Letter to the Editor: “CT diagnosis of closed loop bowel obstruction mechanism is not sufficient to indicate emergent surgery”

by Pr Eric Delabrousse (edelabrousse@chu-besancon.fr)

CT diagnosis of closed loop bowel obstruction mechanism is not sufficient to indicate emergent surgery

Dear Editor,

We read with great interest the article “CT diagnosis of closed loop bowel obstruction mechanism is not sufficient to indicate emergent surgery” by Rondenet C et al [1]. The topic of adhesive small bowel obstruction (SBO) imaging and management is exciting and it should be noted that the authors of this article are experts in the subject [2-4]. Over the last 15 years, the diagnosis of adhesive SBO has benefited largely from the advent of computed tomography (CT). Nowadays, and thanks to CT, adhesive bands can be differentiated from matted adhesions [5], simple SBO can be differentiated from closed loop SBO [6], and uncomplicated adhesive SBO can be differentiated from adhesive SBO with signs of ischemia [3]. This triple differentiation is of great importance because only closed loop SBOs secondary to adhesive bands present a real strangulation risk [3-5]. In recent years, the management of adhesive SBOs has also dramatically changed. Today, simple SBO due to adhesive band and SBO due to matted adhesion without CT signs of ischemia generally benefit from first-line conservative treatment, while SBO with signs of ischemia and closed loop SBO remain emergency surgical indications [2, 7].

In the title of their article, the authors state that closed loop SBO mechanism is not sufficient to indicate emergent surgery. In the light of the literature published to date on the subject, this statement throws a stone into the water! It is quite surprising, moreover, that a local institutional board gave its consent for the use of conservative treatment for patients with closed loop SBO. The results of this study seem at first sight extremely interesting since 19/62 (31%) patients with closed loop SBO could be treated without surgery. However, it is quickly noted that 43/62 (69%) patients nevertheless required delayed surgery. In addition, in patients that finally underwent procedures, intestinal ischemia was diagnosed in 19/43 (44%) at the time of surgery. The authors do not distinguish in their article between cases of reversible bowel ischemia and cases of transmural bowel infarction requiring bowel resection. That is very unfortunate. In all cases, 19/43 (44%) patients with SBO closed loop were finally operated on at a complicated stage, whereas their closed loop SBO was not complicated at the time of the initial CT diagnosis. Considering the difference in morbidity and mortality between surgery of closed loop SBO at an uncomplicated stage and surgery of closed loop SBO complicated with bowel ischemia or even transmural bowel necrosis requiring intestinal resection, is it really reasonable to let patients with closed loop SBO run such a risk? In our opinion, the question remains unanswered.