APSA - A contrast challenge is safe in children with adhesive small bowel obstruction- a multi-institutional review - Nathan Rubalcava

Adhesive small bowel obstructions are a well-known cause of morbidity in children following abdominal surgery

Traditional treatment for adhesive small bowel obstruction has been gastric decompression, bowel rest, fluid resuscitation, and electrolyte replacement

Over the last two decades, water-soluble contrast agents in management of small bowel obstructions have become well established in adult literature given their ability to predict success of non-operative management

A contrast challenge is performed after a period of gastric decompression, with abdominal X-ray obtained 8 to 10 hours after contrast administration

Contrast in the colon is considered having passed the contrast challenge, and patients are discharged after demonstrating clinical improvement with tolerance of regular diet

Patients without contrast in colon after repeat abdominal X-ray at 24 hours are considered to have failed their contrast challenge and are taken to surgery for exploration

Limited data exists regarding safety and use of contrast challenge in the pediatric population, despite multiple pediatric institutions adopting contrast challenge algorithms

The study performed retrospective review of all children undergoing contrast challenge across 5 children's hospitals over 8 years

By group consensus, a complication rate less than 5% would be considered safe to use a contrast challenge for clinical practice

Major complications were defined as aspiration, pneumonia, anaphylaxis, cardiovascular complications, and renal failure; minor complications included urticaria, dyspnea, and worsening abdominal pain

82 children underwent a contrast challenge; 57 initially passed with 53 having clinical improvement and successful discharge; 25 failed and were taken to surgery

There was a significant age difference between groups, with those passing the challenge being a median of 7 years older, but no differences between each age group

Over 30% of patients had neurologic and pulmonary comorbidities

Contrast agents used were institution-specific with relatively similar osmolality, with dilute gastrographin being the most commonly utilized agent

There were no major or minor complications in the study, with a 0% complication rate and confidence interval of 0 to 3.6%, significantly below the pre-set acceptable complication rate of 5%

There were no mortalities in either group

The group that failed their contrast challenge had a significantly longer hospital stay by 5 days

A total of 6 patients were readmitted within 30 days for recurrent small bowel obstruction

The contrast challenge has a sensitivity of 100%, specificity of 86%, negative predictive value of 100%, and positive predictive value of 93%

Every institution had a similar protocol that had been mirrored to Doctor Grace Mack from University of Chicago's study from 2018

This review of 82 patients is the largest to date in children demonstrating that a contrast challenge is safe, effective, and highly predictive in children

The Midwest Pediatric Surgery Consortium is conducting a prospective study looking at contrast challenges in pediatric adhesive small bowel obstruction

More pediatric surgeons have adopted the practice after the study showed it was safe and effective in predicting which children will be successfully managed non-operatively

This study will impact every single child that undergoes abdominal surgery because for the rest of their life they are at risk of adhesive small bowel obstruction