Best of the Best APSA Winner

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.

In the contrast challenge protocol, after gastric decompression the patient is given contrast and an abdominal X-ray is obtained 8 to 10 hours later. Contrast in the colon indicates passing the challenge.

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

Limited data exists regarding safety and use of contrast challenge in the pediatric population, yet multiple pediatric institutions have adopted contrast challenge algorithms.

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

Primary outcome was any complication related to contrast administration, with complication rate less than 5% considered safe for clinical practice by group consensus.

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 contrast challenge. 57 initially passed, of which 53 had clinical improvement and were successfully discharged. 25 failed and were taken to surgery.

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

6 patients were readmitted within 30 days for recurrent small bowel obstruction.

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

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

Over 30% of patients had neurologic and pulmonary comorbidities.

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

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

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

There were no mortalities in either group.

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

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 seeing it was safe and effective in predicting which children will be successfully managed non-operatively.

This contrast challenge will positively impact management of every child that undergoes abdominal surgery because they are at risk of adhesive small bowel obstruction for the rest of their life.