J Gastrointest Surg (2014) 18:363–368 DOI 10.1007/s11605-013-2347-6
2013 SSAT POSTER PRESENTATION
Role of Gastrografin Challenge in Early Postoperative Small Bowel Obstruction Mohammad A. Khasawneh & Maria L. Martinez Ugarte & Boris Srvantstian & Eric J. Dozois & Michael P. Bannon & Martin D. Zielinski
Received: 24 June 2013 / Accepted: 29 August 2013 / Published online: 29 October 2013 # 2013 The Society for Surgery of the Alimentary Tract
Abstract Introduction Early small bowel obstruction following abdominal surgery presents a diagnostic and therapeutic challenge. Abdominal imaging using Gastrografin has been shown to have diagnostic and therapeutic properties when used in the setting of small bowel obstruction outside the early postoperative period (>6 weeks). We hypothesize that a GG challenge will reduce need for re-exploration. Methods Patients with early small bowel obstruction who underwent a Gastrografin challenge between 2010 and 2012 were case controlled, based on age ±5 years, sex, and operative approach to an equal number of patients that did not receive the challenge. Results One hundred sixteen patients received a Gastrografin challenge. There were 87 males in each group with an average age of 62 years. A laparoscopic approach in the index operation was done equally between groups (18 vs. 18 %). There was no difference between groups in operative re-exploration rates (14 vs. 10 %); however, hospital duration of stay was greater in patients who received Gastrografin challenge (17 vs. 13 days). Two in hospital deaths occurred, one in each group, both of infectious complications. Conclusion Use of the Gastrografin challenge in the immediate postoperative period appeared to be safe. There was no difference, however, in the rate of re-exploration between groups. Keywords Small bowel obstruction . Gastrografin challenge . Early postoperative bowel obstruction . Water-soluble contrast . Outcome
Introduction Early postoperative small bowel obstruction (ESBO) presents a diagnostic and therapeutic challenge to surgeons. This complication, affecting up to 9.5 % of patients after laparotomy, Poster presentation, Digestive Disease Week/Society for Surgery of the Alimentary Tract, Orlando, Florida, May 19–21, 2013 M. A. Khasawneh : M. L. M. Ugarte : B. Srvantstian : E. J. Dozois : M. P. Bannon : M. D. Zielinski Department of Surgery, Mayo Clinic, Rochester, MN, USA M. D. Zielinski (*) Division of Trauma, Critical Care and General Surgery, St. Mary’s Hospital, Mayo Clinic, Mary Brigh 2-810 1216 Second Street SW, Rochester, MN 55902, USA e-mail: [email protected]
mimics postoperative paralytic ileus given the similarities in – physical examination findings and time course.1 4 Small bowel obstruction (SBO) indicates interruption of the continuity of the intestinal tract, whereas ileus indicates a , nonmechanical insult that disrupts normal peristalsis.5 6 Currently, no consensus exists to differentiate ESBO from postoperative ileus. Both disease states cause abdominal pain/distension concurrent with nausea and vomiting. The difference between the disease states relies on radiographic imaging, particularly in the postoperative state when multiple surgically correctable causes of ESBO can be diagnosed.4 Differentiating them is critical as nonoperative management may improve both disease states; however, reoperation in the presence of ileus will prolong hospitalization and increase , complication rates.7 8 Distinguishing these processes from one another is also necessary given the intimate association with increasing complications from reoperation greater than , , 10–14 days after the initial exploration.4 9 10 Gastrografin (GG; sodium diatrizoate/meglumine diatrizoate) has been shown to have diagnostic and therapeutic capabilities in adhesive SBO outside of the immediate
364
postoperative period. This hyperosmolar water-soluble contrast agent has 96 % sensitivity and 97 % specificity in predicting the success of nonoperative management for , SBO.11 12 With an osmolarity about six times more than extracellular fluid (1,900 mOsm/L), it has been postulated that the contrast agent draws fluid from bowel wall into the lumen, thereby decreasing edema and increasing the pressure – gradient across obstructive sites.13 15 Clinical trials evaluating the diagnostic and therapeutic role of GG in SBO excluded patients presenting in the immediate postoperative period.11 The reasons for this are several folds and stem from the dissimilar causes, treatments, and outcomes of ESBO compared to those outside the immediate postoperative period. For instance, ESBO has a greater rate of strangulation and mortality as well as a greater rate of nonadhesive causes including abscess, hematoma, , , hernia, dehiscence, intussusception, and stricture.9 16 17 We aimed to assess the association of Gastrografin in the resolution of ESBO without surgical intervention and hypothesized that administration of GG would decrease the need for operative intervention and the duration of hospital stay.
J Gastrointest Surg (2014) 18:363–368
abdominal film is obtained; presence of contrast within the large bowel or passing a bowel movement represents a successful challenge and nonoperative management is pursued. Failure of the GG challenge warrants operative re-exploration if within 10–14 days of the index procedure based on surgeon’s judgment. Statistical analysis was conducted between patient groups using chi-square, Fisher exact, 2-sample Student’s t , and Wilcoxon rank-sum tests as appropriate. Sensitivity, specificity, positive, and negative predictive values were calculated. A true positive GG challenge represented a successful GG challenge without the need for operative exploration, whereas a true negative GG challenge represented a failed GG and the patient underwent exploration for ESBO. A false positive was considered as a successfully passed GG challenge but underwent exploration, while a false negative was defined by failure without exploration. Data are presented as means (standard deviation) for continuous variables and as percentages for discrete variables. Statistical significance was considered at p
2013 SSAT POSTER PRESENTATION
Role of Gastrografin Challenge in Early Postoperative Small Bowel Obstruction Mohammad A. Khasawneh & Maria L. Martinez Ugarte & Boris Srvantstian & Eric J. Dozois & Michael P. Bannon & Martin D. Zielinski
Received: 24 June 2013 / Accepted: 29 August 2013 / Published online: 29 October 2013 # 2013 The Society for Surgery of the Alimentary Tract
Abstract Introduction Early small bowel obstruction following abdominal surgery presents a diagnostic and therapeutic challenge. Abdominal imaging using Gastrografin has been shown to have diagnostic and therapeutic properties when used in the setting of small bowel obstruction outside the early postoperative period (>6 weeks). We hypothesize that a GG challenge will reduce need for re-exploration. Methods Patients with early small bowel obstruction who underwent a Gastrografin challenge between 2010 and 2012 were case controlled, based on age ±5 years, sex, and operative approach to an equal number of patients that did not receive the challenge. Results One hundred sixteen patients received a Gastrografin challenge. There were 87 males in each group with an average age of 62 years. A laparoscopic approach in the index operation was done equally between groups (18 vs. 18 %). There was no difference between groups in operative re-exploration rates (14 vs. 10 %); however, hospital duration of stay was greater in patients who received Gastrografin challenge (17 vs. 13 days). Two in hospital deaths occurred, one in each group, both of infectious complications. Conclusion Use of the Gastrografin challenge in the immediate postoperative period appeared to be safe. There was no difference, however, in the rate of re-exploration between groups. Keywords Small bowel obstruction . Gastrografin challenge . Early postoperative bowel obstruction . Water-soluble contrast . Outcome
Introduction Early postoperative small bowel obstruction (ESBO) presents a diagnostic and therapeutic challenge to surgeons. This complication, affecting up to 9.5 % of patients after laparotomy, Poster presentation, Digestive Disease Week/Society for Surgery of the Alimentary Tract, Orlando, Florida, May 19–21, 2013 M. A. Khasawneh : M. L. M. Ugarte : B. Srvantstian : E. J. Dozois : M. P. Bannon : M. D. Zielinski Department of Surgery, Mayo Clinic, Rochester, MN, USA M. D. Zielinski (*) Division of Trauma, Critical Care and General Surgery, St. Mary’s Hospital, Mayo Clinic, Mary Brigh 2-810 1216 Second Street SW, Rochester, MN 55902, USA e-mail: [email protected]
mimics postoperative paralytic ileus given the similarities in – physical examination findings and time course.1 4 Small bowel obstruction (SBO) indicates interruption of the continuity of the intestinal tract, whereas ileus indicates a , nonmechanical insult that disrupts normal peristalsis.5 6 Currently, no consensus exists to differentiate ESBO from postoperative ileus. Both disease states cause abdominal pain/distension concurrent with nausea and vomiting. The difference between the disease states relies on radiographic imaging, particularly in the postoperative state when multiple surgically correctable causes of ESBO can be diagnosed.4 Differentiating them is critical as nonoperative management may improve both disease states; however, reoperation in the presence of ileus will prolong hospitalization and increase , complication rates.7 8 Distinguishing these processes from one another is also necessary given the intimate association with increasing complications from reoperation greater than , , 10–14 days after the initial exploration.4 9 10 Gastrografin (GG; sodium diatrizoate/meglumine diatrizoate) has been shown to have diagnostic and therapeutic capabilities in adhesive SBO outside of the immediate
364
postoperative period. This hyperosmolar water-soluble contrast agent has 96 % sensitivity and 97 % specificity in predicting the success of nonoperative management for , SBO.11 12 With an osmolarity about six times more than extracellular fluid (1,900 mOsm/L), it has been postulated that the contrast agent draws fluid from bowel wall into the lumen, thereby decreasing edema and increasing the pressure – gradient across obstructive sites.13 15 Clinical trials evaluating the diagnostic and therapeutic role of GG in SBO excluded patients presenting in the immediate postoperative period.11 The reasons for this are several folds and stem from the dissimilar causes, treatments, and outcomes of ESBO compared to those outside the immediate postoperative period. For instance, ESBO has a greater rate of strangulation and mortality as well as a greater rate of nonadhesive causes including abscess, hematoma, , , hernia, dehiscence, intussusception, and stricture.9 16 17 We aimed to assess the association of Gastrografin in the resolution of ESBO without surgical intervention and hypothesized that administration of GG would decrease the need for operative intervention and the duration of hospital stay.
J Gastrointest Surg (2014) 18:363–368
abdominal film is obtained; presence of contrast within the large bowel or passing a bowel movement represents a successful challenge and nonoperative management is pursued. Failure of the GG challenge warrants operative re-exploration if within 10–14 days of the index procedure based on surgeon’s judgment. Statistical analysis was conducted between patient groups using chi-square, Fisher exact, 2-sample Student’s t , and Wilcoxon rank-sum tests as appropriate. Sensitivity, specificity, positive, and negative predictive values were calculated. A true positive GG challenge represented a successful GG challenge without the need for operative exploration, whereas a true negative GG challenge represented a failed GG and the patient underwent exploration for ESBO. A false positive was considered as a successfully passed GG challenge but underwent exploration, while a false negative was defined by failure without exploration. Data are presented as means (standard deviation) for continuous variables and as percentages for discrete variables. Statistical significance was considered at p
