Predictors of medical treatment failure in patients with adhesive small bowel obstruction

Small bowel obstruction (SBO) is a common cause of hospitalization worldwide with approximately 80% of cases resulting from surgical adhesions. While medical treatment is often advocated for SBO, some patients require surgical intervention. The aim of this study was to evaluate predictors of medical treatment failure in patients with adhesive SBO (ASBO).

We performed a retrospective analysis of a consecutive series of patients with ASBO between 2014 and 2024. The sample was divided into two groups; patients who resolved with conservative treatment (G1) and those who required surgical intervention after initial conservative management (G2). Demographic and preoperative variables were compared between groups. A multivariable logistic regression analysis was performed to identify independent factors associated with medical treatment failure.

A total of 225 patients were included; 125 (55.5%) belonged to G1 and 100 (45.5%) to G2. Demographic and laboratory variables were similar between groups, except for mean lactate levels, which were higher in G2 (G1: 0.5 vs G2: 1.1 mmol/L), p = 0.001). Patients in G1 had higher number of previous ASBO episodes (G1: 47 (37.6%) vs. G2: 20 (20.0%), p = 0.004). Previous open surgery (G1: 89 (71.2%) vs. G2: 86 (86%), p = 0.007) and open appendectomy (G1: 16 (12.8%) vs. G2: 24 (24%), p = 0.02) as surgical history were more frequent in G2. Time elapsed since symptoms onset was longer in G2 (G1: 2.2 vs. G2: 2.7 days, p = 0.001). An abrupt transition point (G1:86 (71%) vs. G2: 85 (86.7%), p = 0.005) and a beak sign (G1: 48 (39.6%) vs. G2: 52 (53%), p = 0.04) on CT scan were more frequently observed in G2. In the multivariate analysis, the presence of a transition point on CT (OR 2.25, IC 95% 1.07-4.71, p < 0.03), higher lactic acid levels (OR 1.37, IC 95% 1.07-1.77, p < 0.01), and history of previous open surgery (OR 2.55, IC 95% 1.23-5.30, p < 0.01) were independent predictors of treatment failure. History of multiple previous episodes of ASBO treated successfully with medical treatment (OR 0.43, IC 95% 0.23-0.84, p < 0.01) was associated with medical treatment success. After 50.8 months of follow-up, recurrence of ASBO was higher in G1 (G1: 16 (12.8%) vs G2: 1 (5%), p = 0.04).

ASBO in patients with a transition point on CT, high lactic acid levels, and/or history of previous open operation is significantly less likely to respond to medical treatment. Closer monitoring and early consideration of surgical intervention in these patients might be reasonable to reduce potential morbidity and mortality associated with delayed surgery.