Letter 2: clinicoradiological score for predicting the risk of strangulated small bowel obstruction (Br J Surg 2010; 97; 1119-1125).

Sir We read this article with interest. The study sought to predict the risk of ischaemia in patients with small bowel obstruction (SBO). Existing evidence in the literature supports a strong association between metabolic acidosis and ischaemic bowel in SBO1,2. Surprisingly, metabolic acidosis was not included as a parameter for evaluating such patients in the study. Furthermore, the predictive factors were analysed by including patients with SBO who were successfully treated conservatively (95 patients) and those who had undergone small bowel resection for ischaemic bowel within 24 h (45 patients), as cited in Table 2. The data for the 93 patients who underwent laparotomy during first 24 h but did not merit bowel resection, and/or those who underwent laparotomy after 24 h of observation (number unknown; these were excluded from the study) were not used in the final analysis for establishing predictive factors. Decision making can sometimes be difficult in the subgroup of patients who have been treated conservatively for an initial 24–48 h and have not improved considerably. Predictive factors can be a useful tool in such a subgroup. By excluding the latter group from the final analysis, an opportunity was lost for assessing the very group of patients whomight have warranted critical decision making based on predictive factors. D. Debnath and A. J. Ogedegbe Department of Surgery, Queen’s Hospital, Romford, UK (e-mail: [email protected]) DOI: 10.1002/bjs.7316