Best of the Best APSA Winner

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

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

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

A contrast challenge is performed when a patient presents with a small bowel obstruction that qualifies for non-operative management. After a period of gastric decompression, the patient is given the contrast and will wait a period of 8 to 10 hours after which an abdominal X-ray is obtained.

Contrast in the colon is considered having passed their contrast challenge, and after the patient demonstrates clinical improvement with tolerance of a regular diet, they are discharged from the hospital.

For those who still don't have contrast in their colon after a repeat abdominal X-ray at 24 hours, they're considered to have failed their contrast challenge and will be taken to surgery for exploration.

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

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

Overall, 82 children underwent a contrast challenge. 57 initially passed their challenge, of which 53 had clinical improvement and were successfully discharged. There were 25 who failed and were taken to surgery. The 4 that failed to completely resolve were also taken to surgery.

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 a recurrent small bowel obstruction.

There was a significant age difference between the two groups, with those passing the challenge between a median of 7 years older.

The cohort included patients affected with neurologic and pulmonary comorbidities which were present in over 30% of patients.

The contrast challenge has a sensitivity of 100%, specificity of 86%, negative and positive predictive values of 100% and 93% respectively for predicting successful non-operative management.

The contrast agents used were institution-specific, all had relatively similar osmodality, with dilute gastrographin being the most commonly utilized agent.

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.

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

There were no mortalities in either group.

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

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

More pediatric surgeons are now saying the study showed it was safe and effective in being able to predict which child will successfully be managed with non-operative management.

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