Therapeutic Value of Gastrografin in Adhesive Small Bowel Obstruction After Unsuccessful Conservative Treatment: A Prospective Randomized Trial

Hok-Kwok Choi, FRCS (Edin); Kin-Wah Chu, FRCS (Edin), FACS; Wai-Lun Law, FRCS (Edin), FACS

Disclosures

Annals of Surgery. 2002;236(1) 

In This Article

Methods

Patients older than 16 years of age admitted through the emergency room to the Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, with clinical and radiologic evidence of adhesive small bowel obstruction were included in this study. Patients with documented intraabdominal malignancy, inflammatory bowel disease, or history of abdominal irradiation were excluded. A detailed history, including information on previous abdominal surgery and adhesive obstruction, was taken and a complete physical examination was performed for every patient. A nasogastric tube was inserted for decompression, with strict measurement of output. Intravenous fluid replacement was given and electrolyte imbalances were corrected as required. Supine and erect abdominal radiographs were taken and the maximal diameter of the small bowel was measured on admission.

Emergency laparotomy was performed for patients with suspected bowel strangulation. Those without suspicion of bowel strangulation were treated conservatively, with close monitoring of vital and abdominal signs and daily abdominal radiographs. Patients with obstruction that improved clinically or radiologically in the initial 48 hours continued to receive conservative treatment. Clinical improvement was defined as the presence of decreased abdominal pain, distention, tenderness, or nasogastric tube output, or bowel opening if the patient had constipation on admission. Radiologic improvement was defined as a decrease in the number of dilated bowel loops or in the diameter of dilated small bowel.

Patients who showed neither clinical nor radiologic improvement within 48 hours were considered to have failed conservative treatment and were randomized to undergo either laparotomy or Gastrografin meal and follow-through study. Randomization was accomplished by opening an envelope. The Gastrografin study was performed by a radiologist after informed consent was obtained. One hundred milliliters Gastrografin was administered through a nasogastric tube, and the transit of the contrast was followed by fluoroscopy and serial abdominal radiographs. Patients in whom contrast appeared in the large bowel within 24 hours were regarded as having partial obstruction, in which the obstructing site could still allow the passage of a small amount of gas and fluid. Conservative treatment was continued for these patients. If contrast failed to reach the large bowel within 24 hours, the patient was regarded as having complete obstruction; these patients proceeded to laparotomy. Patients who showed no progressive clinical and radiologic improvement after 48 hours, either in the Gastrografin group or in the group solely managed by conservative treatment, also underwent surgery.

Complete resolution of bowel obstruction was established when the symptoms and signs of obstruction subsided and abdominal radiographs showed no dilated small bowel. A liquid diet was then started. A soft diet was usually given the next day, and solid food the day after. Patients were discharged when solid food was well tolerated. Complications, death rates, and hospital stays were recorded. A flow chart illustrating the management plan in the study is shown in Figure 1.

Study protocol.

Data were prospectively collected and entered into a computer database. SPSS software (SPSS Inc., Chicago, IL) was used for data analysis. Univariate analysis was performed by the Student t test or the Mann-Whitney test for continuous variables and by chi-square or Fisher exact tests for categorical variables. P < .05 was considered statistically significant.

A sample size of 154 obstructive episodes was originally planned to give a power of 80%, assuming that the failure rate of conservative treatment in adhesive small bowel obstruction was 30% and the operative rate could be reduced by 26% with the use of Gastrografin for patients with failed conservative treatment. The failure rate of conservative treatment was derived from articles on adhesive obstruction.[2,12,13] The reduction in operative rate was estimated from randomized controlled trials on the therapeutic effect of water-soluble contrast.[8,9,10,11] Our results revealed that the use of Gastrografin significantly reduced the operative rate by 74% after 139 obstructive episodes were recruited, giving a power of more than 95%; therefore, the study was stopped.

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