Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2013 update of the evidence-based guidelines from the world society of emergency surgery ASBO working group

Salomone Di Saverio; Federico Coccolini; Marica Galati; Nazareno Smerieri; Walter L Biffl; Luca Ansaloni; Gregorio Tugnoli; George C Velmahos; Massimo Sartelli; Cino Bendinelli; Gustavo Pereira Fraga; Michael D Kelly; Frederick A Moore; Vincenzo Mandalà; Stefano Mandalà; Michele Masetti; Elio Jovine; Antonio D Pinna; Andrew B Peitzman; Ari Leppaniemi; Paul H Sugarbaker; Harry Van Goor; Ernest E Moore; Johannes Jeekel; Fausto Catena

doi:10.1186/1749-7922-8-42

Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2013 update of the evidence-based guidelines from the world society of emergency surgery ASBO working group

World J Emerg Surg. 2013 Oct 10;8(1):42. doi: 10.1186/1749-7922-8-42.

Authors

Salomone Di Saverio^#¹, Federico Coccolini², Marica Galati¹, Nazareno Smerieri¹, Walter L Biffl³, Luca Ansaloni², Gregorio Tugnoli¹, George C Velmahos⁴, Massimo Sartelli⁵, Cino Bendinelli⁶, Gustavo Pereira Fraga⁷, Michael D Kelly⁸, Frederick A Moore⁹, Vincenzo Mandalà¹⁰, Stefano Mandalà¹⁰, Michele Masetti¹, Elio Jovine¹, Antonio D Pinna¹¹, Andrew B Peitzman¹², Ari Leppaniemi¹³, Paul H Sugarbaker¹⁴, Harry Van Goor¹⁵, Ernest E Moore³, Johannes Jeekel¹⁶, Fausto Catena^#^{11

17}

Affiliations

¹ Emergency and Trauma Surgery Unit, Departments of Emergency and Surgery, Maggiore Hospital Trauma Center, Bologna, Italy.
² General Surgery I, Ospedali Riuniti di Bergamo, Bergamo, Italy.
³ Department of Surgery, Denver Health, University of Colorado Health Sciences Denver, Denver Health Medical Center, 777 Bannock Street, Denver CO 80204, USA.
⁴ Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
⁵ Department of Surgery, Macerata Hospital, Via Santa Lucia 2, 62100 Macerata, Italy.
⁶ Department of Surgery, John Hunter Hospital and University of Newcastle, Locke Bag 1 Hunter Region Maile Centre, Newcastle, NSW 2310, Australia.
⁷ Division of Trauma Surgery, University of Campinas, Campinas, SP, Brazil.
⁸ Upper GI Unit, Department of Surgery, Frenchay Hospital, North Bristol, NHS Trust, Bristol, UK.
⁹ Department of Surgery, University of Florida, Gainesville, FL 32610-0254, USA.
¹⁰ Department of General and Emergency Surgery, Associated Hospitals "Villa Sofia - Cervello", Palermo, Italy.
¹¹ Emergency Surgery Unit, Department of General and Multivisceral Transplant Surgery, S Orsola Malpighi University Hospital, Bologna, Italy.
¹² Division of General Surgery, University of Pittsburgh Physicians, Pittsburgh 15213 PA, USA.
¹³ Emergency Surgery, Department of Abdominal Surgery, Meilahti Hospital, University of Helsinki, Haartmaninkatu 4, 340, Helsinki FIN-00029 HUS, Finland.
¹⁴ Washington Cancer Institute, Washington Hospital Center, Washington, 20010 DC, USA.
¹⁵ Department of Surgery, Radboud University Nijmegen Medical Centre, P.O. Box 9101 6500 HB, Nijmegen, The Netherlands.
¹⁶ Department of Surgery, Erasmus University Medical Center, PO Box 2040 3000 CA, Rotterdam, The Netherlands.
¹⁷ Department of Emergency and Trauma Surgery, Maggiore Hospital of Parma, Parma, Italy.

^# Contributed equally.

Abstract

Background: In 2013 Guidelines on diagnosis and management of ASBO have been revised and updated by the WSES Working Group on ASBO to develop current evidence-based algorithms and focus indications and safety of conservative treatment, timing of surgery and indications for laparoscopy.

Recommendations: In absence of signs of strangulation and history of persistent vomiting or combined CT-scan signs (free fluid, mesenteric edema, small-bowel feces sign, devascularization) patients with partial ASBO can be managed safely with NOM and tube decompression should be attempted. These patients are good candidates for Water-Soluble-Contrast-Medium (WSCM) with both diagnostic and therapeutic purposes. The radiologic appearance of WSCM in the colon within 24 hours from administration predicts resolution. WSCM maybe administered either orally or via NGT both immediately at admission or after failed conservative treatment for 48 hours. The use of WSCM is safe and reduces need for surgery, time to resolution and hospital stay.NOM, in absence of signs of strangulation or peritonitis, can be prolonged up to 72 hours. After 72 hours of NOM without resolution, surgery is recommended.Patients treated non-operatively have shorter hospital stay, but higher recurrence rate and shorter time to re-admission, although the risk of new surgically treated episodes of ASBO is unchanged. Risk factors for recurrences are age <40 years and matted adhesions. WSCM does not decrease recurrence rates or recurrences needing surgery.Open surgery is often used for strangulating ASBO as well as after failed conservative management. In selected patients and with appropriate skills, laparoscopic approach is advisable using open access technique. Access in left upper quadrant or left flank is the safest and only completely obstructing adhesions should be identified and lysed with cold scissors. Laparoscopic adhesiolysis should be attempted preferably if first episode of SBO and/or anticipated single band. A low threshold for open conversion should be maintained.Peritoneal adhesions should be prevented. Hyaluronic acid-carboxycellulose membrane and icodextrin decrease incidence of adhesions. Icodextrin may reduce the risk of re-obstruction. HA cannot reduce need of surgery.Adhesions quantification and scoring maybe useful for achieving standardized assessment of adhesions severity and for further research in diagnosis and treatment of ASBO.