M. B. Mulder1, M. D. Ray-Zack2, M. Hernandez2, D. Cullinane4, D. Turay5, S. Wydo3, M. Zielinski2, D. Yeh1 5Loma Linda University School Of Medicine,Department Of Surgery,Loma Linda, CA, USA 1University Of Miami,Ryder Trauma Center: Division Of Trauma And Surgical Critical Care,Miami, FL, USA 2Mayo Clinic,Division Of Trauma, Critical Care, And General Surgery,Rochester, MN, USA 3Cooper University Hospital,Department Of Trauma Surgery,Camden, NJ, USA 4University Of Wisconsin,Department Of Surgery Marshfield Clinic,Madison, WI, USA
Introduction: Gastrografin (GG)-based non-operative approach is both diagnostic and therapeutic for partial small bowel obstruction (SBO). Absence of x-ray evidence of GG in the colon after 8 hours (h) is predictive of the need for operation and a recent trial used 48 h to prompt operation. We hypothesize that a significant number of patients receiving the GG challenge require >48 h before an effect is seen.
Methods: In this post-hoc analysis of a multi-institutional SBO database, only patients receiving the GG Challenge were included. We excluded those without a nasogastric tube (NGT), NGT removal on the same day as insertion, and flatus before NGT insertion. Date of NGT insertion and removal were used to calculate the number of days of NGT decompression. Passage of flatus and NGT removal were used as surrogate endpoints for evidence of passing the GG Challenge. “Hard” preoperative signs for operation included: closed loop obstruction, septic shock, and peritonitis. Multiple logistic regression analysis controlling for age, prior abdominal operation, and prior SBO exploration was performed to identify predictors of delayed (>48 h) GG Challenge effect.
Results: Of 319 patients receiving GG, 225 patients (71%) were successfully managed non-operatively (mean age 64 ± 16 years; 56% female). X-ray was performed after a median 8 [4-8.5] h and GG was observed in the colon in 179 (80%). A total of 64 patients (28%) had NGT decompression for >48 h (n=58) or required >48 h to pass flatus (n=37), with some requiring both (n=21). By 4 days, 215 (96%) of those who successfully passed the GG challenge had passed flatus. Regression analysis demonstrated that previous abdominal surgery was predictive (OR 0.37 [0.16-0.88], p=0.024) of a delayed GG Challenge effect. Ninety-four patients (29%) receiving GG underwent operative exploration (mean age 63 ± 17 years; 61% female). X-ray was performed after a median 8 [6-9] h and GG was observed in the colon in 17 (18%). Of the 94 undergoing operation, 24 (25%) underwent operation before day 4 without “hard” signs and also did not have intraoperative findings of strangulation, perforation, or require bowel resection. In these 24 subjects, x-ray was performed after a median 8 [6-9] h and GG was observed in the colon in 6 (25%).
Conclusion: A significant proportion of patients (20%) “failed” the 8 h GG Challenge but were successfully managed non-operatively. At 48 h, a large proportion (28%) still required NGT or had not yet passed flatus, but were nevertheless successfully managed non-operatively. Extending the GG Challenge to 96 h may help avoid operation in some patients, especially those without previous abdominal surgery.
