Browsing by Subject "gastrografin challenge"

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    Early or Late Gastrografin Challenge for the Non-Operative Management of Small Bowel Obstruction
    (2020-09-10) Holder, Erik; Murphy, Patrick; Meagher, Ashley; Rodriguez, Rachel
    Introduction: Gastrogafin (GG) challenge is becoming the standard of care for the non-operative management of adhesive small bowel obstruction (aSBO). Protocols vary in the timing of GG challenge from early (≤ 24 hours) to late (> 24 hours). Concerns remain regarding the safety of early GG due to inadequate stomach and bowel decompression raising fear of complication such as aspiration. Few studies have investigated the relationship between the timing of GG and patient outcomes, including time to OR, length of stay or complication rate. We hypothesized early GG challenge would be non-inferior to late GG challenge and would have shorter length of stay. Methods: A retrospective cohort study of 215 patients over two years (2018-2019) who underwent non-operative management of adhesive SBO. We stratified patients by timing of GG challenge, ≤ 24 hours (Early GG) or > 24hours (Late GG). Our primary outcome was success of GG challenge defined by discharge without an operation. Secondary outcomes included bowel resection, re-admission rate, hospital length of stay, and mortality. Our non-inferiority margin was 4%. We used the Chen Quasi-Exact method to determine confidence intervals for small sample sizes to determine non-inferiority. Continuous data was assessed by one-way ANOVA and categorical data with Fischer’s Exact test. Results: A total of 215 patients underwent planned non-operative management of adhesive SBO over the study period, of whom 102 received a GG challenge. Early GG was administered in 33 (32%), Late GG was administered in 79 (68%). There was no difference in age or gender, but more African Americans received Late GG (40% vs 15%, p = 0.01). The need for operative intervention was lowest in the early group, 6.1% compared to 17.7% in the late group. The difference of -11.6% [95% CI -22.9% - 3.3%] was non-inferior (p=0.03) but did not meet superiority. No patient receiving Early GG required bowel resection compared to 5 (35%) in the Late GG group (p = 0.45). Hospital length of stay was a median of 3 (IQR 2) for Early GG compared to 4 (IQR 8) for Late GG (p < 0.001). There was no difference in mortality, re-admission rates, ICU admission or ICU length of stay between groups. Conclusion: Early GG challenge (≤ 24 hours) is non-inferior to late GG challenge (> 24 hours) for the non-operative management of adhesive SBO. Patients who received early GG had a shorter length of stay, and no complications associated with early GG. Additionally, fewer patients who received early GG received a bowel resection, although this is not statistically significant. This indicates need for multi-center evaluation of GG administration and development of practice management guidelines for patients with adhesive SBO. We recommend early GG challenge to decrease the time for operative decision making and reduce length of stay. A prospective study comparing early versus late GG challenge is needed to determine optimal timing.