Operating for adhesive obstruction: less recurrence, more early harm

Design

Systematic review and meta-analysis, 3 RCTs and 42 observational studies

Population

205,717 adults and children with adhesive small bowel obstruction

Primary outcome

In-hospital mortality, complications, stay, 5-year recurrence and reoperation

Effect

Mortality OR 1.87 (1.21–2.89); 5-year recurrence OR 0.41 (0.30–0.56)

A systematic review pooled 45 studies (3 randomised trials, 9 prospective and 33 retrospective) covering 205,717 adults and children with adhesive small bowel obstruction, comparing operative and conservative management.

Surgery was associated with higher in-hospital mortality (OR 1.87, 95% CI 1.21 to 2.89), more complications (OR 5.33) and about four extra days in hospital. It was also associated with lower five-year recurrence (OR 0.41, 0.30 to 0.56). Five-year reoperation did not differ significantly. Certainty was very low for most outcomes and low for recurrence.

The early harm figures are heavily confounded: sicker patients, and those with strangulation, go to theatre. The recurrence finding is the more useful one, and is consistent with earlier work suggesting adhesiolysis lowers later readmission.

This does not change the standard approach of a trial of non-operative management with a low threshold for surgery when ischaemia is suspected. It does inform the discussion with patients who have had several admissions.

• Offer a trial of conservative management when there are no signs of ischaemia.
• Discuss the lower recurrence after surgery with patients facing repeated admissions.
• Do not read the higher surgical mortality as a reason to delay theatre in suspected strangulation.
• Consider water-soluble contrast to guide the decision at 24–48 hours.

Why it matters

For recurrent adhesive obstruction, the case for an elective-minded operation rests on recurrence, not on early outcomes.

Don't overread it

Mostly observational data with confounding by indication; surgery did not cause the higher mortality shown here.

The statistics, in plain English

An odds ratio of 0.41 means the odds of recurrence within five years were less than half after surgery. I² values of 64% to 99% show the studies differed greatly, so pooled numbers are rough. Very low certainty means the true effect may be substantially different.

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