Small bowel obstruction in older adults: similar nonoperative success but worse outcomes across management strategies - insights from the ESTES SnapSBO study

BACKGROUND: Small bowel obstruction (SBO) is a common surgical emergency. It remains unclear whether adverse outcomes in older patients reflect impaired obstruction resolution, differences in disease phenotype, or reduced physiologic tolerance. METHODS: We performed a prespecified age-stratified analysis of the multicenter SnapSBO cohort, which consecutively enrolled adults with radiologically-confirmed mechanical SBO, stratified as younger (< 65 years) or older (≥ 65 years). Presentation, etiology, management, and outcomes were compared using risk differences and odds ratios. Exploratory analyses evaluated patients aged 65-79 years and ≥ 80 years. RESULTS: Among 1,731 patients, 729 (42.1%) were aged ≥ 65 years. Older adults had more non-adhesive etiologies, including neoplastic and inflammatory obstruction, and more imaging features of severe disease. They were less likely to undergo a trial of nonoperative management (67.9% vs. 72.7%; absolute risk difference, - 4.8%; P = 0.037). However, among those managed nonoperatively, resolution rates were similar (68.8% vs. 69.5%). Despite this, older adults experienced higher rates of complications (16.7% vs. 6.7%), aspiration pneumonia (3.8% vs. 1.0%), and in-hospital mortality (6.9% vs. 3.6%). Those aged ≥ 80 years showed similar management but substantially higher mortality and complications. CONCLUSIONS: Older adults achieved similar nonoperative resolution despite worse outcomes, suggesting chronological age incompletely captures treatment-relevant risk. These outcomes may reflect disease phenotype, frailty, physiologic vulnerability, or response to complications. Decision-making should integrate etiology, imaging-defined severity, frailty, and physiologic vulnerability rather than age alone.