# Challenges and Outcomes of Three Years of the Adhesive Intestinal Obstruction Management Protocol

## TL;DR

This study evaluates a three-year protocol for managing adhesive intestinal obstructions, showing that conservative treatments with Gastrografin can reduce surgery rates and hospital stays.

## Contribution

The study provides new insights into predictive factors for treatment success and outcomes of adhesive SBO management in a high-volume center.

## Key findings

- 69.6% of patients had successful conservative management with therapeutic Gastrografin.
- Elderly patients and those with COPD were more likely to require surgery.
- No significant difference in 30-day mortality between surgical and conservative groups.

## Abstract

Introduction: Small bowel obstruction (SBO) is a significant contributor to surgical morbidity, mortality, and healthcare costs, contributing to a significant number of emergency laparotomies. Advancements in diagnostic techniques have improved the accuracy in delineating simple from complicated SBOs. Some adhesive SBOs will ultimately need surgical intervention, mostly when they are complicated cases. Recently, minimally invasive surgeries, enhanced recovery protocols, and multidisciplinary approaches have become more popular in optimising recovery and minimising recurrence risks. On the other hand, most adhesive SBOs can be managed conservatively with bowel rest, nasogastric (NG) decompression, intravenous fluid therapy, and water-soluble oral contrast agents, leading to a significant reduction in operation-related morbidity, hospital stays, and healthcare costs. Current guidelines recommend a trial of conservative management, although not without controversy.

Aim: This study aimed to explain the predictive factors of success or failure of treatments of adhesive SBOs and statistically report the effect of co-morbidities and expected outcomes of SBO management, based on three-year data from a single high-volume centre in London, UK.

Methodology: Our retrospective-descriptive study included patients with clinical signs of SBO, older than 16 years old, and CT proving adhesive SBO, who required hospital admission. We excluded patients with other causes of SBO and those who had no CT evidence of adhesive disease. Data were collected from online hospital records and analysed in Microsoft Excel® (Microsoft Corporation, Redmond, Washington). Hospital protocol was NG decompression for at least six hours in uncomplicated cases, followed by oral or NG Gastrografin, with abdominal X-rays taken at six and 12 hours post-Gastrografin intake to assess contrast in the colon or rectum. Successful cases were then given a trial of oral feeds before discharge. Those with no contrast in the large intestine, persistent abdominal pain, and onset abdominal tenderness or peritonitis were taken to surgery.

Results and limitations: Out of 415 patients, 30.4% required surgery either as initial mode of treatment or after failed conservative management, proving the effectivity of therapeutic Gastrografin (69.6%), followed by 35.2% being 75 or less years old, proving SBO is more prevalent in elderly population with co-morbidities, as 40.5% are ASA Grade 3, prone to post-operative complications. Surprisingly, COPD patients required surgery more often than those who did not have it, as they desaturate due to distension easily. On the other hand, not much statistical difference is seen in the 30-day mortality rate between the operated and conservatively managed groups.

Conclusion: Our study aligns with the literature to prove that our management protocol is safe. Alongside, the post-operative burden of those undergoing surgery is high; it is vital to identify complex patients for surgery to reduce mortality and morbidity. This goes hand in hand with weighing risks and benefits. Elderly patients carry the risk of major complications plus a higher mortality rate. Timely intervention with therapeutic Gastrografin can minimise the hospital stay and the costs for the NHS owing to long stay post-operatively.