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Multi-institutional, prospective, observational study comparing the Gastrografin challenge versus standard treatment in adhesive small bowel obstruction

Zielinski, Martin D. MD; Haddad, Nadeem N. MD; Cullinane, Daniel C. MD; Inaba, Kenji MD; Yeh, Dante D. MD; Wydo, Salina MD; Turay, David MD; Pakula, Andrea MD; Duane, Therese M. MD; Watras, Jill MD; Widom, Kenneth A. MD; Cull, John MD; Rodriguez, Carlos J. DO; Toschlog, Eric A. MD; Sams, Valerie G. MD; Hazelton, Joshua P. DO; Graybill, John Christopher MD; Skinner, Ruby MD; Yune, Ji-Ming MDEAST SBO Workgroup: Martin D. Zielinski, MD; Nadeem N. Haddad, MD; Asad J. Choudhry, MBBS; Daniel C. Cullinane, MD; Kenji Inaba, MD; Agustin Escalante; D. Dante Yeh, MD; Salina Wydo, MD; David Turay, MD; Andrea Pakula, MD; Therese M. Duane, MD; Jill Watras, MD; Kenneth A. Widom, MD; John Cull, MD; Carlos J. Rodriguez, DO; Eric A. Toschlog, MD; Valerie G. Sams, MD; Joshua P. Hazelton, DO; John Christopher Graybill, MD, Ruby Skinner, MD, Ji-Ming Yune, MD

Journal of Trauma and Acute Care Surgery: July 2017 - Volume 83 - Issue 1 - p 47–54
doi: 10.1097/TA.0000000000001499
EAST Plenary Paper

INTRODUCTION Existing trials studying the use of Gastrografin for management of adhesive small bowel obstruction (SBO) are limited by methodological flaws and small sample sizes. We compared institutional protocols with and without Gastrografin (GG), hypothesizing that a SBO management protocol utilizing GG is associated with lesser rates of exploration, shorter length of stay, and fewer complications.

METHODS A multi-institutional, prospective, observational study was performed on patients appropriate for GG with adhesive SBO. Exclusion criteria were internal/external hernia, signs of strangulation, history of abdominal/pelvic malignancy, or exploration within the past 6 weeks. Patients receiving GG were compared to patients receiving standard care without GG.

RESULTS Overall, 316 patients were included (58 ± 18 years; 53% male). There were 173 (55%) patients in the GG group (of whom 118 [75%] successfully passed) and 143 patients in the non-GG group. There were no differences in duration of obstipation (1.6 vs. 1.9 days, p = 0.77) or small bowel feces sign (32.9% vs. 25.0%, p = 0.14). Fewer patients in the GG protocol cohort had mesenteric edema on CT (16.3% vs. 29.9%; p = 0.009). There was a lower rate of bowel resection (6.9% vs. 21.0%, p < 0.001) and exploration rate in the GG group (20.8% vs. 44.1%, p < 0.0001). GG patients had a shorter duration of hospital stay (4 IQR 2–7 vs. 5 days IQR 2–12; p = 0.036) and a similar rate of complications (12.5% vs. 17.9%; p = 0.20). Multivariable analysis revealed that GG was independently associated with successful nonoperative management.

CONCLUSION Patients receiving Gastrografin for adhesive SBO had lower rates of exploration and shorter hospital length of stay compared to patients who did not receive GG. Adequately powered and well-designed randomized trials are required to confirm these findings and establish causality.

LEVEL OF EVIDENCE Therapeutic, level III.

From the Mayo Clinic (M.D.Z., N.N.H.), Rochester, Minnesota; Marshfield Clinic (D.C.C.), Marshfield, Wisconsin; University of Southern California (K.I.), Los Angeles, California; Massachusetts General Hospital (D.D.Y.), Chelsea, Massachusetts; Cooper University (S.W., J.P.H.), Camden, New Jersey; Loma Linda University (D.T., J.-M.Y.), Loma Linda, California; Kern Medical Center (A.P., R.S.), Bakersfield, California; John Peter Smith Hospital (T.M.D.), Ft. Worth, Texas; Inova Fairfax Hospital (J.W.), Falls Church, Virginia; Geisinger Medical Center (K.A.W.), Danville, Pennsylvania; Greenville Memorial Hospital (J.C.), Greenville, South Carolina; Walter Reed National Military Medical Center (C.J.R.), Bethesda, Maryland; East Carolina University (E.A.T.), Greenville, North Carolina; and San Antonio Military Medical Center (V.G.S., J.C.G.), San Antonio, Texas.

Submitted: December 1, 2016, Revised: January 17, 2017, Accepted: February 9, 2017, Published online: April 18, 2017.

Presented in part as an oral presentation at the EAST Annual Scientific Assembly, January 2017, Hollywood, Florida.

Address for reprints: Martin D. Zielinski, MD, Division of Trauma, Critical Care and General Surgery, Mary Brigh 2-810, St. Mary’s Hospital, Mayo Clinic, 1216 Second St. SW, Rochester, MN 55902; email:

© 2017 Lippincott Williams & Wilkins, Inc.