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

We have APSA as our last society. Um, I know they're up to the task for, uh, winning the competition. So first we have Doctor Naru Bolava. Um, he's gonna, we're gonna watch his presentation on, uh, contrast challenges in children with small bowel obstructions. Of the process. Stop the presses. Hold on a second here. We got a little bit of drama. We're gonna address it in about maybe 15 minutes. Stay tuned for the drama. We're gonna figure this problem out, but say in 15 minutes, you'll see the drama. It has to relate to the UPSA finalists. All right, let's roll the video. Hi, everyone. I'm Nate Rubocava, and I'm a research fellow at the University of Michigan. Adhesive small bowel obstructions are a well-known cause of morbidity in children following abdominal surgery. Traditionally, the treatment has been gastric decompression, bowel rest, fluid resuscitation, and electrolyte replacement. However, 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. Despite this practice in adults, 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. Therefore, we sought to evaluate the safety of a water-soluble contrast challenge in children presenting with an adhesive small bowel obstruction. For this study, we performed a retrospective review of all children undergoing a contrast challenge across 5 children's hospitals over a period of 8 years. Our primary outcome was any complication related to contrast administration and by group consensus, a complication rate less than 5% would be considered safe to use a contrast challenge for clinical practice. Contrast-associated complications were defined as major and minor complications with major complications including 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. There was a significant age difference between the two groups, with those passing the challenge between a median of 7 years older. However, there were no differences between each age group. Our cohort included patients affected with neurologic and pulmonary comorbidities which were present in over 30% of our patients. The contrast agents used were institution-specific, all had relatively similar osmodality, with dilute gastrographin being the most commonly utilized agent. There were no major or minor complications in the study, and with a 0% complication rate and the confidence interval of 0 to 3.6%, this was significantly below our 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 a recurrent small bowel obstruction. In our contingency table for the contrast challenge, we compared medical versus surgical small bowel obstructions. Contrast in the colon was considered a positive test, and a bowel obstruction that resolved without surgery, a medical small bowel obstruction was considered positive, uh, disease positive. With these considerations, the contrast challenge has a sensitivity of 100%, specificity of 86%, negative and positive predictive values of 100% and 93% respectively. Predicting who will be successful with non-operative management remains challenging. However, in our review of 82 patients, which is the largest to date in children, we demonstrated that a contrast challenge is safe, effective, and highly predictive in children and provides informative data for the surgeon to use in their clinical decision making. Thank you very much and please reach out if you have any questions. Doctor Rubbo Cava, um, I was so excited to see this when you guys initially presented it, and I was so excited to get to discuss it again here because honestly, I think this is what's gonna, um, make Absa the victor today no matter what the drama is over on the IPEG side. Uh, you know, I think a lot of us have been doing this for a long time based off of the adult data, but depending on where we were, got some pushback from either the radiologist or our colleagues. Um, my question for you is if you guys were reviewing this at different institutions with different algorithms, did you worry in the retrospective review that there was bias, that there were kids that had bowel obstructions that individual surgeons just were like, well, not willing to, to do this when, when it's not well studied in kids, um, and kind of how did you look at that? Um, did you look at it all the kids who didn't have contrast challenges? Uh, and then with this kind of data that it's safe, have you seen in the last year or so, uh, any barriers to adoption? Are there still people that are arguing it or you've seen people that are, that are now kind of believers? Yeah, thank you so much for the opportunity to, to discuss our study. Uh, first question about sort of the, the protocols, that, you know, every institution fortunately had a similar protocol that had been actually mirrored, uh, uh, uh, to Doctor Grace Mack from University of Chicago's, uh, uh, study that she did back, uh, uh, in 2018. Um, 2, um, We, we did, we, we tried to account by account or or because of that, that allowed us to be able to study it a little bit easier than it might, than if they had been completely different. Now, with regards to the contrast agents themselves, those ones were the, the, uh, probably the most different between the different institutions as we described the, the Omniate gastrographin, diluted gastrographin, uh, cystographin, but that does bring up a good point in that the, uh, the Midwest Pediatric Surgery Consortium is actually doing a Uh, a prospective study that's looking at contrast challenges in, uh, at pediatric adhesive small bowel structure and we're looking at those specific, uh, uh, uh, issues and we'll hopefully be able to have data for you guys, uh, in the not so distant future. Now, in terms of, are there still holdouts there. I'll say that I have seen more people or more pediatric surgeons say, you know what, you guys were able to show that it was safe, but not only is it safe in terms of zero complications, but it's effective in being able to predict which child will successfully uh Uh, uh, be managed non with non-operative management. What the heck? You know what, we'll go ahead and try and, and, and do it. And then there's the other camp that's similar to you, Doctor Castle, that's saying, you know, we've been doing this for a while. We're glad that it's, that it's safe. Thank you so much. So that laser noise you heard was the 1 minute mark. We probably got about 30 seconds is my guess. Um, I, uh, I, I haven't make a comment, but I want to make sure anyone else doesn't first. Any other comments, uh, Doctor Castle, or anyone else? No, thank you so much. I, I, I have 1011 last, one last, one last comment. OK, go ahead. Uh, go ahead, I think that this is a, this is a game-changing, practice-changing study for, for the, the only reason that, uh, this will impact every single child that undergoes abdominal surgery because for the rest of their life, they're, they're at risk of adhesive small bowel obstruction and This contrast challenge will positively impact their management in the hospital. Thank you. All right, so refs, I don't know how to handle those punches after the bell. I don't know. We'll have to review the tape and see if that's allowed, uh, but, uh, I agree with you. I think this is game-changing and it's changed my practice.