Operative versus conservative management of adhesional intestinal obstruction

AIMS: This prospective controlled trial was undertaken to resolve the controversy over whether intestinal obstruction due to postoperative adhesions should be managed by immediate operation or by conservative care. METHODS: A randomized prospective controlled study was undertaken of all private and public sector patients admitted under the care of one surgeon with intestinal obstruction due to postoperative adhesions over a 15-year period. The patients were randomly allocated either to immediate operation or conservative care with nasogastric aspiration and intravenous fluids. Patients managed conservatively who had not settled after 5 days were operated on. The data were analysed by Student's t test and Fisher's exact test. RESULTS: There were 127 patients. The two groups were statistically identical regarding age, number of previous operations and time since last operation, and heart rate, blood pressure, haemoglobin concentration, white count and urea level on admission. Sixty-three patients were treated conservatively; 22 failed to settle and were operated on, of whom 11 required a bowel resection. There were two postoperative deaths. In 64 patients treated immediately by operation, the incidence of bowel resection was not significantly reduced (22 per cent; P > 0.05) but there were four postoperative deaths. There was no significant difference in the length of stay. CONCLUSIONS: Conservative management of postoperative adhesional intestinal obstruction is safe and 65 per cent settle. In those who fail to settle there is no significantly increased risk of bowel strangulation. There is no way of identifying those who will not settle from the history or initial investigations on admission.