International Journal of Surgery 45 (2017) 58e66

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International Journal of Surgery

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Review

Operative versus non-operative management of adhesive small bowel

obstruction: A systematic review and meta-analysis
Shahab Hajibandeh*, 1, Shahin Hajibandeh, Nilanjan Panda, Rao Muhammad Asaf Khan,
Samik Kumar Bandyopadhyay, Sanjay Dalmia, Sohail Malik, Zahirul Huq,
Moustafa Mansour
Department of General Surgery, North Manchester General Hospital, Manchester, UK

h i g h l i g h t s

Operative management of adhesive SBO is associated with risk of morbidity and mortality.

Operative management may reduce the risk of future recurrence.

Surgery could be preserved for cases with evidence of bowel strangulation.

The baseline suspicion of strangulation is a major confounder in current literature.

RCTs are required to compare outcomes in patients with low suspicion of strangulation.

a r t i c l e i n f o a b s t r a c t

Article history:
Objectives: To investigate outcomes of operative and non-operative management of adhesive small
Received 24 May 2017
bowel obstruction (SBO).
Received in revised form
8 July 2017 Methods: We performed a systematic review in accordance with Preferred Reporting Items for Sys-
Accepted 15 July 2017 tematic Reviews and Meta-Analyses statement standards. We conducted a search of electronic infor-
Available online 17 July 2017 mation sources to identify all randomised controlled trials (RCTs) and observational studies investigating
outcomes of operative versus non-operative management of patients with adhesive SBO. We used the
Keywords: Cochrane risk of bias tool and the Newcastle-Ottawa scale to assess the risk of bias of RCTs and obser-
Small bowel obstruction vational studies, respectively. Fixed-effect or random-effects models were applied to calculate pooled
Surgery outcome data.
Conservative Results: We found one RCT, two prospective and three retrospective observational studies, enrolling a
Adhesion total of 876 patients. The analyses showed that operative management of adhesive SBO was associated
Adhesiolysis with a lower risk of future recurrence [odds ratio (OR) 0.54, 95% confidence interval (CI) 0.38e0.76,
P ¼ 0.0005] but a higher risk of mortality [risk difference (RD) 0.03, 95% CI 0.01e0.06, P ¼ 0.01] and
complications (OR 5.39, 95% CI 2.97e9.78, P < 0.00001). There was no difference in need for surgical re-
intervention rate (OR 0.72, 95% CI 0.35e1.47, P ¼ 0.36) and length of stay [mean difference (MD) 5.07, 95%
CI -2.36e12.49, P ¼ 1.0] between operative and non-operative managements. The baseline suspicion of
strangulation was a major confounding factor. When the baseline suspicion of strangulation was higher
in the operative group, the risk of mortality (RD 0.04, 95% CI 0.02e0.07, P ¼ 0.0006) and complications
(OR 8.14, 95% CI 4.16e15.94, P ¼ 0.00001) were higher in the operative group but the risk of recurrence
was lower (OR 0.62, 95% CI 0.43e0.90, P ¼ 0.01). When the baseline suspicion of strangulation was low in
both groups, there was no difference in any of the outcomes except recurrence (OR 0.09, 95% CI 0.02
e0.37, P ¼ 0.0009) which was lower in the operative group.
Conclusions: The difference in baseline suspicion of strangulation between operative and non-operative
groups is a major confounding factor in current literature. The benefit of surgical treatment should be
balanced with the risks associated with surgery, patient's co-morbidities, and presence or absence of
strangulation. Based on the best available evidence it could be argued that surgical intervention could be
preserved for cases with high suspicion or evidence of bowel strangulation. The controversy still remains

* Corresponding author.
E-mail address: shahab_hajibandeh@yahoo.com (S. Hajibandeh).
1
Shahin Hajibandeh and Shahab Hajibandeh equally contributed to this paper
and joined first authorship is proposed.

http://dx.doi.org/10.1016/j.ijsu.2017.07.073
1743-9191/Crown Copyright © 2017 Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. All rights reserved.
 S. Hajibandeh et al. / International Journal of Surgery 45 (2017) 58e66
for optimum length of conservative management and timing of surgery (early or late) for cases with low
baseline suspicion of strangulation. Randomised controlled trials are required to compare outcomes of
early operation (<24 h) versus late operation (>24 h) and early operation versus conservative man-
agement in patients with low suspicion of strangulation.
Crown Copyright © 2017 Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. All rights
1. Introduction
Acute small bowel obstruction (SBO) accounts for about 20% of
all surgical emergencies in Western societies [1,2]. SBO is
commonly caused by adhesions [3]. Adhesive SBO occurs in 3% of all
laparotomies, 1% during the first postoperative year [3,4]. The
recurrent nature of adhesive SBO, ranging from 19 to 53%, repre-
sents a major clinical problem [5,6].
The management of adhesive SBO is based on clinical evalua-
tion, biological tests, and computed tomography (CT) imaging. The
choice between initial operative or non-operative treatment of SBO
still remains controversial. Considering that adhesive obstruction is
commonly caused because of previous abdominal surgery, surgical
treatment may seem like a paradox [7]. Successful conservative
treatment may leave adhesions that could cause recurrence; on the
other hand, surgery may be the source of new adhesions. It has
been shown that up to 70% of adhesive SBO can be resolved by
conservative management with nasogastric tube, intravenous fluid,
analgesics, regular assessments and correction of electrolyte
imbalance [8,9]. Adhesive SBO can lead to small bowel strangula-
tion which is considered as a major cause of morbidity and even
mortality due to associated bowel ischemia and subsequent bowel
resection; when an extensive resection is required, short bowel
syndrome is a significant consequence. Therefore, surgery is indi-
cated in patients with clinical deterioration or with radiological
evidence of strangulation [10,11]. However, there are no clear
guidelines for surgery in non-strangulated adhesive obstruction.
The timing of surgery and optimum length of operative manage-
ment have always been the subject of debate. Moreover, consid-
ering that laparoscopic surgery is becoming more common in
emergency surgery, laparoscopic approach for treatment of adhe-
sive SBO has been investigated by some authors [12].
In spite of ongoing debate, operative and non-operative man-
agement of adhesive SBO have been compared by a few studies. To
our knowledge, there is no comprehensive review and meta-
analysis in the current literature investigating this. In view of this,
we aimed to perform a comprehensive systematic review and
conduct a meta-analysis of outcomes to compare operative and
non-operative management of adhesive SBO. A critical discussion
of results was attempted to determine the strengths and limitations
of available data, evaluate the quality of the available evidence and
identify areas for future research.
2. Methods
We performed a systematic review according to an agreed
predefined protocol which was registered at Research Registry. The
review was conducted and presented according to Preferred
Reporting Items for Systematic Reviews and Meta-Analyses
(PRISMA) statement standards [13].
2.1. Eligibility criteria
We included all observational studies and randomised
59
reserved.
controlled trials (RCTs) investigating outcomes of operative versus
non-operative management of adhesive SBO. The study population
comprised of all adult patients age >16 with diagnosis of adhesive
SBO. The diagnosis of SBO was based on the clinical and radiological
assessment. Operative management was considered as the inter-
vention of interest and was defined as laparoscopic or open adhe-
siolysis with or without small bowel resection. Non-operative
management was considered as the comparator and was defined as
conservative treatment with nasogastric tube, intravenous fluid,
analgesics, regular assessments and correction of electrolyte
imbalance. Other causes for SBO including malignancy, volvulus,
post-operative ileus, Crohn's disease, intussusception, gallstone,
hernia, or Meckel's diverticulum were excluded from this study.
2.2. Outcome measures
Mortality and recurrence were considered as primary outcome
measures. The secondary outcome measures included need for
surgical re-intervention (adhesiolysis or bowel resection), compli-
cations, length of stay, time-interval to recurrence and number of
recurrences during follow up.
2.3. Literature search strategy
Two authors (NP, SH) independently searched the following
electronic databases: MEDLINE, EMBASE, CINAHL, and the
Cochrane Central Register of Controlled Trials (CENTRAL). The last
search was run on 01 April 2017. Thesaurus headings, search op-
erators and limits in each of the above databases were adapted
accordingly. The literature search strategy is outlined in Appendix I.
In addition, World Health Organization International Clinical Trials
Registry (http://apps.who.int/trialsearch/), ClinicalTrials.gov
(http://clinicaltrials.gov/) and ISRCTN Register (http://www.isrctn.
com/) were searched for details of ongoing and unpublished
studies. The bibliographic lists of relevant articles and reviews were
interrogated for further potentially eligible studies. No language
restrictions were applied in our search strategies.
2.4. Study selection
The title and abstract of articles identified from the literature
searches were assessed independently by two authors (NP, SH). The
full-texts of relevant reports were retrieved and those articles that
met the eligibility criteria of our review were selected. Any dis-
crepancies in study selection were resolved by discussion between
the authors. An independent third author (SH) was consulted in the
event of disagreement.
2.5. Data collection
We created an electronic data extraction spreadsheet which was
pilot-tested in randomly selected articles and was adjusted
accordingly. Our data extraction spreadsheet included: study-
related data (first author, year of publication, country of origin of
60 S. Hajibandeh et al. / International Journal of Surgery 45 (2017) 58e66
the corresponding author, journal in which the study was pub-
lished, study design, study size and clinical condition of the study
participants), baseline demographic and clinical information of the
study populations (age, gender, previous abdominal surgery, basis
for SBO diagnosis, timing of surgery and baseline suspicion of
strangulation) and primary and secondary outcome data. Data
collection was performed independently by two authors (NP,SH)
and disagreements were resolved by discussion. If no agreement
could be reached a third author (SH) was consulted.
2.6. Methodological quality and risk of bias assessment
Two authors (NP and SH) independently assessed the method-
ological quality and risk of bias of the included articles using the
Cochrane tool and the Newcastle-Ottawa scale (NOS) [14] for
assessing the risk of bias of randomized trials and observational
studies, respectively. The Cochrane tool assesses domains including
selection bias, performance bias, detection bias, attrition bias,
reporting bias and other sources of bias and, for each individual
domain, classifies studies into low, unclear, and high risk of bias.
The NOS uses a star system with a maximum of nine stars to
evaluate a study in three domains (8 items): the selection of the
study groups, the comparability of the groups and the ascertain-
ment of outcome of interest. For each item of the scale, we judged
each study as low risk (one star awarded) or high risk (no star
awarded). We determined studies that received a score of nine stars
to be of low risk of bias, studies that scored seven or eight stars to
be of moderate risk, and those that scored six or less to be of high
risk of bias. Disagreements were resolved by discussion between
the reviewers. If no agreement could be reached, a third author (SH)
acted as an adjudicator. A risk of bias graph was constructed to
present the results.
2.7. Data synthesis and statistical analyses
For dichotomous outcome variables (mortality, recurrence,
complications, need for surgical re-intervention), we calculated the
odds ratio (OR) as the summary measure. The OR is the odds of an
event in the operative group compared to the non-operative group.
An OR of less than one would favour the operative group and an OR
of more than one would favour the non-operative group. We
calculated the risk difference (RD) when more than 25% of the
studies had zero events in both groups. For continuous parameters
(length of stay), we calculated the mean difference (MD) between
the two groups. Individual patient was used as the unit of analysis.
The final analysis was based on intention-to-treat data from the
individual clinical studies.
We used the Review Manager 5.3 software for data synthesis
[15]. We applied random effects models if considerable heteroge-
neity among the studies was identified and results were reported in
a forest plot with 95% confidence intervals (CIs).
Heterogeneity among the studies was assessed using the
Cochran Q test (c2). We quantified inconsistency by calculating I2
and interpreted it using the following guide: 0%e50% may repre-
sent low heterogeneity, 50%e75% may represent moderate het-
erogeneity and 75%e100% may represent high heterogeneity. We
planned to construct funnel plots and evaluate their symmetry to
visually assess publication bias for outcomes reported by at least 10
studies. In order to quantify the bias captured by the funnel plot
and to formally assess reporting bias, we planned to calculate the
Egger's regression intercept for outcomes reported by at least 10
studies using the Comprehensive Meta-Analysis (CMA) software
(Biostat, Englewood, NJ). We also planned to calculate the intercept
from a linear regression of normalised effect estimate (estimate
divided by its standard error) against precision (reciprocal of the
standard error of the estimate). Considering that the number of
included studies did not reach the minimum of 10, we were not
able to construct funnel plots and calculate Egger's regression
intercept to formally assess reporting bias.
2.8. Sensitivity and sub-group analyses
In order to explore potential sources of heterogeneity and assess
the robustness of our results, additional analyses were conducted
for outcomes that were reported by at least 4 studies. For each
outcome we repeated the primary analysis using the random ef-
fects and fixed effect model. In addition, we calculated the risk ratio
(RR) and risk difference (RD) for each dichotomous variable. We
assessed the effect of each study on the overall effect size and
heterogeneity by repeating the analysis after removing one study at
a time. We also planned to perform separate analyses for RCTs with
low risk of selection bias in terms of randomisation and allocation
concealment, and for observational studies with low or moderate
risk of bias to assess the change in direction of the effect size.
Moreover, we planned to perform separate analyses for randomised
trials.
Timing of surgery and indication for surgery (ischemia or
strangulation) are potential confounders in operative management
of adhesive SBO. In order to control these confounders, where
possible, we planned to perform sub-group analyses based on 1)
timing of surgery (early surgery, defined as operation within 24 h of
presentation to hospital), and 2) low or high baseline suspicion of
strangulation (presence of one or more of the following signs in-
dicates high suspicion: continuous pain, fever, tachycardia, signs of
peritoneal irritation, leucocytosis, and metabolic acidosis).
3. Results
3.1. Results of the search
Searches of electronic databases identified 517 articles of which
6 studies [16e21] were eligible for this review. These included one
RCT [16], two prospective [17,18] and three retrospective observa-
tional studies [19e21], enrolling a total of 876 patients. Overall, 352
patients underwent adhesiolysis, with or without small bowel
resection, and 524 patients underwent conservative management.
All patients had previous abdominal surgery and adhesion was the
cause of SBO in all patients. At baseline, the suspicion of strangu-
lation was higher in operative group in five studies [17e21] while it
was low and comparable to conservative group in one study, which
was a RCT [16]. Three studies [16,18,21] exclusively compared early
surgery (within 24 h of presentation) with conservative manage-
ment. The follow-up period ranged from 2 to 6 years. The literature
search flow chart, baseline characteristics of the included studies
and baseline characteristics of the included population are
demonstrated in Fig. 1, Table 1 and Table 2, respectively.
3.2. Methodological quality and risk of bias
The summary and results of methodological quality assessment
of the 5 observational studies 1721and one RCT [16] are demon-
strated graphically in Fig. 2.
3.3. Outcome synthesis
3.3.1. Mortality
Mortality was reported in 6 studies [16e21], enrolling 876 pa-
tients (Fig. 3). The risk of mortality was higher in the operative
group (RD 0.03, 95% CI 0.01e0.06, P ¼ 0.01). A low level of het-
erogeneity among the studies existed (I2 ¼ 17%, P ¼ 0.31).
 S. Hajibandeh et al. / International Journal of Surgery 45 (2017) 58e66
Fig. 1. Study flow diagram.
3.3.2. Recurrence
Recurrence was reported in 4 studies [16,17,20,21], enrolling 715
patients (Fig. 3). The risk of recurrence was lower in the operative
group (OR 0.43, 95% CI 0.19e0.95, P ¼ 0.04). A moderate level of
heterogeneity among the studies existed (I2 ¼ 68%, P ¼ 0.03).
3.3.3. Need for surgical re-intervention
Need for surgical re-intervention was reported in 5 studies
[16e18,20,21], enrolling 824 patients (Fig. 3). There was no signif-
icant difference in need for surgical re-intervention between the
operative and non-operative groups (OR 0.72, 95% CI 0.35e1.47,
P ¼ 0.36). A low level of heterogeneity among the studies existed
61
(I2 ¼ 0%, P ¼ 0.78).
3.3.4. Complications
Complications was reported in 4 studies, enrolling 622 patients
(Fig. 3). The risk of complications was higher in the operative group
(OR 4.76, 95% CI 1.38e16.41, P ¼ 0.01). A moderate level of het-
erogeneity among the studies existed (I2 ¼ 65%, P ¼ 0.03).
3.3.5. Length of stay
Length of stay was reported in 5 studies [16e18], enrolling 843
patients (Fig. 3). There was no significant difference in length of
stay between the operative and non-operative groups (MD 5.07,
95% CI -2.36e12.49, P ¼ 1.0). A high level of heterogeneity among
the studies existed (I2 ¼ 99%, P < 0.00001).
The other outcomes were not reported adequately by the
included studies.
3.4. Additional analyses
3.4.1. Sensitivity analyses
We performed sensitivity analyses for the outcomes that were
reported by at least 4 studies. The use of random-effects or fixed-
effect models did not affect the direction of the effect size in any
of the outcomes. Moreover, the direction of the effect size for all of
the outcomes remained unchanged when RRs or RDs were calcu-
lated. The separate analyses for studies with low or moderate risk of
bias did not affect the direction of the effect sizes. Removing one
study at a time changed the direction of the effect size and the
overall heterogeneity for mortality and length of stay.
3.4.2. Randomised controlled trial
One RCT [16] enrolling a total of 51 patients was included. There
was no difference in the risk of mortality (OR 0.33, 95% CI 0.06e1.91,
P ¼ 0.22), need for surgical re-intervention (OR 0.96, 95% CI
0.17e5.26, P ¼ 0.96) and complications (OR 0.68, 95% CI 0.14e3.42,
P ¼ 0.64) between the two groups. The risk of recurrence was lower
in the operative group (OR 0.09, 95% CI 0.02e0.37, P ¼ 0.0009) and
length of stay was shorter in the operative group (MD -4.90, 95% CI
-5.41 to 4.39, P < 0.00001).
3.4.3. Operative group with high baseline suspicion of strangulation
When the baseline suspicion of strangulation was higher in the
operative group (reported by five studies [17e21]), the risk of
mortality (RD 0.04, 95% CI 0.02e0.07, P ¼ 0.0006) and complica-
tions (OR 8.14, 95% CI 4.16e15.94, P ¼ 0.00001) were higher in the
operative group. Operative management was associated with a
lower risk of recurrence (OR 0.62, 95% CI 0.43e0.90, P ¼ 0.01) and
longer length of stay (MD 7.02, 95% CI 4.17e9.87, P < 0.00001).
There was no difference in the need for surgical re-intervention (OR
0.68, 95% CI 0.31e1.49, P ¼ 0.33) between the two groups.
3.4.4. Operative group with low baseline suspicion of strangulation
When the baseline suspicion of strangulation was low in the
operative group (reported by one study [16]), there was no differ-
ence in the risk of mortality (OR 0.33, 95% CI 0.06e1.91, P ¼ 0.22),
need for surgical re-intervention (OR 0.96, 95% CI 0.17e5.26,
P ¼ 0.96) and complications (OR 0.68, 95% CI 0.14e3.42, P ¼ 0.64)
between the operative and non-operative groups. The risk of
recurrence was lower (OR 0.09, 95% CI 0.02e0.37, P ¼ 0.0009) and
length of stay was shorter (MD -4.90, 95% CI -5.41 to 4.39,
P < 0.00001) in the operative group.
3.4.5. Early operation (within 24 h of presentation)
Three studies [16,18,21] enrolling 364 patients compared early
operation with conservative management. There was no difference
62 S. Hajibandeh et al. / International Journal of Surgery 45 (2017) 58e66

Table 1
Baseline characteristics of included studies.

Study Country Journal Design Follow Presentation Comparison

up

Khalil Egypt The Egyptian Journal of RCT 2 years Recurrent postoperative adhesive small Laparoscopic adhesiolysis vs conservative
2016 Surgery bowel obstruction management
Meier Switzerland World J Surg Retrospective 4.7 Acute adhesive small bowel obstruction Adhesiolysis, with or without small bowel
2014 cohort years resection vs conservative
Duron France Annals of Surgery Prospective 6 years Recurrent adhesive small bowel obstruction Adhesiolysis, with or without small bowel
2006 cohort resection vs conservative
Fevang Norway Eur J Surg Prospective NR Acute adhesive small bowel obstruction Adhesiolysis, with or without small bowel
2002 cohort resection vs conservative
Fraser Canada The American surgeon Retrospective NR Postoperative adhesive small bowel Adhesiolysis, with or without small bowel
2002 cohort obstruction resection vs conservative
Miller Canada British journal of Retrospective 6 years Postoperative adhesive small bowel Adhesiolysis, with or without small bowel
2000 surgery cohort obstruction resection vs conservative

RCT: Randomised controlled trial; NR: Not reported.

Table 2
Baseline characteristics of included population.

Study Sample Operative Non- Age Male Adhesion as Previous abdominal Diagnosis basis Baseline suspicion of Time to
size operative cause surgery strangulation surgery

Khalil 51 26 25 47 vs 46% vs 100%vs 100% 100% vs 100% Clinical and Low in both groups < hour
2016 56 48% radiological
Meier 221 136 85 68 vs 38% vs 100% vs 100% 100% vs 100% Clinical and Higher in operative group 87% < 24 h
2014 65 45% radiological
Duron 33 11 22 NR NR 100% vs 100% 100% vs 100% Clinical and Higher in operative group Variable
2006 radiological
Fevang 109 14 95 NR NR 100% vs 100% 100% vs 100% Clinical and Higher in operative group <24 h
2002 radiological
Fraser 52 22 30 NR 71% 100% vs 100% 100% vs 100% Clinical and Higher in operative group Variable
2002 radiological
Miller 410 143 267 NR NR 100% vs 100% 100% vs 100% Clinical and Higher in operative group Variable
2000 radiological

NR: Not reported.

in mortality (OR 1.66, 95% CI 0.59e4.68, P ¼ 0.34), complications
(OR 2.12, 95% CI 0.78e5.80, P ¼ 0.14), need for surgical re-
intervention (OR 1.08, 95% CI 0.46e2.53, P ¼ 0.85) and length of
stay (MD -0.95, 95% CI -9.61e7.72, P ¼ 0.83) between the two
groups. The risk of recurrence was lower in the operative group (OR
0.31, 95% CI 0.17e0.56, P ¼ 0.0001).
4. Discussion
We performed a systematic review of the literature and meta-
analysis of reported outcomes to compare operative and non-
operative management of adhesive SBO. We included one RCT
[16], two prospective [17,18] and three retrospective [19e21]
observational studies, enrolling a total of 876 patients. When the
results of all studies were pooled, our analyses suggested that
operative management of adhesive SBO was associated with a
lower risk of future recurrence but a higher risk of mortality and
complications. There was no difference in need for surgical re-
intervention rate and length of stay between operative and non-
operative managements. The baseline suspicion of strangulation
was higher in the operative group in most of the included studies
except Khalil 2016 [16] which was a RCT in which both operative
and non-operative groups had low suspicion of strangulation.
When the baseline suspicion of strangulation in the operative
group was higher than non-operative group, the operative man-
agement was associated with a higher risk of mortality and com-
plications, longer length of stay and lower risk of recurrence. When
the baseline suspicion of strangulation was low in both groups,
there was no difference in any of the outcomes except recurrence
between the two groups. This highlights that baseline suspicion of
strangulation is a significant confounding factor affecting the out-
comes of operative management in the available studies and should
be controlled in future studies. The between-study heterogeneity
was low to moderate for most of the outcomes. The quality of the
available evidence was moderate.
The research interest and clinical evidence are arising in adhe-
sions prevention. The intraoperative use of adhesion barriers in
prevention of adhesions has been controversial. It has been shown
that oxidised regenerated cellulose and hyaluronate carboxy
methylcellulose reduce adhesion formation [22]. Moreover, it has
been shown that use of icodextrin 4% solution in adhesive SBO is
safe and reduces intra-abdominal adhesion formation and the risk
of re-obstruction [23].
Strangulation is undoubtedly an indication for operative man-
agement of SBO. Open surgery has been the preferred method for
surgical treatment of strangulating adhesive SBO as well adhesive
SBO that fails to respond to conservative management. Considering
that laparoscopic surgery is becoming more common in emergency
surgery, research interest in laparoscopic approach for treatment of
adhesive SBO is arising. A meta-analysis comparing laparoscopic
and open adhesiolysis in 334 patients showed that patients treated
by the laparoscopic approach had less complications and faster
return of bowel function [24]. There is an ongoing trial that is
currently recruiting participants aiming to compare laparoscopic
surgery versus open surgery in the treatment of adhesive SBO [12].
The main controversy in management of adhesive SBO exists
about early operation versus watchful waiting in cases without
evidence of strangulation. The danger in non-operative manage-
ment of SBO is the risk of development of strangulation and asso-
ciated morbidity; this makes the optimum length of conservative
 S. Hajibandeh et al. / International Journal of Surgery 45 (2017) 58e66
Fig. 2. Risk of bias summary and graph showing authors' judgements about each risk of bias item for: a) Randomised trials b) Observational studies.
management of SBO controversial. Some [25e28] argued that
conservative management of SBO should be initially tried while
others [29e33] recommend early operation for adhesive SBO as it
decreases immediate morbidity. Our results suggest that there is no
difference between early operation and conservative management
in terms of mortality, complications, need for surgical re-
intervention and length of stay; however, the risk of recurrence
was lower in the operative group.
The available evidence suggests that the only advantage of
surgical intervention for adhesive SBO without evidence of stran-
gulation is the lower risk of recurrence in operative management
compared to non-operative management. The recurrence as an
outcome following treatment for adhesive SBO should be inter-
preted with cautions as it should be interpreted closely with time-
interval to recurrence and the number of recurrences after inter-
vention of interest. The included studies in the present study had
variable follow up periods and did not provide adequate data
regarding time-interval to recurrence and the number of re-
currences; these do not provide a robust basis for meaningful
conclusions about this outcome.
The benefit of surgical treatment should be balanced with the
risks associated with surgery, particularly for patients with
comorbidities and advanced age. The morbidity associated with
operative management of adhesive SBO may decrease the quality of
life of the patients [34]. Patient's specific factors and co-morbidities
may predict the extent of postoperative morbidity. Jeppesen et al.
[35] showed that chronic nephropathy, obstructive pulmonary
disease and steroid therapy were associated with post-operative
morbidity in patients with adhesive SBO. Moreover, they showed
that low physical performance, metabolic disease and perioperative
blood transfusion were independently associated with mortality
63
[35]. Furthermore, Karamanos et al. [36] showed that diabetes
mellitus was associated with worse postoperative outcomes in
patients undergoing surgery for adhesive SBO later than 24 h of
admission [36].
Management of adhesive SBO is associated with high costs.
Krielen et al. [37] showed that the average costs for a non-operative
episode were over V2000 and for a surgical episode over V16 000.
The majority of costs were related to ward and ICU stay. Moreover,
Colonna et al. [38] showed that surgery performed after earlier
episodes of SBO was more costly but also more effective. In fact, the
cost difference between surgery after the 1st SBO recurrence and
the 2nd SBO recurrence was $1,643, with an increase of 0.135
quality adjusted life years (QALYs).
The current literature regarding operative and non-operative
management of adhesive SBO has the following shortcomings: 1)
the populations in operative and non-operative groups are not
comparable in terms of baseline characteristics such as suspicion of
strangulation; 2) the timing of surgery (early versus late) has not
been clarified in most of the available studies, 3) there is inadequate
data about important outcomes such as the time-interval to
recurrence and the number of recurrences and 4) most of the
available studies have non-randomised design with small sample
sizes, not providing a robust evidence and adequate power to
minimise possibility of type 1 and type 2 errors, respectively.
Therefore, there is a need for high quality randomised trials to
provide adequately robust evidence about long term outcomes of
operative versus non-operative management of adhesive SBO.
The reported outcomes of our review should be viewed and
interpreted in the context of inherent limitations. We identified
only 6 eligible studies of which five were non-randomised obser-
vational studies that are inevitably subject to selection bias. The
64 S. Hajibandeh et al. / International Journal of Surgery 45 (2017) 58e66

Fig. 3. Forest plots of the comparisons of a) Mortality; b) Recurrence; c) Need for surgical re-intervention; d) Complications and e) Length of stay. The solid squares denote the odds
ratio (OR), risk difference (RD), or mean difference (MD); the horizontal lines represent the 95% confidence intervals (CIs), and the diamond denotes the pooled OR, RD, or MD.

baseline suspicion of strangulation was higher in the operative
group compared to non-operative group in five studies, subjecting
their results to confounding bias and confounding by indication.
We based the final analysis on intention-to-treat data from the
individual clinical studies; however, considering the retrospective
nature of the most of the included studies, the possibility of bias
associated with our intention-to-treat analysis cannot be ruled out.
Some of the included studies in our review included few partici-
pants and therefore occurrence of few outcome events in these
studies might have led to imprecise effects estimates. The number
 S. Hajibandeh et al. / International Journal of Surgery 45 (2017) 58e66 65

of eligible studies for this review was less than 10, not allowing for Writing the article: Shahab H, NP, Shahin H.
formal assessment of publication bias as planned in our protocol; Critical revision of the article: Shahab H, Shahin H, NP, AK,
therefore, the reporting bias cannot be excluded in this study. SKB,SD,SM,ZH,MM.
Final approval of the article: Shahab H, NP, Shahin H,AK,SD, SKB,
SM,ZH,MM.
5. Conclusions
Statistical analysis: Shahab H, Shahin H, NP.
The difference in baseline suspicion of strangulation between
operative and non-operative groups is a major confounding factor Conflicts of interest
in current literature. The benefit of surgical treatment should be
balanced with the risks associated with surgery, patient's co- Nothing to declare.
morbidities, and presence or absence of strangulation. Based on
the best available evidence it could be argued that surgical inter- Research registration Unique Identifying Number (UIN)
vention could be preserved for cases with high suspicion or evi-
dence of bowel strangulation. The controversy still remains for Not applicable.
optimum length of conservative management and timing of sur-
gery (early or late) for cases with low baseline suspicion of stran- Guarantor
gulation. Randomised controlled trials are required to compare
outcomes of early operation (<24 h) versus late operation (>24 h) Shahab Hajibandeh.
and early operation versus conservative management in patients
with low suspicion of strangulation. References

[1] NELA Project Team, The Second Patient Report of the National Emergency
Funding sources and conflicts of interest Laparotomy Audit (NELA), The Royal College of Anaesthetists, London, 2016.
[2] J.W. Scott, O.A. Olufajo, G.A. Brat, J.A. Rose, C.K. Zogg, A.H. Haider, et al., Use of
National Burden to define operative emergency general surgery, JAMA Surg.
There are no funding sources for this work and no conflicts of
151 (6) (2016 June 15) e160480.
interest and financial disclosures for the authors. [3] R.P. ten Broek, Y. Issa, E.J. van Santbrink, N.D. Bouvy, R.F. Kruitwagen, J. Jeekel,
E.A. Bakkum, M.M. Rovers, H. van Goor, Burden of adhesion in abdominal and
pelvic surgery: systematic review and met-analysis, BMJ 347 (2013 Oct 3)
Appendix I f5588.
[4] D. Menzies, Peritoneal adhesions: incidence, cause, and prevention, Surg.
Annu. 24 (1992) 27e45.
[5] S. Di Saverio, F. Catena, M.D. Kelly, G. Tugnoli, L. Ansaloni, Severe adhesive
small bowel obstruction, Front. Med. 6 (4) (2012) 436e439.
Search No Search strategyy [6] H. Markogiannakis, E. Messaris, D. Dardamanis, N. Pararas, D. Tzertzemelis,
P. Giannopoulos, et al., Acute mechanical bowel obstruction: clinical presen-
#1 MeSH descriptor: [ intestinal obstruction] explode all trees tation, etiology. management and outcome, World J. Gastroenterol. 13 (3)
#2 small bowel obstruction: TI,AB,KW (2007) 432e437.
#3 small intestinal obstruction: TI,AB,KW [7] M. Ayman, M.D. Hassanien, M. Sarwat, Laparoscopic adhesiolysis for recurrent
#4 sbo: TI,AB,KW small bowel obstruction with ultrasonically activated shears, Egypt J. Surg. 23
#5 #1 OR#2 OR#3 OR#4 (2004) 67e73.
#6 operative: TI,AB,KW [8] G. McEntee, Current spectrum of intestinal obstruction, Br. J. Surg. 74 (1987)
#7 surg*: TI,AB,KW 976e980.
#8 adhesiolysis: TI,AB,KW [9] J.G. Mosley, A. Shoaib, Operative versus conservative management of adhe-
sional intestinal obstruction, Br. J. Surg. 87 (2000) 362e373.
#9 surg* near 2 management: TI,AB,KW
[10] E.J. Balthazar, George W. Holmes Lecture: CT of smallbowel obstruction, AJR
#10 #6 OR#7 OR#8 OR#9
Am. J. Roentgenol. 162 (1994) 255e261.
#11 conservative: TI,AB,KW [11] V. Donckier, J. Closset, D. Van Gansbeke, et al., Contribution of computed to-
#12 non-operative: TI,AB,KW mography to decision making in the management of adhesive small bowel
#13 non-surgical: TI,AB,KW obstruction, Br. J. Surg. 85 (1998) 1071e1074.
#14 #11 OR#12 OR#13 [12] V. Sallinen, H. Wikstro € m, M. Victorzon, P. Salminen, V. Koivukangas,
#15 #5 AND#10 AND#14 E. Haukij€arvi, et al., Laparoscopic versus open adhesiolysis for small bowel
obstruction - a multicenter, prospective, randomized, controlled trial, BMC
y This search strategy was adopted for following databases: MEDLINE, EMBASE,
Surg. 14 (2014 Oct 11) 77.
CINAHL and the Cochrane Central Register of Controlled Trials (CENTRAL). [13] A. Liberati, D.G. Altman, J. Tetzlaff, C. Mulrow, P.C. Gøtzsche, J.P. Ioannidis,
M. Clarke, P.J. Devereaux, J. Kleijnen, D. Moher, The PRISMA statement for
reporting systematic reviews and meta-analyses of studies that evaluate
healthcare interventions: explanation and elaboration, BMJ 339 (2009) b2700.
[14] Wells GA, Shea B, O'Connell D, Peterson J, Welch V, Losos M, et al. The
Ethical approval
Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised
studies in meta-analyses. Available at: http://www.ohri.ca/programs/clinical_
Considering the design of our study, ethical approval was not epidemiology/oxford.asp. Accessed April 15, 2017.
[15] Higgins JP, Altman DG, editors. Chapter 8: Assessing risk of bias in included
required.
studies. In: Higgins JP, Green S, editors. Cochrane handbook for systematic
reviews of interventions. Version 5.0.1 [updated September 2008]. Available
Funding at: http://hiv.cochrane.org/sites/hiv.cochrane.org/files/uploads/Ch08_Bias.pdf.
Accessed April 15, 2017.
[16] Khalil OMH, Abdalla WM, Allam ZA. Early laparoscopic adhesiolysis versus
None. conservative treatment of recurrent adhesive small intestinal obstruction: a
prospective randomized controlled trial. Egyptian J Surgery 35:96e101.
[17] Jean-Jacques Duron, Nathalie Jourdan-Da Silva, Sophie Tezenas du Montcel,
Author contribution
Anne Berger, Fabrice Muscari, Henri Hennet, et al., Adhesive postoperative
small bowel obstruction: incidence and risk factors of recurrence after sur-
Conception and design: Shahab H, MM. gical treatment a multicenter prospective study, Ann. Surg. 244 (5) (2006 Nov)
Literature search and study selection: Shahab H, Shahin H, NP. 750e757.
[18] B.T. Fevang, D. Jensen, K. Svanes, et al., Early operation or conservative
Data collection: Shahab H, Shahin H, NP. management of patients with small bowel obstruction? Eur. J. Surg. 168
Analysis and interpretation: Shahab H, Shahin H, NP. (2002) 475e481.
66 S. Hajibandeh et al. / International Journal of Surgery 45 (2017) 58e66
[19] S.A. Fraser, I. Shrier, G. Miller, P.H. Gordon, Immediate postlaparotomy small
bowel obstruction: a 16-year retrospective analysis, Am. Surg. 68 (9) (2002)
780e782.
[20] G. Miller, J. Boman, I. Shrier, P.H. Gordon, Natural history of patients with
adhesive small bowel obstruction, Br. J. Surg. 87 (9) (2000 Sep) 1240e1247.
[21] R.P. Meier, W.O. de Saussure, L.A. Orci, E.M. Gutzwiller, P. Morel, F. Ris, et al.,
Clinical outcome in acute small bowel obstruction after surgical or conser-
vative management, World J. Surg. 38 (12) (2014 Dec) 3082e3088.
[22] R.P. ten Broek, M.W. Stommel, C. Strik, C.J. van Laarhoven, F. Keus, H. van Goor,
Benefits and harms of adhesion barriers for abdominal surgery: a systematic
review and meta-analysis, Lancet 383 (9911) (2014 Jan 4) 48e59.
[23] F. Catena, L. Ansaloni, S. Di Saverio, A.D. Pinna, P.O.P.A. study: prevention of
postoperative abdominal adhesions by icodextrin 4% solution after laparot-
omy for adhesive small bowel obstruction. A prospective randomized
controlled trial, World Soc. Emerg. Surg. J. Gastrointest. Surg. 16 (2) (2012 Feb)
382e388.
[24] M.Z. Li, L. Lian, L. Xiao, W. Wu, Y. He, X. Song, Laparoscopic versus open
adhesiolysis in patients with adhesive small bowel obstruction: a systematic
review and meta-analysis, AJS 204 (2012) 1e8.
[25] J. Sosa, B. Gardner, Management of patients diagnosed as acute intestinal
obstruction secondary to adhesions, Am. Surg. 59 (1993) 125e128.
[26] R.H. Stewardson, Critical operative management of small bowel obstruction,
Ann. Surg. 187 (1978) 189e193.
[27] C. Tanphiphat, S. Chittmittrapap, K. Prasopsunti, Adhesive small bowel
obstruction. A review of 321 cases in a Thai hospital, Am. J. Surg. 154 (1987)
283e287.
[28] P.J. Wolfson, J.J. Bauer, I.M. Gelernt, et al., Use of the long tube in the
management of patients with small-intestinal obstruction due to adhesions,
Arch. Surg. 120 (1985) 1001e1006.
[29] H. Ellis, Mechanical intestinal obstruction, BMJ 283 (1981) 1203e1204.
[30] P.J. Fabri, A. Rosemurgy, Reoperation for small bowel obstruction, Surg. Clin.
North Am. 71 (1991) 131e148.
[31] S.E. Davis, L. Sperling, Obstruction of the small intestine, Arch. Surg. 99 (1969)
424e426.
[32] R.H. Playforth, J.B. Holloway, W.O. Grifn, Mechanical small bowel obstruction:
plea for earlier surgical intervention, Ann. Surg. 171 (1970) 783e787.
[33] B.J. Zedah, J.M. Davis, P.C. Cantizaro, Small bowel obstruction in the elderly,
Am. J. Surg. 51 (1985) 470e473.
[34] M. Jeppesen, M.B. Tolstrup, I. Go € genur, Chronic pain, quality of life, and
functional impairment after surgery due to small bowel obstruction, World J.
Surg. 40 (9) (2016 Sep) 2091e2097.
[35] M.H. Jeppesen, M.B. Tolstrup, S. Kehlet Watt, I. Go € genur, Risk factors affecting
morbidity and mortality following emergency laparotomy for small bowel
obstruction: a retrospective cohort study, Int. J. Surg. 28 (2016 Apr) 63e68.
[36] E. Karamanos, S. Dulchavsky, E. Beale, K. Inaba, D. Demetriades, Diabetes
mellitus in patients presenting with adhesive small bowel obstruction:
delaying surgical intervention results in worse outcomes, World J. Surg. 40 (4)
(2016 Apr) 863e869.
[37] P. Krielen, B.A. van den Beukel, M.W. Stommel, H. van Goor, C. Strik, R.P. Ten
Broek, In-hospital costs of an admission for adhesive small bowel obstruction,
World J. Emerg. Surg. 11 (2016 Oct 6) 49.
[38] A.L. Colonna, N.R. Byrge, S.D. Nelson, R.E. Nelson, M.C. Hunter, R. Nirula,
Nonoperative management of adhesive small bowel obstruction: what is the
break point? Am. J. Surg. 212 (6) (2016 Dec) 1214e1221.