Optimal Timing of Surgical Intervention in Small Bowel Obstruction: A Systematic Review and Meta-Analysis of Clinical Outcomes and Risk Predictors

Optimal timing for surgical intervention in small bowel obstruction remains controversial, with traditional guidelines recommending 48-72 h of conservative management before considering surgery. We conducted a systematic review and meta-analysis to determine whether early surgical intervention improves clinical outcomes and to identify predictors of failed conservative management. We searched PubMed, Embase, Cochrane Library, and Web of Science from January 2010 to October 2024 for studies comparing surgical timing in adults with small bowel obstruction. Primary outcomes included mortality, bowel resection rates, and complications. Random-effects models were used to calculate pooled risk ratios and odds ratios with 95% confidence intervals. Among 47 studies comprising 12 486 patients, early surgery within 24 h significantly reduced mortality (RR 0.53, 95% CI 0.34-0.82, P = 0.004), bowel resection rates (RR 0.56, 95% CI 0.43-0.73, P < 0.001), and overall complications (RR 0.62, 95% CI 0.48-0.79, P < 0.001) compared to delayed intervention. Time-stratified analysis revealed a progressive increase in complications from 18% at less than 6 h to 52% beyond 48 h (P < 0.001). Conservative management succeeded in 73% of patients overall. Significant predictors of failure included absence of flatus (OR 3.3), fever (OR 2.8), complete obstruction (OR 4.1), and free fluid on CT (OR 3.7). A risk score combining three or more factors predicted failure with 84% sensitivity and 78% specificity. This meta-analysis provides robust evidence that early surgical intervention within 24 h significantly improves outcomes in appropriately selected patients with small bowel obstruction. Risk stratification using clinical and radiological predictors enables individualized decision-making rather than adherence to arbitrary waiting periods.