBO without nasogastric tube decompression is possible, with no significant differences in operative rates, mortality, or rates of bowel resection compared to patients who received NGT decompression 6.