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Flavio G. Rocha, MD; Todd A. Theman, BS; Evan Matros, MD; Stephen M. Ledbetter, MD, MPH; Michael J. Zinner, MD; Stephen J. Ferzoco, MD

Arch Surg. 2009;144(11):1000-1004.

Objective  To determine the natural history and treatment of high-grade small bowel obstruction (HGSBO). Small bowel obstruction is a frequent complication of abdominal surgery. Complete and strangulating obstructions are managed operatively while partial obstructions receive a trial of nonoperative therapy. The management and outcome of patients with HGSBO diagnosed by computed tomography (CT) has not been examined.

Design  Retrospective medical record review. Outcomes for nonoperative vs operative management were analyzed using Fisher exact and log-rank tests.

Setting  Tertiary care referral center.

Patients  One thousand five hundred sixty-eight consecutive patients admitted from the emergency department with a diagnosis of small bowel obstruction between 2000 and 2005 by CT criteria.

Main Outcome Measures  Recurrence of symptoms and complications.

Results  One hundred forty-five patients (9%) with HGSBO were identified, with 88% follow-up (median, 332 days; range, 4-2067 days). Sixty-six (46%) were successfully managed nonoperatively while 79 (54%) required an operation. Length of stay and complications were significantly increased in the operative group (4.7 days vs 10.8 days and 3% vs 23%; P < .001). Nonoperative management was associated with a higher recurrence rate (24% vs 9%; P < .005) and shorter time to recurrence (39 days vs 105 days; P < .005) compared with operative intervention. Computed tomography signs of ischemia, admission laboratory results, and presence of cancer or inflammatory bowel disease were not predictive of an operation.

Conclusions  Patients with HGSBO by CT can be managed safely with nonoperative therapy; however, they have a significantly higher rate of recurrence requiring readmission or operation within 5 years.

Author Affiliations: Departments of Surgery (Drs Rocha, Matros, Zinner, and Ferzoco and Mr Theman) and Radiology (Dr Ledbetter), Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.

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Questioning the Small-Bowel Obstruction Paradigm: Comment on "Nonoperative Management of Patients With a Diagnosis of High-grade Small Bowel Obstruction by Computed Tomography"
H. Leon Pachter
Arch Surg. 2009;144(11):1005.
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