Initial Adhesive Small Bowel Obstruction Management Pathway Drives Infectious Complication Occurrence.

Introduction: The Bologna guideline outlines three small bowel obstruction (SBO) management pathways. It remains unclear how pathway selection influences post-operative infections. Methods: A multi-national, prospective, observational, audit of SBO management (November 1, 2023-May 31, 2024) captured demographics, care, and outcomes. Patients were grouped by pathway (successful non-operative management [NOM], NOM followed by surgery [NOM-T], direct to surgery [DTS]). Intergroup comparisons by chi-square or Fisher exact test, significance for p < 0.05. Results: A total of 1,737 patients were assessed across 21 countries (850 NOM, 379 NOM-T, 508 DTS). Operative cohorts demonstrated similar age (NOM-T 65.2 ± 17.3 vs. DTS 65.5 ± 18.4 y; p = 0.834) and gender (NOM-T 53.6% vs. DTS, 52% female; p = 0.688). Comorbidities were more frequent in patients undergoing NOM-T (77.8%) versus DTS (69.7%; p < 0.001). DTS demonstrated more intestinal ischemia (NOM-T 22.8% vs. DTS 33%; p = 0.002). Time to OR was longer in NOM-T (43.8 ± 30.6 vs. DTS 12.4 ± 15.2 h; p < 0.001). Hospital length of stay (LOS) (NOM-T 12.4 ± 15.2 vs. DTS 7.7 ± 8.0 d; p < 0.001) and LOS (NOM-T 10.1 ± 10.4 vs. DTS 6.6 ± 9.1 d; p < 0.001) were longer in NOM-T. Superficial wound dehiscence (3.9%) and fascial dehiscence (2.6%) were uncommon. Overall surgical site infection (SSI) incidence was similar (NOM-T 8.7% vs. DTS 7.7%; p = 0.578). Deep SSI overall frequency was low (3.9%) but increased in NOM-T (5.5%) versus DTS (2.8%, p = 0.035). Conclusions: An NOM trial before operation for adhesive SBO seems to increase deep SSI risk and likely reflects time to OR as well as hospital and surgeon factors-elements that merit specific evaluation.