Operative Versus Non‐Operative Management of Adhesive Small Bowel Obstruction: An Updated Systematic Review and Meta‐Analysis

Background The optimal management of adhesive small bowel obstruction (ASBO) remains controversial, particularly in patients without evidence of strangulation. While non‐operative management is commonly favoured initially, operative intervention may reduce recurrence at the expense of increased short‐term morbidity. Objectives This updated systematic review and meta‐analysis aimed to compare clinical outcomes of operative versus non‐operative management of ASBO. Methods A comprehensive and systematic literature search was conducted across MEDLINE (via PubMed), Embase, CINAHL, Scopus, Web of Science, the Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Library published up to January 2026. Two authors independently conducted screening and data extraction with Preferred Reporting Items for Systematic Reviews and Meta‐analyses guidelines. To identify studies evaluating operative versus conservative management of small bowel obstruction (SBO). The outcomes included recurrence, complications, readmission, intensive care unit (ICU) admission, length of hospital stay, reoperation and mortality. Results Forty‐two studies including 329 977 patients were analysed. 89 942 patients underwent operative management, while over 240 035 were treated non‐operatively. Operative patients were more likely to present with advanced obstruction and strangulation (RR: 6.55, 95% CI: 1.66–25.88). Operative management was associated with a significantly lower risk of recurrence (RR: 0.53, 95% CI: 0.31–0.92) but a higher risk of overall complications (RR: 4.49, 95% CI: 2.72–7.41) and ICU admission (RR: 5.19, 95% CI: 1.32–20.33). Operative treatment was also associated with a longer hospital stay (mean difference 5.12 days, 95% CI: 1.08–9.15). No statistically significant differences were observed in reoperation rates (RR: 1.21, 95% CI: 0.46–3.18) or mortality (RR: 1.74, 95% CI: 0.84–3.61). Conclusion Operative management of ASBO reduces recurrence but is associated with increased short‐term morbidity. No significant difference in mortality was observed. Treatment decisions should be individualized, balancing operative risk against recurrence risk. High‐quality prospective studies and randomized trials are needed to better define optimal management strategies.