|Year : 2014 | Volume
| Issue : 3 | Page : 84-87
Absolute benefit of gastrografin in adhesive small bowel obstruction: A retrospective study and review of the literature
Asri Che Jusoh, Fatimah Halwani Ismail, Ong Yanzie
Department of General Surgery, Kuala Krai Hospital, Kuala Krai 18000 Kelantan, Malaysia
|Date of Web Publication||15-Dec-2014|
Asri Che Jusoh
Department of General Surgery, Kuala Krai Hospital, Kuala Krai 18000 Kelantan
Source of Support: None, Conflict of Interest: None
Introduction: Adhesive small bowel obstruction (ASBO) is a major cause of postoperative morbidity. The objectives of the study are to evaluate the diagnostic and therapeutic properties of gastrografin (GF) in ASBO. Materials and Methods: A retrospective review of all adult patients admitted from January 2011 to January 2013 with ASBO, who undergone GF test was done. Apart from establishing its diagnostic property, therapeutic effects following the test were also determined such as reduced need for surgery and shortened the hospital stay. An undiluted GF (100 ml) was given once the patient is adequately rehydrated followed by supine abdominal X-ray 4-6 h later. If the contrast is seen in the colon, the test is considered as positive. Otherwise, a repeat X-ray is done 20 h later (24 h postGF). A positive test patient was considered as partially obstructed and selected for nonoperative management. Otherwise, if remain negative at 24 h surgery is considered. Results and Analyses: A total of 21 patients who fulfilled the criteria was analyzed. Majority were male (16 patients, 76.2%), aged between 14 and 84 years (mean 45.3). A total hospital stay was 5 days (median) with only 3 days for successful GF test. Eight patients (38.1%) developed first ASBO following open appendectomy whereas 28.5% (six patients) after colorectal surgery. Previous midline laparotomy was the most common approach seen (57.1%, 12 patients) followed by lanz incision (23.8%, five patients). A positive test was only demonstrated in 66.7%, 38.1% (eight patients), and 28.6% (six patients) at 4 h and 24 h, respectively. Surgery was required in seven patients (33.3%) with only one patient can be approached laparoscopically. We had no adhesion-related bowel gangrene or mortality. Conclusion: Our analysis demonstrated that GF test is safe and very beneficial in managing ASBO. It reduces the need for surgery and shortens hospital stay even in high adhesion risk group.
Keywords: Adhesion, gastrografin, small bowel obstruction
|How to cite this article:|
Jusoh AC, Ismail FH, Yanzie O. Absolute benefit of gastrografin in adhesive small bowel obstruction: A retrospective study and review of the literature. Saudi Surg J 2014;2:84-7
|How to cite this URL:|
Jusoh AC, Ismail FH, Yanzie O. Absolute benefit of gastrografin in adhesive small bowel obstruction: A retrospective study and review of the literature. Saudi Surg J [serial online] 2014 [cited 2019 Jan 18];2:84-7. Available from: http://www.saudisurgj.org/text.asp?2014/2/3/84/147026
| Introduction|| |
Adhesive small bowel obstruction (ASBO) is a major cause of postoperative morbidity. Good evidences are available to support conservative management in patients with SBO without signs of strangulation. , However, delayed treatment will increase the mortality rate from 3% to 5% for simple obstruction to 30% in cases of strangulation or necrotic bowel.  Even though emergency surgery is strongly indicated when features of strangulation or complete obstruction exist, the way to predict progression to strangulation or resolution is less clear. , Current studies are looking at the role of water-soluble contrast agent (WSCA). 
Gastrografin (GF) is a radio-opaque water soluble, hypertonic liquid contrast agent (1900 mosm/l) which revolutionized the management of ASBO. Enough data are available confirming the diagnostic property of GF where it can predict the requirement for surgery. However, its therapeutic role is only recently proved. It was well demonstrated that its use enhances rate of resolution of SBO without surgery, reduces the need for surgery, time from admission to complete resolution, hospital stay, and mortality. 
Our primary objective of the study was to determine the diagnostic property of the GF in ASBO, differentiates partial or complete obstruction. Apart from that, additional objectives are to ascertain some therapeutic properties of GF such as its ability to shorten the hospital stay and reduce the need for surgery.
| Materials and Methods|| |
Since January 2011, all adult patients aged more than 12-year-old admitted into our general surgical ward for uncomplicated adhesive bowel obstruction would undergo oral GF test. The standard protocol was made and followed by all medical staffs. Inclusion and exclusion criteria were established. Demographic data, type of initial surgery, its approach, and results of a test at 4 and 24 h were documented. The study was conducted until January 2013 (2 years period). Those who had signs of strangulation, early ASBO (defined as less than a month from initial surgery), virgin abdomen with suspected of ASBO and history of previous ASBO were excluded from the study even though we do give GF to majority of them except to the former.
Once the diagnosis is made, 100 ml of undiluted GF is given orally or via Ryle's tube at any convenient time. In our series, they were given in the ward once adequately rehydrated. Subsequently, the tube was clamped and observed for vomiting. The presence of contrast at cecum or colon 4-6 h later indicates a partial obstruction thus patient is fed as tolerated. We considered them as positive GF test. Otherwise, another plain abdominal X-ray is done at 24 h postcontrast. The absence of contrast at cecum or colon indicates complete obstruction and surgery is considered: A negative GF test.
| Results and Statistical Analysis|| |
A total of 21 patients fulfilled the inclusion criteria with all of them completed the contrast study with no problems. Sixteen patients were male (76.2%) and 5 (23.8%) female. Their age ranged from 14 to 84 years (mean 45.3 years). Total hospital stay (median) was 5 days. In nonoperated (positive GF) group, the median stay was only 3 days. Majority of them had open appendectomy (38.1%, eight patients) followed by colorectal surgery in six patients (28.5%). Only one patient had ASBO following lower segment caesarean section [Table 1].
As expected, majority of them (57.1%, 12 patients) had midline laparotomy, followed by lanz incision for open appendectomy in five patients (23.8%) [Table 1]. Other approaches appear less likely associated with adhesion. Surprisingly, at 4 h, the test was only positive in eight patients (38.1%). In remaining six patients (28.6%), it was positive at 24 h. Therefore, total positive GF test was only 66.7% (14 patients). They were fed and discharged once tolerate orally well.
If ASBO were to happen, majority (71.5%, 15 patients) are expected to occur within 5 years after the initial (index) surgery [Figure 1].
|Figure 1: Duration of first adhesive small bowel obstruction after initial surgery with its frequency|
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Surgery was required in seven patients (33.3%). Almost all (six out of seven, 86%) of them had midline laparotomy with colorectal surgery was the most common followed by small bowel. The most common approach for adhesiolysis at our center was laparotomy (six out of seven patients, 86%). In one patient, his small bowel needs to be resected not because of gangrene but due to iatrogenic tears (severe) during adhesiolysis. Previously, he had undergone cystoprostatectomy for bladder cancer a year before followed by pelvic radiotherapy. There was dense pelvic adhesion noted intra-operatively [Table 2].
| Discussion|| |
In our series, ASBO occurred mainly in the male patient (76%) as in Nasrin et al. (64%) and Salamah et al. (65.7%). , Nearly, 70% of ours were due to post open appendectomy and colorectal surgery. The total incidence is much higher than in reported review article which was 43%.  On the other hand, it was only 23% in Solomone et al. series. Majority were following obstetric and gynecologic surgery (31.5%).  It is important to notice that majority of our first ASBO cases (71%) occurred within the first 5 years of index surgery. Similar finding was also demonstrated by Moran (58%). 
Small bowel obstruction can be classified as either partial or complete. Unfortunately, bedside examinations and imaging cannot confidently distinguish between the two. Fortunately, GF has a strong diagnostic value in differentiating types of obstruction.  Based on our study, positive GF test was seen in only 66.7% of the patients much lower than others which ranged from 80 to 90%. ,,, The reasons were they excluded those who had pelvic irradiation, and 20% of Salamah et al. series were a virgin abdomen.  Meta-analysis supports the use of GF to predict needs for surgery.  If it reaches the colon by 4-24 h, obstruction will resolve without surgery in 99% of patient (positive predictive value [PPV]). Otherwise, obstruction is unlikely to resolve without operation in 90% of patients (Negative predictive value [NPV]).  Similarly,
Di Saverio et al. demonstrated that 96% of patients who fail GF within 24 h need surgery.  All our positive GF patients responded well with conservative management with no one requires surgery, reconfirming the established high PPV.
Even though, Branco et al. established that sensitivity/specificity, PPV and NPV were similar between 4 and 8 h and at 24 h,  our series highlighted the contradictory. In a significant percentage of patients (28.6%, six patients), the test was only positive at 24 h. Further studies are needed to clarify these differences. Based on this finding, we decided to routinely repeat the X-ray if it was negative at 4 h. Furthermore, the percentage of positive rate was almost comparable between 4 and 24 h.
Mean hospital stay for patients who successfully managed conservatively was 5.6 days, significantly longer compare to GF group, 3.9 days.  Similarly, Nasrin et al. demonstrated the significant reduction from 4.6 days to 2.7 days for control and GF groups, respectively, a significant reduction by 57.6% which comparable to Biondo et al. (52%) and Di Saverio et al. (59.8%).  Ours was 3 days (Median) for nonoperated GF group and 5 days for total GF patients (operated and nonoperated). A longer stay than others could be attributed by long mean stay of our operated patients. Three days stay for nonoperated GF group is much shorter than nonoperated, nonGF group which normally around 5 days to a week.
Emergency surgery is warranted when strangulation or complete obstruction occurs with reported rate ranges from 27% to 42%. , Initial meta-analysis of four randomized controlled trials in 2007 showed, WSCA did not reduce the need for surgery, but recent meta-analysis with additional three more randomized control trials concluded that it significantly reduced the need for surgery (30-20%) and shortened the hospital stay. , Jonathan et al. in their trials clearly demonstrated the therapeutic effect of GF. 73% of GF patients had complete resolution within 24 h, whereas only 52% in the placebo group.  Interestingly, a randomized trial by Nasrin et al. highlighted the real therapeutic effect of GF. Obstruction resolved in 90% of GF group versus only 76% in control (nonGF) after 4 days. In addition, surgery was only needed in 9.5% of GF group versus 24% in the control group.  To further demonstrates the therapeutic benefit of GF, Di Saverio et al. established that after unsuccessful conservative management, use of GF significantly reduced the need for surgery by 74% with no significant complications. 
In stark contrast, our operative rate was 33.3%, higher than most series. Few possible explanations can be made. Our series included those who had abdominal irradiation following laparotomy, not like others. If they were excluded (three patients), our operative rate is 22.2%, slightly lower than established operative rate for ASBO, which was between 27% and 42%. Thus, an additional benefit of GF was also demonstrated from our study. Furthermore, in Solomone et al. series, types of index surgery were totally different from ours. 20% of their cases were following esophagogastric surgeries and only 7% (from 58 patients) were from colorectal. On the other hand, 28.5% of ours were postcolorectal cancer surgery and had adjuvant chemo-radiotherapy. Only one patient (4.8%) developed ASBO after cesarean section.
Patients who fail GF test preferably not directly undergo surgery. Conservative management is often continued depending on clinical assessment.  Multiple studies have shown that up to 30% of patient who have retained the contrast in the small bowel after 24 h can still be managed nonoperatively.  In Salamah et al. series, four out of 13 (30.8%) patients who fail initial GF test can still be managed conservatively.  Despite that we offered surgery to all of our failed GF patients as most of them had midline laparotomy and postcolorectal surgery. Both were strong predictors for matted adhesion which would not resolve easily without surgery.  Moreover, its NPV was 90%.  We strongly belief on the idea proposed by Zielinski and Bannon was to divert the old concept of differentiating SBO to predicting failure of nonoperative management with the aim of operating those with predicted failure as early as possible.  Our low threshold practice to operate them would definitely contribute to higher operative rate than others. Reviewing the latest guideline, deciding for surgery in failed GF group can be delayed up to 3 days or even longer with certain parameters have to look for such as amount of naso-gastric drainage (not more than 500 ml at day 3), temperature, leukocytosis (>15 000/mm 3 ) or signs of complications.  Based on our current practice, we had no gangrenous bowel requiring resection and mortality.
Many limitations can be elicited from our case series by its nature. A comparative, prospective study with proper statistical analysis would definitely provide more meaningful results. However, results from this review will set a standard of care for ASBO patients in future.
| Conclusion|| |
Numerous attempts have been made to prevent adhesion but till now, no method is proven completely effective. Meta-analysis strongly supports the use of WSCA in ASBO as it has both diagnostic and therapeutic role. Its use significantly reduced operative rate and shortened hospital stay even in high adhesion risk patients without posing additional adverse effects.
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[Table 1], [Table 2]