Predictors of Postoperative Complications in Bezoar-induced Small Bowel Obstruction: A Retrospective Analysis

Technical Summary: Predictors of Postoperative Complications in Bezoar-induced Small Bowel Obstruction

Problem Statement
Bezoars, intraluminal masses of indigestible material, represent a rare but clinically significant cause of mechanical small bowel obstruction (SBO), accounting for approximately 0.4–4% of cases. While the predisposing factors for bezoar formation (e.g., gastric surgery, diabetes, hypothyroidism) and diagnostic imaging techniques (CT) are well-documented, there is a scarcity of data regarding predictors of postoperative complications specifically in bezoar-related SBO. Existing literature largely focuses on predisposing factors and diagnostic findings rather than postoperative outcomes. Consequently, the influence of preoperative inflammatory markers, comorbidity burden, and surgical timing on postoperative morbidity in this specific patient population remains unclear.

Methodology
This study employed a retrospective analysis of adult patients (≥18 years) who underwent emergency surgery for bezoar-induced mechanical intestinal obstruction at a single center between January 2020 and March 2026.

• Cohort: From an initial pool of 25 patients, 23 were included after excluding two due to incomplete data.
• Exclusion Criteria: Patients with immunosuppressive diseases/treatments, chronic inflammatory diseases, malignancies, or colorectal obstructive lesions were excluded.
• Data Collection: Researchers recorded demographic data, comorbidity indices (ASA score, Charlson Comorbidity Index [CCI]), and laboratory parameters (CRP, Neutrophil-to-Lymphocyte Ratio [NLR], lactate, amylase). Surgical timing was categorized as "same-day" (admission day) or "delayed" (>1 day).
• Outcome Measure: Postoperative complications were classified using the Clavien-Dindo system. Patients with a score ≥2 were considered to have significant complications.
• Statistical Analysis: Comparative tests (t-test, Mann-Whitney U, Chi-square, Fisher's exact) were used to compare groups. Receiver Operating Characteristic (ROC) analysis was performed to assess the predictive performance of CRP and surgical delay.

Key Results

• Patient Demographics: The cohort consisted of 23 patients (69.6% female, median age ~68). The majority presented with moderate-to-severe comorbidity burdens (73.9% had CCI ≥3) and were classified as moderate-to-high risk (39.1% ASA ≥IIIE). Diabetes mellitus was the most common predisposing comorbidity (60.9%).
• Complication Rate: Postoperative complications (Clavien-Dindo ≥2) occurred in 39.1% (9/23) of patients.
• Predictive Factors:
  • Traditional Scores: No significant association was found between complications and age, BMI, ASA score, CCI, NLR, lactate, or amylase levels (p > 0.05).
  • Inflammatory Markers: Patients with complications exhibited higher C-reactive protein (CRP) levels (86 mg/L vs. 48.6 mg/L), though this approached but did not reach statistical significance (p = 0.068).
  • Surgical Timing: A strong trend was observed regarding surgical delay. Patients undergoing surgery >1 day after admission had a complication rate of 71.4%, compared to 25% for those operated on the admission day (p = 0.066). The median time to surgery was 3 days for the complication group versus 1 day for the non-complication group (p = 0.06).
  • Hospital Stay: Patients with complications had significantly longer hospital stays (13 days vs. 9 days; p = 0.011).
• ROC Analysis:
  • CRP: Showed moderate predictive ability with an Area Under the Curve (AUC) of 0.730. The optimal cut-off was 54.65 mg/L (Sensitivity: 78%, Specificity: 43%).
  • Surgical Delay: Also showed moderate predictive ability (AUC = 0.726) with a cut-off of 2 days (Sensitivity: 56%, Specificity: 86%).

Key Contributions and Claims
The study contributes to the limited literature by shifting the focus from predisposing factors to postoperative outcome predictors in bezoar-induced SBO. The authors claim that:

1. Risk Stratification: Traditional risk scores (ASA, CCI) do not significantly predict postoperative complications in this specific context, suggesting bezoar-related obstruction may follow a clinical course distinct from general surgical risk classifications.
2. Inflammatory Status and Timing: Postoperative complications are more closely associated with preoperative inflammatory status (specifically CRP levels) and the timing of surgical intervention than with traditional comorbidity indices.
3. Clinical Utility: Early surgical intervention (specifically within 24–48 hours of admission) and the assessment of CRP levels may improve risk stratification. The data suggests that delaying surgery beyond 1–2 days significantly increases the risk of complications, likely due to the progression of bowel ischemia or perforation.

Significance
The authors conclude that bezoar-related obstruction represents a distinct clinical picture where early diagnosis and rapid surgical management are critical. While the study is modest regarding its claims due to the small sample size (n=23) and the borderline statistical significance of some findings, it proposes that integrating inflammatory markers (CRP) with clinical decision-making could optimize patient management. The findings underscore the potential benefit of minimizing the time to surgery to reduce morbidity, suggesting that in bezoar-induced SBO, surgical timing may be a more crucial determinant of outcomes than traditional preoperative risk scores.