Bezoar ileus in patients with previous abdominal surgery: an observational comparison of conservative and surgical management

Evidence on the management of bezoar ileus in patients who have already undergone abdominal surgery is limited. We reviewed conservative and surgical pathways in clinically selected patients, with particular attention to patient selection criteria and how each pathway was defined. We reviewed 80 patients with CT-confirmed bezoar ileus and previous abdominal surgery who were treated between January 2010 and December 2021. Twenty-six completed conservative treatment, and 54 underwent surgery. In practice, conservative treatment was used for clinically stable patients without peritonitis or CT signs suggesting ischaemia, perforation or closed-loop obstruction, provided that close clinical monitoring was possible. Conservative treatment included bowel rest, intravenous fluids, electrolyte correction, symptom-directed medication and nasogastric decompression when needed. Failure was defined by clinical deterioration, persistent or worsening obstruction, inability to tolerate oral intake, or new radiological concern. The primary outcome was clinical resolution during the index admission. Secondary outcomes were hospitalisation, in-hospital mortality, postoperative complications and readmission after discharge. The treatment groups were not equivalent at baseline. Patients treated surgically more often had gastric bezoars (18/54, 33.3% vs. 0/26, p = 0.002), multiple bezoars (18/54, 33.3% vs. 1/26, 3.8%, p = 0.009) and greater small-bowel dilatation (median 4.0 cm vs. 3.4 cm, p = 0.014). All 26 patients in the conservative pathway completed the index admission without operation, although routine radiological confirmation of resolution was not performed. Median hospitalisation was 4 days (IQR 4–5) in the surgical group and 7 days (6–8) in the conservative group ( p < 0.001); this difference should be interpreted in the context of clinical selection and local practice. Postoperative complications occurred in 11/54 surgical patients (20.4%), including two deaths from pulmonary embolism. Among discharged patients, readmission did not differ significantly between groups (13/52, 25.0% after surgery vs. 5/26, 19.2% after conservative treatment; p = 0.776). Exploratory regression findings were treated as hypothesis-generating only. Conservative treatment may be feasible in selected stable patients with bezoar ileus after previous abdominal surgery. Surgery remains appropriate for patients with peritonitis, suspected ischaemia, perforation or closed-loop obstruction, clinical deterioration, or failure of conservative management. Because treatment was not protocolised and the groups differed at baseline, the findings should be read as observational and hypothesis-generating, not as evidence that either strategy is superior.