Safety of Foregoing Operation for Small Bowel Obstruction in the Virgin Abdomen: Systematic Review and Meta-Analysis

Our objective was to assess the safety of foregoing surgery in patients without abdominopelvic surgery history presenting with small bowel obstruction (SBO). Classic dogma has counseled early surgical intervention for SBO in the virgin abdomen-patients without abdominopelvic surgery history-given their presumed higher risk of malignant or potentially catastrophic etiologies compared with those who had undergone previous abdominal operations. The term virgin abdomen was coined before widespread use of CT, which now elucidates many SBO etiologies. Despite recent efforts to re-evaluate clinical management standards, the prevalence of SBO etiologies in the virgin abdomen and the current management landscape (nonoperative vs operative) in these patients remain unclear. Our random-effects meta-analysis of 6 studies including 442 patients found the prevalence of malignant etiologies in patients without abdominopelvic surgery history presenting with SBO varied from 7.7% (95% CI 3.0 to 14.1) to 13.4% (95% CI 7.6 to 20.3) on sensitivity analysis. Most malignant etiologies were not suspected before surgery. De novo adhesions (54%) were the most common etiology. More than half of patients underwent a trial of nonoperative management, which often failed. Subgroups of patients likely have variable risk profiles for underlying malignant etiologies, yet no study had consistent follow-up data and we did not find convincing evidence that foregoing operative management altogether in this population can be generally recommended.