Surgical Versus Conservative Management for Adhesive Small Bowel Obstruction: A Systematic Review and Meta-Analysis

To compare the clinical outcomes of surgical versus conservative management for adhesive small bowel obstruction (ASBO) in adult and pediatric patients by evaluating clinical outcomes, including in-hospital mortality, length of stay (LOS), in-hospital complications, 5-year recurrence, and 5-year reoperation.

PubMed, Scopus, and Embase databases were searched for all randomized controlled trials (RCTs) and observational studies until March 2, 2026. Both adult and pediatric studies were included. Risk of bias (ROB) was evaluated using the Cochrane Risk-of-Bias 2 (RoB2) tool for RCTs, and the ROBINS-I tool for observational studies. A pairwise meta-analysis used a random-effects model to estimate the clinical outcomes. The odds ratio (OR) and mean difference (MD) were employed to analyze dichotomous and continuous outcomes, respectively, with heterogeneity assessed by the I² statistic.

45 studies were included (9 prospective studies, 33 retrospective studies, and 3 RCTs), with a total of 205,717 patients with ASBO. Forty studies involved adults, and five involved pediatric patients. The surgical management may be associated with higher in-hospital mortality (OR = 1.87; 95% CI 1.21-2.89; I² = 63.68%, p = 0.010, very low certainty), more in-hospital complications (OR = 5.33; 95% CI 3.17-8.97; I² = 76.89%, p < 0.001, very low certainty), and longer LOS (MD = 4.10; 95% CI 3.44-4.76; I² = 98.81%, p < 0.001, very low certainty) compared with the conservative management. However, surgical management may be associated with a lower risk of 5-year recurrence (OR = 0.41; 95% CI 0.30-0.56; I² = 78.44%, p < 0.001, low certainty) compared with conservative management. No statistically significant association was observed in 5-year reoperation between the surgical and conservative management (OR = 0.73; 95% CI 0.22-2.49; I² = 21.28%, p = 0.620, very low certainty).

Surgical management may be associated with a lower risk of 5-year recurrence in patients with ASBO but may be associated with higher in-hospital mortality, more in-hospital complications, and a longer length of stay. However, these findings should be interpreted with caution because of substantial heterogeneity and risk of bias.