Impact of Increased Time for Trial of Nonoperative Management in Small Bowel Obstruction: Evidence from the American College of Surgeons NSQIP Emergency General Surgery Targeted Database

BACKGROUND: Small bowel obstruction (SBO) is a common emergency general surgery condition frequently initially managed nonoperatively, although the optimal duration of nonoperative management (NOM) before operative intervention remains uncertain. We evaluated national variation in NOM duration and its association with clinical outcomes and healthcare use. STUDY DESIGN: We performed a retrospective cohort study using the American College of Surgeons NSQIP Emergency General Surgery Targeted Database (June 2022-December 2024). Adults with SBO who underwent an initial trial of NOM followed by surgery were included. Patients were stratified by quartiles of NOM duration after excluding high-duration outliers. Multivariable regression adjusted for demographics, comorbidities, and disease severity. A sensitivity analysis was performed in patients with adhesive SBO. RESULTS: Among 8,993 patients with SBO, 70.0% underwent initial NOM, and 1,865 ultimately required surgery. Mean NOM duration was 3.3 ± 2.4 days. Baseline demographic characteristics were similar across quartiles. Longer NOM duration was independently associated with increased postoperative and total length of stay (both p<0.001), with a significant linear trend across quartiles. After adjustment, 30-day morbidity, mortality, and readmission did not differ by NOM duration. Findings were consistent in the adhesive SBO sensitivity analysis. CONCLUSIONS: National variation in NOM duration for SBO is substantial. Among patients ultimately requiring operative intervention, prolonged NOM was associated with increased healthcare utilization without measurable improvement in short-term postoperative outcomes, supporting efforts to optimize and standardize time-limited nonoperative management.