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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%.

The flip side, however, to the nonoperative approach for patients with HGSBO is that 24% required subsequent readmission vs 9% for the operative group. Additionally, the interval to recurrence in the nonoperative group was significantly shorter than for those undergoing surgery. While these statistics are of concern, 75% of the patients nevertheless avoided surgical intervention.

The findings delineated in this article notwithstanding, I would stress that in centers with experienced radiologists, CT scanning can be an extremely useful tool in predicting intestinal ischemia. Its usefulness lies not in its positive predictive value, as seen in this article, but rather in its negative predictive value. Data from the literature would suggest that the negative predictive value for CT scanning when assessing intestinal ischemia is as high as 95% to 98%. In the meantime, CT findings of decreased bowel-wall enhancement, mural thickening, congestion of mesenteric veins, and ascites, in the appropriate setting, should give one cause for concern and vigilance.

Correspondence: Dr Pachter, New York University, New York, NY 10016 (leon.pachter@nyumc.org).

Financial Disclosure: None reported.