J. Schnuck Olapo1, D. Flum1, K. Fischkoff2 1University Of Washington, General Surgery, Seattle, WA, USA 2Columbia University College Of Physicians And Surgeons, Acute Care Surgery, New York, NY, USA
Introduction: Adhesive small bowel obstruction (aSBO) is one of the most common diagnoses among hospitalized patients. Most patients with aSBOs improve with supportive care and NGT decompression, but approximately 15% of patients fail nonoperative management and require a lysis of adhesions which may result in prolonged hospitalizations and considerable risk of morbidity and death. Emerging evidence suggests that inflammation plays an important role in the progression of SBO raising the potential that anti-inflammatory agents may be a therapeutic option for treatment.
Methods: In patients with SBO, corticosteroids can exert a strong anti?inflammatory effect and also act as anti?emetics. The use of steroids to speed up resolution of malignant SBO (mSBO) is recommended as best practice by the NCCN. A review of all published studies of dexamethasone support this recommendation, finding a ~50% reduction in unresolved SBO with a low incidence of side effects. Importantly, more than 85% of patients categorized as having mSBO in these studies had prior abdominopelvic surgery. Since the cause of SBO can only be distinguished at operation, adhesions were a likely cause of obstruction in many. Two small prospective studies suggest improvement in resolution of aSBO with the use of steroids. Despite these studies showing efficacy, an evidence gap remains about the efficacy and effectiveness of dexamethasone for patients with aSBO.
Results: The 15% of patients who fail non-operative management of aSBO require a lysis of adhesions. Studies show postoperative mortality rates of 2-4.7% and rates of postoperative complications including iatrogenic bowel injury, prolonged ileus, postoperative surgical site infections and hospital acquired infections between 20 and 25%. In part, because the operative management of aSBO carries significant risk and millions of people experience aSBO, there is a critical need for innovative and effective non-operative approaches. The Comparison of Outcomes of Management of Bowel Obstruction (COMBO) Trial is a double-blinded randomized study of a short course of dexamethasone and supportive care versus supportive care alone for patients with aSBO. The primary outcome is resolution of SBO without operative management and/or major complications as defined using modified NSQIP criteria. Secondary outcomes include time to resolution of SBO, time with an NGT, time until eating, time until flatus, length of stay and recurrence of SBO.
Conclusion: aSBO is a very common condition with tremendous impact on patients and the healthcare system. If a patient fails non-operative management and requires an operation, there is significant associated postoperative morbidity and mortality. Reducing inflammation with dexamethasone may improve the success of non-operative management of aSBO and could change the management of millions of patients.