Adhesive small bowel obstruction in the virgin abdomen: comparable phenotype, divergent management

In small bowel obstruction (SBO), the absence of prior abdominal surgery is commonly interpreted as a marker of higher-risk pathology and is often associated with a lower threshold for early operative intervention. Whether this assumption reflects differences in disease phenotype or decision-making remains uncertain.

This post hoc analysis of a prospective, multicenter cohort study included consecutive adults with CT-confirmed mechanical SBO. Analyses were restricted to patients with adhesion-related SBO to enable comparison between virgin abdomen adhesive SBO (vaASBO) and prior-surgery adhesive SBO (psASBO). Clinical presentation, imaging findings, management strategies, and 60-day outcomes, including patient-reported outcome measures (PROMs), were evaluated. Analyses were associative and unadjusted.

Among 1,737 patients, 417 (24.0%) had no prior abdominal surgery; adhesions accounted for 30% of cases in this subgroup. The adhesion-restricted cohort included 982 patients, of whom 127 (12.9%) had vaASBO. Clinical and radiological features were similar between groups; however, management differed substantially. Patients with vaASBO had higher rates of direct-to-surgery (+ 15.0% points), lower use of water-soluble contrast (- 19.1% points), and higher rates of nonoperative management (NOM) failure (+ 25.1% points). Among patients undergoing surgery, complication rates were lower in vaASBO (9.2% vs. 23.3%), with similar rates of major complications, mortality, and length of stay. Among patients successfully managed nonoperatively, clinical outcomes and PROMs were comparable.

In an adhesion-restricted cohort, patients with and without prior abdominal surgery had comparable clinical phenotype, yet management diverged. These findings suggest that surgical history is associated with treatment selection beyond measured markers of disease severity. A CT-guided, risk-stratified approach may provide a more consistent and reproducible basis for decision-making and reduce unnecessary surgery without compromising clinical or patient-reported outcomes.