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

Results

From July 1999 to December 2000, 124 patients with 139 episodes of adhesive small bowel obstruction were included. Eighty-one patients were male and 43 female. The mean age was 66 years (range 17-95). Ninety patients had undergone a single previous abdominal operation. Colorectal surgery, appendicectomy, cholecystectomy, and gastroduodenal surgery were the most common single antecedent operations. Thirty-four patients had more than one previous abdominal operation (Fig. 2). Thirty-eight patients had a history of adhesive obstruction before the study period. Fifteen patients developed two episodes of obstruction during the study. The time interval between the two episodes ranged from 2 to 17 months, with a median of 5 months. They were all treated conservatively for the first episode without Gastrografin or surgery.

Antecedent operations that cause adhesive small bowel obstruction.

The mean duration of symptoms before admission was 1.84 days (range 1-7). The maximal diameter of the small bowel on admission was a mean of 42 mm (range 20-72). Because the duration of nasogastric tube decompression varied with different patients, the average nasogastric tube output of each patient (total amount of drainage/duration) was used for evaluation. For patients who underwent Gastrografin study or surgery, only the output before the procedure was considered. The mean output was 24 mL/h (range 0-124).

Three patients had emergency surgery performed within 24 hours after admission because of suspected bowel strangulation. Laparotomy confirmed strangulation in two of them, and the diseased bowel segments were resected. One hundred one cases showed improvement or resolution of obstruction during the initial 48 hours, and conservative treatment was continued. Only one of these patients required laparotomy and enterolysis on day 6 after admission. The remaining 100 cases had bowel obstruction resolved with conservative treatment; the mean time of complete resolution was 60 hours (range 7-150) after admission.

Thirty-five patients showed no improvement within 48 hours. Statistical analysis showed that nasogastric tube output was significantly higher in patients who failed to respond to conservative treatment versus those successfully treated by conventional methods (33 vs. 21 mL/h, P = .02). Other variables including sex, age, duration of symptoms before admission, number of previous abdominal operations and adhesive small bowel obstruction, and maximal diameter of small bowel on admission were not significantly different between the two groups ( Table 1 ).

Nineteen patients were randomized to have Gastrografin study and 16 patients surgery. The groups were well matched in terms of age, sex, duration of symptoms before admission, number of previous abdominal operations and adhesive obstruction, maximal diameter of small bowel, and output of nasogastric tube ( Table 2 ). In the Gastrografin group, the mean time that the study started was 60 hours (range 48-68) after admission. Partial obstruction was demonstrated in 14 patients. Obstruction resolved subsequently in all of them at a mean time of 41 hours (range 6-80) after administration of Gastrografin. The remaining five patients had complete obstruction shown by the contrast study and underwent laparotomy. Gastrografin significantly reduced the need for surgery by 74% (14/19, P < .001).

The administration of Gastrografin was not associated with any complications. There was one postoperative complication in the Gastrografin group as a result of unsuccessful enterolysis and two complications in the group randomized to undergo surgery. One patient in the latter group died of peritonitis after enterolysis ( Table 3 ). No bowel strangulation was noted in either group. The median hospital stay of patients who had received Gastrografin was 10 days (range 5-65); that of the other group was 10 days (range 5-34).

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