Water soluble contrast follow-through in the management of adhesive small bowel obstruction: A prospective randomized trial

Optimal Timing of First Abdominal Radiography after Gastrografin Administration for Small Bowel Obstruction

BACKGROUND

Water-soluble contrast agent (WSCA) administration is commonly used to evaluate adhesive small bowel obstruction (SBO) either via a challenge or follow-through study. This analysis aimed to determine optimal timing to first abdominal radiograph after WSCA administration.

MATERIALS AND METHODS

A post hoc review of the Eastern Association for the Surgery of Trauma SBO database was used to compare data from two institutions using different methodologies, either the small bowel follow through method or the challenge method, from March 2015-January 2018. The primary outcome was timing of contrast into the colon. Outcomes were also analyzed. A multivariate regression analysis controlled for age, sex, body mass index, previous SBO admissions, and abdominal surgeries.

RESULTS

A total of 236 patients met inclusion and exclusion criteria (A, 119; B, 117). There were minor demographic differences between cohorts and no significant differences between institutions regarding the confirmed presence of WSCA in the colon, rates of operative intervention, length of operation, hospital length of stay, or 30-d readmission rates.Institution A, where the challenge method was practiced, had 95 (80%) patients with contrast to colon overall; four of 95 (4%) patients had confirmed contrast to colon at or before 7 h, and 89 of 95 (94%) patients had confirmed contrast to colon between 7.1 and 10 h. Institution B, where the small bowel follow through method was practiced, had 94 (80%) patients with contrast to colon overall; 73 of 94 (78%) patients had confirmed contrast to colon at or before 7 h, and 15 of 94 (16%) patients had confirmed contrast to colon between 7.1 and 10 h.

CONCLUSIONS

Either method is effective for evaluation of SBO. Adding a radiograph at 4 h is feasible, could promote earlier disposition, be conducted as part of an emergency department protocol, and possibly allow for the selection of patients who are candidates for outpatient treatment.

Therapeutic Role of Water-Soluble Contrast Media in Adhesive Small Bowel Obstruction: a Systematic Review and Meta-Analysis

BACKGROUND

Adhesive small bowel obstruction (ASBO) is a common post-operative cause of hospitalisation. Water-soluble contrast media (WSCM) has become a popular non-surgical approach to treatment. However, previous reviews have concluded with conflicting results. This meta-analysis of randomised controlled trials (RCTs) re-evaluated the therapeutic value of WSCM in the management of ASBO.

METHODS

A comprehensive search of PubMed, Embase, and Cochrane databases was undertaken to identify RCTs from January 2000 to November 2018. The primary outcomes of length of stay and secondary outcomes of time to resolution, need for surgery, and mortality were extracted from the included studies. Quantitative pooling of the data was based on the random effects model.

RESULTS

Eight hundred and seventy-nine patients from the nine studies were included in the analysis. The administration of oral WSCM reduced the length of hospital stay (weighted mean difference - 0.15 days, P < 0.0001). However, WSCM does not reduce the need for surgery (relative risk 0.84, P < 0.009) and makes no difference to mortality rate (RR 0.99, P < 1.000). The definition of time to resolution of ASBO differed between the studies, ranging from time to passing flatus, to cessation of abdominal pain, and time to initiating oral intake. The significant differences in definition precluded meaningful quantitative pooling of this outcome.

CONCLUSIONS

This meta-analysis evaluating the therapeutic value of WSCM has shown that it does not reduce the need for operative management in ASBO or impact mortality rates. It shortens hospital stay by 0.15 days (3.6 h) which is not clinically significant.

Gastrografin reduces the need for additional surgery in postoperative small bowel obstruction patients without long tube insertion: A meta-analysis

BACKGROUND

Small bowel obstruction (SBO) is a well-known major postoperative complication requiring immediate diagnosis and treatment to avoid additional invasive surgical procedures. Water-soluble contrast medium is often given not only for diagnosis but also for treatment. Although numerous studies have investigated the significance of this treatment, no consensus has yet been established regarding its indications and efficacy.

OBJECTIVE

To explore whether Gastrografin can reduce the need for additional surgery in patients with postoperative SBO (PSBO).

METHODS

We carried out a comprehensive electronic search of the literature (Cochrane Library, MEDLINE, PubMed and the Web of Science) up to February 2017 to identify studies that had shown efficacy of Gastrografin in reducing the need for surgery in patients with PSBO. To integrate the individual effects of Gastrografin, a meta-analysis was done using random-effects models to calculate the risk ratio (RR) and 95% confidence interval (CI), and heterogeneity was analyzed using I 2 statistics.

RESULTS

Twelve studies involving a total of 1153 patients diagnosed as having PSBO were included in this meta-analysis. Not all patients received long-tube insertion. Among 580 patients who received Gastrografin, 100 (17.2%) underwent surgery, whereas among 573 patients who did not receive Gastrografin, 143 (25.0%) underwent surgery. Giving Gastrografin significantly reduced the need for surgery (RR, 0.66; 95% CI, 0.46-0.95; P = 0.02; I 2 = 52%) in comparison with patients who did not receive Gastrografin.

CONCLUSION

Results of this meta-analysis show that giving Gastrografin reduces the need for surgery in PSBO patients without long-tube insertion.

Use of water-soluble contrast medium (gastrografin) does not decrease the need for operative intervention nor the duration of hospital stay in uncomplicated acute adhesive small bowel obstruction? A multicenter, randomized, clinical trial (Adhesive Small Bowel Obstruction Study) and systematic review

BACKGROUND

This study evaluated the association between oral gastrografin administration and the need for operative intervention in patients with presumed adhesive small bowel obstruction.

METHODS

Between October 2006 and August 2009, 242 patients with uncomplicated acute adhesive small bowel obstruction were included in a randomized, controlled trial (the Adhesive Small Bowel Obstruction Study, NCT00389116) and allocated to a gastrografin arm or a saline solution arm. The primary end point was the need for operative intervention within 48 hours of randomization. The secondary end points were the resection rate, the time interval between the initial computed tomography and operative intervention, the time interval between oral refeeding and discharge, risk factors for the failure of nonoperative management, in-hospital mortality, duration of stay, and recurrence or death after discharge. We performed a systematic review of the literature in order to evaluate the relationship between use of gastrografin as a diagnostic/therapeutic measure, the need for operative intervention, and the duration of stay.

RESULTS

In the gastrografin and saline solution arms, the rate of operative intervention was 24% and 20%, respectively, the bowel resection rate was 8% and 4%, the time interval between the initial computed tomography and operative intervention, and the time interval between oral refeeding and discharge were similar in the 2 arms. Only age was identified as a potential risk factor for the failure of nonoperative management. The in-hospital mortality was 2.5%, the duration of stay was 3.8 days for patients in the gastrografin arm and 3.5 days for those in the saline solution arm (P = .19), and the recurrence rate of adhesive small bowel obstruction was 7%. These results and those of 10 published studies suggest that gastrografin did not decrease either the rate of operative intervention (21% in the saline solution arm vs 26% in the gastrografin arm) or the number of days from the initial computed tomography to discharge (3.5 vs 3.5; P = NS for both).

CONCLUSION

The results of the present study and those of our systematic review suggest that gastrografin administration is of no benefit in patients with adhesive small bowel obstruction.

Determination of therapeutic strategy for adhesive small bowel obstruction using water-soluble contrast agents: An audit of 776 cases in a single center

BACKGROUND

Several studies have investigated the diagnostic and therapeutic role of water-soluble contrast agents in adhesive small bowel obstruction, but there is no clear diagnostic classification for the determination of therapeutic strategy. The aim of this study was to clarify the clinical value of classification using water-soluble contrast agents in patients with adhesive small bowel obstruction.

METHODS

Between January 2009 and December 2015, 776 consecutive patients with adhesive small bowel obstruction were managed initially with water-soluble contrast agents and were included in the study. Abdominal x-rays were taken 5 hours after administration of 100 mL water-soluble contrast agents and classified into 4 types. The medical records of the patients with adhesive small bowel obstruction were analyzed retrospectively and divided into 2 groups of patients with complete obstruction (ie, the absence of contrast agent in the colon) with (type I) or without (type II) a detectable point of obstruction and a group with an incomplete obstruction (ie, the presence of contrast agent in the colon) with (type IIIA) or without (type IIIB) dilated small intestine.

RESULTS

Types I, II, IIIA, and IIIB were identified in 27, 90, 358, and 301 patients, respectively. The overall operative rate was 16.6%. In the patients treated conservatively (types IIIA and IIIB), 647 patients (98.2%) were treated successfully without operative intervention. The operative rate was 3.4% (n = 12/358) in type IIIA vs 0% (n = 0/301) in the type IIIB group (P = .001). Compared with type IIIA, type IIIB was associated with earlier initiation of oral intake (2.1 vs 2.6 days, P < .001) and a lesser hospital stays (9 vs 11 days, P < .001).

CONCLUSION

This new classification using water-soluble contrast agents is a simple and useful diagnostic method for the determination of therapeutic strategy for adhesive small bowel obstruction.

Systematic review and meta-analysis of the diagnostic and therapeutic role of water-soluble contrast agent in adhesive small bowel obstruction

BACKGROUND

This meta-analysis assessed the diagnostic and therapeutic role of water-soluble contrast agent (WSCA) in adhesive small bowel obstruction (SBO).

METHODS

PubMed, Embase and Cochrane databases were searched systematically. The primary outcome in the diagnostic role of WSCA was its ability to predict the need for surgery. In the therapeutic role, the following were evaluated: resolution of SBO without surgery, time from admission to resolution, duration of hospital stay, complications and mortality. To assess the diagnostic role of WSCA, pooled estimates of sensitivity, specificity, positive and negative predictive values, and likelihood ratios were derived. For the therapeutic role of WSCA, weighted odds ratio (OR) and weighted mean difference (WMD) were obtained.

RESULTS

Fourteen prospective studies were included. The appearance of contrast in the colon within 4-24 h after administration had a sensitivity of 96 per cent and specificity of 98 per cent in predicting resolution of SBO. WSCA administration was effective in reducing the need for surgery (OR 0.62; P = 0.007) and shortening hospital stay (WMD -1.87 days; P < 0.001) compared with conventional treatment.

CONCLUSION

Water-soluble contrast was effective in predicting the need for surgery in patients with adhesive SBO. In addition, it reduced the need for operation and shortened hospital stay.

Oral water soluble contrast for the management of adhesive small bowel obstruction

BACKGROUND

Adhesions are the leading cause of small bowel obstruction. Gastrografin transit time may allow for the selection of appropriate patients for non-operative management. Some studies have shown when the contrast does not reach the colon after a designated time it indicates complete intestinal obstruction that is unlikely to resolve with conservative treatment. When the contrast does reach the large bowel, it indicates partial obstruction and patients are likely to respond to conservative treatment. Other studies have suggested that the administration of water-soluble contrast is therapeutic in resolving the obstruction.

OBJECTIVES

To determine the reliability of water-soluble contrast media and serial abdominal radiographs in predicting the success of conservative treatment in patients admitted with adhesive small bowel obstruction.Furthermore, to determine the efficacy and safety of water-soluble contrast media in reducing the need for surgical intervention and reducing hospital stay in adhesive small bowel obstruction.

SEARCH STRATEGY

The search was conducted using MESH terms: ''Intestinal obstruction'', ''water-soluble contrast'', "Adhesions" and "Gastrografin". The later combined with the Cochrane Collaboration highly sensitive search strategy for identifying randomised controlled trials and controlled clinical trials.

SELECTION CRITERIA

1. Prospective studies were included to evaluate the diagnostic potential of water-soluble contrast in adhesive small bowel obstruction.2. Randomised clinical trials were selected to evaluate the therapeutic role.

DATA COLLECTION AND ANALYSIS

1. Studies that addressed the diagnostic role of water-soluble contrast were critically appraised and data presented as sensitivities, specificities and positive and negative likelihood ratios. Results were pooled and summary ROC curve was constructed.2. A meta-analysis of the data from therapeutic studies was performed using the Mantel -Henszel test using both the fixed effect and random effect models.

MAIN RESULTS

The appearance of water-soluble contrast in the colon on an abdominal X ray within 24 hours of its administration predicts resolution of an adhesive small bowel obstruction with a pooled sensitivity of 0.97, specificity of 0.96. The area under the curve of the summary ROC curve is 0.98. Six randomised studies dealing with the therapeutic role of gastrografin were included in the review, water-soluble contrast did not reduce the need for surgical intervention (OR 0.81, p = 0.3). Meta-analysis of four of the included studies showed that water-soluble contrast did reduce hospital stay compared with placebo (WMD= - 1.83) P<0.001.

AUTHORS' CONCLUSIONS

Published literature strongly supports the use of water-soluble contrast as a predictive test for non-operative resolution of adhesive small bowel obstruction. Although Gastrografin does not cause resolution of small bowel obstruction there is strong evidence that it reduces hospital stay in those not requiring surgery.

Meta-analysis of oral water-soluble contrast agent in the management of adhesive small bowel obstruction

BACKGROUND

Adhesions are the leading cause of small bowel obstruction. Identification of patients who require surgery is difficult. This review analyses the role of Gastrografin as a diagnostic and therapeutic agent in the management of adhesive small bowel obstruction.

METHODS

A systematic search of Medline, Embase and Cochrane databases was performed to identify studies of the use of Gastrografin in adhesive small bowel obstruction. Studies that addressed the diagnostic role of water-soluble contrast agent were appraised, and data presented as sensitivity, specificity, and positive and negative likelihood ratios. Results were pooled and a summary receiver-operator characteristic (ROC) curve was constructed. A meta-analysis of the data from six therapeutic studies was performed using the Mantel-Haenszel test and both fixed- and random-effect models.

RESULTS

The appearance of water-soluble contrast agent in the colon on an abdominal radiograph within 24 h of its administration predicted resolution of obstruction with a pooled sensitivity of 97 per cent and specificity of 96 per cent. The area under the summary ROC curve was 0.98. Water-soluble contrast agent did not reduce the need for surgical intervention (odds ratio 0.81, P = 0.300), but it did reduce the length of hospital stay for patients who did not require surgery compared with placebo (weighted mean difference--1.84 days; P < 0.001).

CONCLUSION

Published data strongly support the use of water-soluble contrast medium as a predictive test for non-operative resolution of adhesive small bowel obstruction. Although Gastrografin does not reduce the need for operation, it appears to shorten the hospital stay for those who do not require surgery.