Guidelines for management of small bowel obstruction.

STATEMENT OF THE PROBLEM The description of patients presenting with small bowel obstruction (SBO) dates back to the third or fourth century, when early surgeons created enterocutaneous fistulas to relieve a bowel obstruction. Despite this success with operative therapy, the nonoperative management of these patients with attempted reduction of hernias, laxatives, ingestion of heavy metals (e.g., lead or mercury), and leeches to remove toxic agents from the blood was the rule until the late 1800s, when antisepsis and aseptic surgical techniques made operative intervention safer and more acceptable. A better understanding of the pathophysiology of bowel obstruction and the use of isotonic fluid resuscitation, intestinal tube decompression, and antibiotics have greatly reduced the mortality rate for patients with mechanical bowel obstruction. However, the means for determining when a period of observation is warranted versus early surgical intervention continues to be an area of debate. With the advances in imaging techniques, additional information can be supplied to the clinical information obtained from the history and physical. The question of whether these technological advancements have allowed a more sophisticated evaluation of these patients is yet to be determined. In addition which tests supply the most information has yet to be clearly described. Additionally, the optimal length of observation continues to be debated. In the era of a push toward shorter hospital stays correctly identifying patients who are to fail observation is even more important. It is important to analyze whether clinical or radiographic clues can increase our sensitivity in determining such patients. Finally, as minimally invasive surgery grows and finds new applications are there reproducible benefits to the patients in pursuing these intervention as both a diagnostic and therapeutic intervention.