SP 9.06 Context-Dependent Benefit of Water-Soluble Contrast in Adhesive Small-Bowel Obstruction: A Multinational Prospective Study Using Target Trial Emulation
Dane Isenberg, Jimmy Kelliher, Lewis J Kaplan, Matthew J Lee, Nandita Mitra, Gary A BassAbstract
Background
Adhesive small-bowel obstruction (ASBO) is a common emergency surgical admission, yet non-operative management (NOM) practices remain heterogeneous. Water-soluble enteral contrast (WSEC) and nasogastric tube (NGT) decompression are frequently used, but uncertainty persists regarding when these interventions improve outcomes and how benefit varies by severity.
Methods
We analysed prospectively collected data from the SnapSBO study, a multinational cohort including 70 hospitals across 20 countries. Adults with computed tomography–confirmed ASBO triaged to NOM at admission were included. Initial management strategies were defined within the first 24 hours as bowel rest alone, NGT decompression alone, WSEC alone, or combined NGT plus WSEC. Successful NOM was defined as avoidance of surgery and survival to discharge. To address confounding by indication, we evaluated the effect of WSEC separately among patients who did and did not require NGT decompression.
Results
Of 982 eligible patients, 785 (79.9 %) underwent NOM. Overall, successful NOM was achieved in 549 patients (69.9 %). Patients requiring NGT decompression represented a higher-severity subgroup. Among these patients, early WSEC administration was associated with a 10-percentage-point absolute increase in successful NOM. In contrast, no clinically meaningful improvement in successful NOM was observed among patients managed without NGT decompression.
Conclusions
The benefit of WSEC in ASBO appears context dependent and confined to patients requiring NGT decompression, representing higher-severity presentations. Routine use of WSEC in less severe cases may offer limited benefit. These findings support a targeted, severity-informed approach to NOM in ASBO and provide practical guidance for emergency surgical decision-making.