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Invited Critique
November 16, 2009

Questioning the Small-Bowel Obstruction Paradigm: Comment on “Nonoperative Management of Patients With a Diagnosis of High-grade Small Bowel Obstruction by Computed Tomography”

Arch Surg. 2009;144(11):1005. doi:10.1001/archsurg.2009.184

Small-bowel obstruction, a common complication after abdominal surgery, can be a vexing problem for any surgeon. In the past, partial obstruction was managed nonoperatively because up to 80% resolved with conservative treatment, whereas complete obstruction was almost always operated on because reasonable hopes for spontaneous resolution usually did not exceed 5%.

The article by Rocha et al, although retrospective in nature, dispels some myths and questions the basis for the long-held aforementioned management paradigm. Several key points evolved from this report. Nearly half (46%) of patients with CT evidence of high-grade obstruction could be managed conservatively; most would have been operated on in the past. Computed tomography signs of ischemia, tachycardia, leukocytosis, and acidosis were not, in and of themselves, predictors of the need for surgical intervention; the recurrence rate of SBO, thought rarely to occur after surgical intervention, was in the magnitude of 12% to 18%.

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