Surgery may curb risk of recurrent adhesive small-bowel obstruction

By Marilynn Larkin

NEW YORK (Reuters Health) - 8/2/2019

"Adhesive small bowel obstruction is one of the most common reasons for hospital admissions to a surgical service," Dr. Ramy Behman of the University of Toronto said by email.

"Surgical dogma has long held that operative intervention for patients with aSBO results in more adhesion formation and a greater risk of recurrence. This dogma has driven clinical practice and the current standard of care - a trial of non-operative management."

"Our study challenges this dogma," he told Reuters Health, "showing that operative intervention for aSBO is associated with a significantly lower risk of recurrence."

Dr. Behman and colleagues studied data from 27,904 patients admitted to hospitals in Ontario, Canada for a first episode of aSBO from 2005 through 2014.

As reported online January 30 in JAMA Surgery, 22.2% of patients had surgery to manage the obstruction. These patients were younger (mean age, 60.2 vs. 61.5 years) and had fewer comorbidities than those managed nonoperatively.

Recurrence rates were lower with operative management than without it (13.0% vs. 21.3%; hazard ratio, 0.62). The five-year probability of recurrence increased with each episode until surgical intervention, at which point the risk of subsequent recurrence fell by approximately 50%.

Further, with each episode managed nonoperatively, the increase in the five-year probability of recurrence ranged from 19.2% after the first episode to 48% after the third. When including all patients with recurrences, the relative risk reduction associated with operative management during the second and third episodes was 51% and 55%, respectively. The authors conclude, "The long-term risk of recurrence of aSBO should be considered in management of this patient population."

"These findings significantly alter the way that we think about aSBO - from a disease characterized by independent acute episodes, to a long-term recurrent illness in which different management strategies impact long-term risks," Dr. Behman said. "We anticipate that this paradigm shift will alter the way that clinical decisions are made and will change practice."

Dr. Alexander Greenstein, Associate Professor Surgery and Health Policy at Mount Sinai in New York City, told Reuters Health, "This robust article...has the potential to be a game changer for the surgeon's approach to aSBO."

"Care should be individualized in all cases, but the data presented in the article should make the surgeon at least consider more aggressive and earlier operative intervention for patients with aSBO," he said by email.

"This is especially true when there is a clearly identifiable target on imaging studies and a laparoscopic approach can be attempted," he concluded.

SOURCE: JAMA Surg 2019.

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