ARTICLE IN PRESS

Determination of therapeutic
strategy for adhesive small bowel
obstruction using water-soluble
contrast agents: An audit of 776
cases in a single center
Haruki Mori, MD, Yuji Kaneoka, MD, PhD, Atsuyuki Maeda, MD, PhD, Yuichi Takayama, MD, PhD,
Takamasa Takahashi, MD, PhD, Shunsuke Onoe, MD, PhD, and Yasuyuki Fukami, MD, PhD, Gifu,
Japan

Background. Several studies have investigated the diagnostic and therapeutic role of water-soluble
contrast agents in adhesive small bowel obstruction, but there is no clear diagnostic classification for the
determination of therapeutic strategy. The aim of this study was to clarify the clinical value of
classification using water-soluble contrast agents in patients with adhesive small bowel obstruction.
Methods. Between January 2009 and December 2015, 776 consecutive patients with adhesive small
bowel obstruction were managed initially with water-soluble contrast agents and were included in the
study. Abdominal x-rays were taken 5 hours after administration of 100 mL water-soluble contrast
agents and classified into 4 types. The medical records of the patients with adhesive small bowel
obstruction were analyzed retrospectively and divided into 2 groups of patients with complete obstruction
(ie, the absence of contrast agent in the colon) with (type I) or without (type II) a detectable point of
obstruction and a group with an incomplete obstruction (ie, the presence of contrast agent in the colon)
with (type IIIA) or without (type IIIB) dilated small intestine.
Results. Types I, II, IIIA, and IIIB were identified in 27, 90, 358, and 301 patients, respectively. The
overall operative rate was 16.6%. In the patients treated conservatively (types IIIA and IIIB), 647
patients (98.2%) were treated successfully without operative intervention. The operative rate was 3.4%
(n = 12/358) in type IIIA vs 0% (n = 0/301) in the type IIIB group (P = .001). Compared with type
IIIA, type IIIB was associated with earlier initiation of oral intake (2.1 vs 2.6 days, P < .001) and a
lesser hospital stays (9 vs 11 days, P < .001).
Conclusion. This new classification using water-soluble contrast agents is a simple and useful
diagnostic method for the determination of therapeutic strategy for adhesive small bowel obstruction.
(Surgery 2017;j:j-j.)

From the Department of Surgery, Ogaki Municipal Hospital, Gifu, Japan

SMALL BOWEL OBSTRUCTION caused by adhesions after
abdominal operation (ASBO) is one of the most
common postoperative morbidities. ASBO is char-
acterized by the presence of abdominal pain, vom-
iting, distention, and constipation and is
The authors have no conflicts of interest to disclose.
Accepted for publication January 31, 2017.
Reprint requests: Yasuyuki Fukami, MD, PhD, Department of
Surgery, Ogaki Municipal Hospital, 4-86 Minaminokawa-cho,
Ogaki, Gifu 5038502, Japan. E-mail: yasuyuki490225@yahoo.
co.jp.
0039-6060/$ - see front matter
Ó 2017 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.surg.2017.01.023
confirmed by imaging.1-4 Appropriate manage-
ment using a proper diagnostic and therapeutic
pathway is necessary. Emergency operative inter-
vention is required when strangulation is sus-
pected. Conversely, conservative management is
often sufficient in the majority of patients without
signs of strangulation, but operative intervention is
required in 15% to 30% of cases.1-4 Various
methods have been used to direct either operative
or conservative management in patients with
ASBO, and there are several conservative treat-
ments for ASBO. Nevertheless, the ideal manage-
ment of ASBO remains controversial.5-10
Water-soluble contrast agents (WSCA) have a
high osmolarity and can thereby draw fluid from
intravascular and extracellular spaces into the

SURGERY 1
 ARTICLE IN PRESS
2 Mori et al Surgery
j 2017

Fig 1. Ogaki classification using water-soluble contrast agent. Complete obstruction group: type I: the absence of
contrast agent in the colon with a detectable point of complete obstruction; type II: the absence of contrast agent in
the colon without a detectable point of complete obstruction. Incomplete obstruction group: type IIIA: the presence
of contrast agent in the colon with dilated small intestine; type IIIB: the presence of contrast agent in the colon without
dilated small intestine.

lumen, promoting proximal bowel distention.
Thus, this hyperosmotic solution increases the
pressure gradient across the site of obstruction
and is believed to stimulate motility. A number of
studies have investigated the diagnostic and
therapeutic role of WSCA in patients with
ASBO4-6,11-18; however, there is no clear diagnostic
classification for the determination of therapeutic
strategy. The aim of this study was to clarify the
clinical value of classification using WSCA in pa-
tients with ASBO.
PATIENTS AND METHODS
Between January 2009 and December 2015,
776 consecutive patients with ASBO who received
WSCA (Gastrografin; Bayer Co, Osaka, Japan)
initially at Ogaki Municipal Hospital were
included in the study. Diagnostic criteria for
ASBO included a history of previous abdominal
operation more than 4 weeks prior; clinical symp-
toms and signs of mechanical obstruction, such as
abdominal pain, vomiting, abdominal distension,
and constipation; and results of plain abdominal
radiographs performed with the patient upright
and routine computed tomography (CT) showing
dilated loops of small intestine.
Emergency abdominal exploration was under-
taken in patients with suspected strangulation or
peritonitis, these patients were excluded from the
present study. In addition, patients with a history of
an abdominal operation for cancer and who
showed recurrence were also excluded by routine
 ARTICLE IN PRESS
Surgery
Volume j, Number j
Fig 2. Management of adhesive small bowel obstruction by Ogaki classification using water-soluble contrast agent.
examinations (clinical examination, measurement
of tumor marker levels, ultrasonography, and CT).
Management plan. All patients with ASBO were
managed by the surgical team from the time of
admission. Informed, written consent was obtained
from all patients included in the WSCA manage-
ment. All patients were required to fast, were given
intravenous fluid with electrolytes, and had a
nasogastric tube placed for decompression. Within
24 hours after admission, 100 mL WSCA was
administered by nasogastric tube, and the tube
was then clamped. Abdominal x-rays were per-
formed after WSCA administration and classified
into 4 types (Ogaki classification19) by the surgical
team (Fig 1).
Type I was defined as the absence of contrast
agent in the colon with a detectable point of
complete obstruction. Type II was defined as the
absence of contrast agent in the colon without a
detectable point of complete obstruction. Type
IIIA was defined as the presence of contrast agent
in the colon with dilated small intestine, while
Type IIIB was defined as the presence of contrast
agent in the colon without dilated small intestine.
All patients with types I and II underwent
operative exploration on the same day. Patients
with types IIIA and IIIB continued to receive
nonoperative conservative treatment. Clinical
improvement was defined by the appearance of
flatus and defecation or an abdominal x-ray
showing no dilated small bowel. Nasogastric tubes
were removed when the output decreased to less
Mori et al 3
than 500 mL per day. A liquid diet was initiated
subsequently, usually followed by a soft diet the
next day and then solid food as tolerated.
When there was no improvement in types IIIA
or IIIB patients, a long intestinal tube (Sumitomo
Bakelite Co, Tokyo, Japan) was inserted. The tube
has 3 channels: a main channel, a sump channel,
and the balloon channel. Drainage occurs prox-
imal and distal to the balloon. The long intestinal
tube was advanced as far as possible past the Trietz
ligament. If patients showed signs of persistent or
worsening obstruction by clinical and radiologic
findings, operative intervention was performed
(Fig 2).
According to our institutional policy, if persis-
tent intestinal stenosis caused by adhesions was
identified in the intraoperative findings even after
adhesiolysis, intestinal resection was performed. If
the presence or absence of stenosis could not be
confirmed due to severe adhesions, intestinal
resection was also performed. Therefore, no pa-
tient underwent small intestine bypass due to
severe adhesions.
In 1992, we demonstrated the utility of the
Ogaki classification for ASBO by showing that
types I and II have a high possibility of the need
for operative treatment after conservative treat-
ment, while types IIIA and IIIB improve with
conservative treatment.19 Therefore, our manage-
ment plan shifted gradually to our current
approach whereby patients with types I and II are
subjected to operative exploration and types IIIA
 ARTICLE IN PRESS
4 Mori et al Surgery
j 2017

Table I. Patient characteristics of complete Table II. Clinical outcome of complete

obstruction group obstruction group
Type I Type II Type I Type II
(n = 27) (n = 90) P (n = 27) (n = 90) P
Age (y)* 71 ± 12 71 ± 14 .935 Oral intake (days)* 4.0 ± 4.2 3.9 ± 3.4 .921
Sex (male/female) 18/9 57/33 .822 Hospital stay (days)* 18 ± 6 20 ± 12 .300
ASA status (I/II/III) 19/8/0 56/32/2 .598 Type of operative .660
Region of previous .278 treatment
operation Adhesiolysis 11 (41%) 43 (48%)
Upper abdomen 10 (37%) 23 (26%) Intestinal resection 16 (59%) 47 (52%)
Lower abdomen 10 (37%) 49 (54%) *Mean ± SD.
Other 7 (26%) 18 (20%)
Type of previous intra- .530
abdominal operation overall operative rate was 16.6% (n = 129/776).
Gastrointestinal 7 (26%) 20 (22%) The mortality rate was zero in this series.
Colorectal (or 9 (33%) 34 (38%) Patient characteristics in the complete obstruc-
appendectomy) tion groups (types I and II). A total of 117 patients
Hepato-pancreato- 3 (11%) 3 (3%)
having complete obstruction group were divided
biliary
into 2 groups (types I and II). Table I shows the pa-
Gynecologic 2 13 (14%)
Urologic 0 2 tient characteristics of the complete obstruction
Other (or multiple) 6 (22%) 18 (20%) group (type I, n = 27; type II, n = 90). The age,
No. of previous intra- .313 sex, American Society of Anesthesiologists (ASA)
abdominal operations status, area of previous intra-abdominal operation,
1 24 (89%) 69 (77%) type of previous operation, number of previous op-
2 2 (7%) 18 (20%) erations, interval since the last operation, and a
3 or more 1 3 previous episode of ASBO did not differ between
Interval since last 129 ± 157 119 ± 180 .783 the 2 groups.
operation (mo)* Clinical outcomes of the complete obstruction
Previous ASBO 7 (26%) 33 (37%) .360
group (types I and II). Table II shows the clinical
Previous operation 3 (11%) 9 (10%) 1.000
outcomes of the complete obstruction group
for ASBO
(types I and II). There was no significant differ-
*Mean ± SD.
ence in initiation of oral intake (4.0 vs 3.9 days,
P = .921), duration of hospital stay (18 vs 20 days,
P = .300), or type of operation (P = .660) between
and IIIB are treated initially by conservative treat- the type I and type II groups.
ment. In addition, also prior to 2008, there were Patient characteristics of the incomplete
some patients with missing data. obstruction group (types IIIA and IIIB). A total
The medical records of the patients with ASBO of 659 patients who had incomplete obstruction
were analyzed retrospectively and divided into a were divided into 2 groups (types IIIA and IIIB).
complete obstruction group (types I and II) and Table III shows the patient characteristics of the
an incomplete obstruction group (types IIIA and incomplete obstruction group (type IIIA,
IIIB). n = 358; type IIIB, n = 301). The age, sex, ASA
Statistics. Continuous data are expressed as the status, region of previous operation, type of pre-
means ± standard deviations. Statistical analyses vious operation, number of previous operations,
were performed using Student t tests, v2 tests, and interval since the last operation, and a previous
Fisher exact tests as appropriate. Risk factors for episode of ASBO did not differ between the 2
the need for operative intervention in the Ogaki groups.
classification type IIIA were evaluated using bino- Clinical outcomes of the incomplete obstruction
mial logistic analysis. All statistical calculations group (types IIIA and IIIB). Table IV shows the
were performed using an IBM SPSS software pack- clinical outcomes of the incomplete obstruction
age (Statistics 21; IBM Japan Inc, Tokyo, Japan). group (types IIIA and IIIB). The type IIIB patients
had a somewhat lesser duration of nasogastric tube
RESULTS decompression (2.4 vs 2.0 days, P < .001), intervals
Types I, II, IIIA, and IIIB were identified in 27, until initiation of oral intake (2.6 vs 2.1 days,
90, 358, and 301 patients, respectively (Fig 2). The P < .001), and hospital stay (11 vs 9 days,
 ARTICLE IN PRESS
Surgery Mori et al 5
Volume j, Number j

Table III. Patient characteristics of incomplete Table IV. Clinical outcome of incomplete
obstruction group obstruction group
Type IIIA Type IIIB Type IIIA Type IIIB
(n = 358) (n = 301) P (n = 358) (n = 301) P
Age (y)* 71 ± 14 72 ± 13 .445 Duration of 2.4 ± 1.5 2.0 ± 0.8 <.001
Sex (male/female) 229/129 176/125 .149 nasogastric tube
ASA status (I/II/III) 203/139/16 186/109/6 .134 decompression
Region of previous .737 (days)*
operation Oral intake (days)* 2.6 ± 1.6 2.1 ± 0.7 <.001
Upper abdomen 117 (33%) 94 (31%) Hospital stay (days)* 11 ± 6 9±3 <.001
Lower abdomen 178 (50%) 147 (49%) Need for operative 12 (3%) 0 .001
Other 63 (18%) 60 (20%) intervention
Type of previous .790 Type of operative
intra-abdominal treatment
operation Adhesiolysis 3 -
Gastrointestinal 84 (23%) 72 (24%) Intestinal resection 9 -
Colorectal (or 141 (39%) 117 (39%) *Mean ± SD.
appendectomy)
Hepato-pancreato- 34 (9%) 22 (7%)
biliary
DISCUSSION
Gynecologic 39 (11%) 29 (10%)
Urologic 6 (2%) 5 (2%) The present series demonstrated that classifica-
Other (or 54 (15%) 56 (19%) tion of ASBO using WSCA is useful for the selec-
multiple) tion of an appropriate therapeutic strategy.
No. of previous .647 Patients without contrast agent in the colon
intra-abdominal indicated by x-rays performed at least 5 hours after
operations WSCA administration should be considered for
1 266 (74%) 228 (76%) semiemergency operative exploration. In contrast,
2 68 (19%) 58 (19%) patients with contrast agent in the colon indicated
3 or more 24 (7%) 15 (5%)
by x-rays performed at least 5 hours after WSCA
Interval since last 83 ± 135 78 ± 128 .631
administration can have continued conservative
operation (mo)*
Previous episode of 158 (44%) 138 (49%) .694 treatment with excellent outcomes.
ASBO Furthermore, this study showed that there was
Previous operation 40 (11%) 30 (10%) .617 no value in dividing patients into the Ogaki type I
for ASBO and type II classification because doing so did not
*Mean ± SD.
affect operative outcomes. Conversely, patients
with type IIIB did not need operative treatment.
Although many patients with type IIIA will improve
with conservative treatment, operative intervention
P < .001) than type IIIA patients. In the type IIIA might be necessary in the case of 3 days or more of
group, 12 (3%) patients required operative nasogastric tube decompression or previous ASBO.
intervention at a median (range) of 6 days ASBO is a common and costly condition after
(2–19 days) after admission; of these 12 patients, abdominal operation.20,21 For patients presenting
none were found to have strangulation obstruction without signs of strangulation, there is good evi-
with vascular compromise to the intestine. In dence to support the use of conservative manage-
contrast, no patients needed operative treatment ment.5-9 Abdominal CT and ultrasonography may
in the type IIIB group. improve the diagnostic accuracy for bowel strangu-
Multivariate analysis of risk factors for operative lation, increasing the safety of a nonoperative con-
exploration in Ogaki classification type IIIA. Pre- servative treatment. Moreover, abdominal CT may
dictive risk factors for the need for operative be able to detect the cause of obstruction as well
intervention in type IIIA patients were the dura- as the presence of a closed loop.22-24 Effective
tion of nasogastric tube decompression (>3 days) screening for the determination of when to convert
(P = .012; relative risk 4.672, 95% confidence inter- to operative intervention in patients with the con-
val [CI] 1.396–15.638) and a prior episode of servative management of ASBO remains unclear.
ASBO (P = .048; relative risk 3.565, 95% CI Several studies have investigated the diagnostic
1.012–12.561) (Table V). role of WSCA in patients with ASBO.5,6,17,25-27
 ARTICLE IN PRESS
6 Mori et al Surgery
j 2017

Table V. Multivariate analysis of risk factors for operation in Ogaki classification type IIIA (n = 358)
n Risk ratio 95% CI P
Age ($75 year) 166 0.723 0.204–2.562 .616
Sex (male) 229 0.634 0.189–2.124 .460
Duration of nasogastric tube decompression (>3 days) 104 4.672 1.396–15.638 .012
Number of previous operations (>2) 92 0.885 0.187–4.193 .878
Region of previous operation (upper abdomen) 117 0.990 0.237–4.136 .989
Type of previous intra-abdominal operation 259 1.118 0.271–4.614 .878
Previous episode of ASBO 158 3.565 1.012–12.561 .048
Previous operation for ASBO (present) 40 1.524 0.317–7.341 .599
Interval since last intra-abdominal operation (<60 mo) 233 1.735 0.340–8.861 .508

WSCA is valuable in patients undergoing initial con-
servative management to rule out a complete small
bowel obstruction, which would predict the need
for operative treatment in our therapeutic strategy.5
According to a meta-analysis by Branco et al,18 if
WSCA reaches the colon 4 to 24 hours after admin-
istration, the obstruction will be relieved without
operation in 99% of cases. Conversely, if the
contrast does not reach the colon, more than
90% will require operative treatment for resolution;
thus, the use of WSCA can be considered a good
predictor of an excellent outcome with nonopera-
tive management. Furthermore, a meta-analysis of
508 patients found that, regarding the optimal cut-
off for contrast reaching the colon, there appears to
be no advantage in waiting >8 hours.18 In our sin-
gle center study including 776 patients, we recom-
mended 5 hours after WSCA administration as an
ideal time interval for determination of whether
operative therapy will be necessary (ie, the Ogaki
classification type I and type II). Because it is not
suitable for receiver operating characteristic anal-
ysis, we cannot determine whether a 5-hour cutoff
or an 8-hour cutoff is better. Our current study
does, however, show that a 5-hour cutoff is useful
with excellent discriminative value. Failure rates
for conservative management of ASBO reported
as operative rates have been found to vary between
10% and 30%,1-4 while in our series, the total oper-
ative rate was 16.6%.
The results of a systematic review and meta-
analysis support not only the diagnostic but also the
therapeutic use of WSCA in patients with ASBO.18
WSCA has a very high osmolarity of 1900 mOsm/L.
This hyperosmotic solution is a safe alternative with
potential therapeutic value because of its ability to
draw fluid into the bowel lumen, thus increasing
the pressure gradient across the site of obstruction
and potentially by stimulating aboral motility.
WSCA reaches the cecum in an average of
45 minutes (range, 30–90 minutes).
Furthermore, WSCA is believed to decrease in-
testinal wall edema, and its wetting agent may
also facilitate the passage of bowel content.28,29
Interestingly, nonoperative treatment in the pa-
tients with an Ogaki classification type IIIA and
type IIIB succeeded in 98% of our patients
treated with WSCA. Equally important, none of
the patients meeting the Ogaki classification
type IIIB needed operative intervention. There-
fore, it is meaningful to distinguish type IIIA
from type IIIB.
Several recent studies have focused on identi-
fying predictive factors for failure of conservative
management and the need for operative interven-
tion. Nonoperative management of initial episodes
has been advocated as a risk factor for recur-
rence.18 Sakakibara et al30 reported that the vol-
ume of drainage through the long intestinal tube
on day 3 (cutoff value 500 mL) was an indicator
for operative therapy in patients with ABSO
treated conservatively. We also analyzed predictive
risk factors for operation in the Ogaki classification
type IIIA group. As a result, operative treatment
might be necessary in the case of 3 days or more
of nasogastric tube decompression or a previous
ASBO.
Complications from the use of WSCA in patients
with ASBO are rare, but severe pneumonia from
aspiration of WSCA is a recognized complication,
and it would be unwise to administer this agent to
patients who do not have an empty stomach, who
continue to vomit,31 or who are compromised and
cannot protect their airway; however, routine
gastric drainage by placement of a nasogastric
tube before administration of the WSCA should
prevent this potential complication.
We acknowledge several limitations to our study.
This is a retrospective, nonrandomized review. In
addition, we did not monitor the other patients’
parameters (eg, blood samples, changes in CT
imaging, etc) during conservative treatment. In
 ARTICLE IN PRESS
Surgery
Volume j, Number j
our trial, radiography was performed at least
5 hours after WSCA administration, and the results
were classified into 4 types. Although the optimal
timing of radiography is unclear, it was important
that all patients with ASBO were managed by the
surgical team from the time of admission.
Recently, Aquina et al32 demonstrated that primary
management by a surgical team may improve out-
comes and decrease costs for patients admitted
with ASBO. In addition, the numbers of this
single-institution study have surpassed those identi-
fied in all published meta-analyses.15,18 One
further potential limitation with our treatment
strategy was that all patients in types I and II
ASBO were treated by operative intervention, and
we do not know how many of those patients would
have resolved with nonoperative treatment. The
magnitude of the impact of our study, however,
should be large and prominent.
In conclusion, this new classification using
WSCA is a simple and useful diagnostic method
for the determination of therapeutic strategy in
ASBO. The Ogaki classification using WSCA is a
reasonable strategy for surgical selection of pa-
tients for operative treatment (type I/II). Further-
more, conservative treatment of types IIIA/IIIB
has a high rate of success.
REFERENCES
1. Seror D, Feigin E, Szold A, Allweis TM, Carmon M, Nissan S,
et al. How conservatively can postoperative small bowel
obstruction be treated? Am J Surg 1993;165:121-5.
2. Cox MR, Gunn IF, Eastman MC, Hunt RF, Heinz AW. The
operative aetiology and types of adhesions causing small
bowel obstruction. Aust N Z J Surg 1993;63:848-52.
3. Matter I, Khalemsky L, Abrahamson J, Nash E, Sabo E,
Eldar S. Does the index operation influence the course
and outcome of adhesive intestinal obstruction? Eur J
Surg 1997;163:767-72.
4. Bueno-Lled
o J, Barber S, Vaqu
e J, Frasson M, Garcia-
Granero E, Juan-Burgue~ no M. Adhesive small bowel
obstruction: predictive factors of lack of response in conser-
vative management with Gastrografin. Dig Surg 2016;33:
26-32.
5. Choi HK, Chu KW, Law WL. Therapeutic value of gastrogra-
fin in adhesive small bowel obstruction after unsuccessful
conservative treatment: a prospective randomized trial.
Ann Surg 2002;236:1-6.
6. Biondo S, Par
es D, Mora L, Mart
ı Ragu
e J, Kreisler E,
Jaurrieta E. Randomized clinical study of Gastrografin
administration in patients with adhesive small bowel
obstruction. Br J Surg 2003;90:542-6.
7. Williams SB, Greenspon J, Young HA, Orkin BA. Small
bowel obstruction: conservative vs. surgical management.
Dis Colon Rectum 2005;48:1140-6.
8. Ji ZL, Li JS, Yuan CW, Chen WD, Zhang YN, Ju XT, et al.
Therapeutic value of sesame oil in the treatment of adhe-
sive small bowel obstruction. Am J Surg 2010;199:160-5.
Mori et al 7
9. Fleshner PR, Siegman MG, Slater GI, Brolin RE,
Chandler JC, Aufses AH Jr. A prospective, randomized trial
of short versus long tubes in adhesive small-bowel obstruc-
tion. Am J Surg 1995;170:366-70.
10. Fukami Y, Kurumiya Y, Mizuno K, Sekoguchi E, Kobayashi S.
Clinical effect of hyperbaric oxygen therapy in adhesive
postoperative small bowel obstruction. Br J Surg 2014;101:
433-7.
11. Joyce WP, Delaney PV, Gorey TF, Fitzpatrick JM. The value
of water-soluble contrast radiology in the management of
acute small bowel obstruction. Ann R Coll Surg Engl
1992;74:422-5.
12. Assalia A, Schein M, Kopelman D, Hirshberg A,
Hashmonai M. Therapeutic effect of oral Gastrografin in
adhesive, partial small-bowel obstruction: a prospective ran-
domized trial. Surgery 1994;115:433-7.
13. Chen SC, Lin FY, Lee PH, Yu SC, Wang SM, Chang KJ.
Water-soluble contrast study predicts the need for early
surgery in adhesive small bowel obstruction. Br J Surg
1998;85:1692-4.
14. Fevang BT, Jensen D, Fevang J, Sondenaa K, Ovrebø K,
Røkke O, et al. Upper gastrointestinal contrast study in
the management of small bowel obstruction–a prospective
randomised study. Eur J Surg 2000;166:39-43.
15. Abbas SM, Bissett IP, Parry BR. Meta-analysis of oral water-
soluble contrast agent in the management of adhesive small
bowel obstruction. Br J Surg 2007;94:404-11.
16. Di Saverio S, Catena F, Ansaloni L, Gavioli M, Valentino M,
Pinna AD. Water-soluble contrast medium (gastrografin)
value in adhesive small intestine obstruction (ASIO): a pro-
spective, randomized, controlled, clinical trial. World J Surg
2008;32:2293-304.
17. Farid M, Fikry A, El Nakeeb A, Fouda E, Elmetwally T,
Yousef M, et al. Clinical impacts of oral gastrografin
follow-through in adhesive small bowel obstruction
(SBO). J Surg Res 2010;162:170-6.
18. Branco BC, Barmparas G, Schn€ uriger B, Inaba K, Chan LS,
Demetriades D. Systematic review and meta-analysis of the
diagnostic and therapeutic role of water-soluble contrast
agent in adhesive small bowel obstruction. Br J Surg 2010;
97:470-8.
19. Isogai M, Hachisuka K, Yamaguchi A, Mayumi T, Shiomi M,
Kondo S, et al. The indication and timing of surgery for pa-
tients with small intestinal obstruction]. Prog Acute Abdom
Med 1992;12:363-8; Japanese.
20. Foster NM, McGory ML, Zingmond DS, Ko CY. Small bowel
obstruction: a population-based appraisal. J Am Coll Surg
2006;203:170-6.
21. Duron JJ, Silva NJ, du Montcel ST, Berger A, Muscari F,
Hennet H, et al. Adhesive postoperative small bowel
obstruction: incidence and risk factors of recurrence after
surgical treatment: a multicenter prospective study. Ann
Surg 2006;244:750-7.
22. Balthazar EJ, George W. Holmes lecture. CT of small-bowel
obstruction. AJR Am J Roentgenol 1994;162:255.
23. Gazelle GS, Goldberg MA, Wittenberg J. Efficacy of CT in
distinguishing small-bowel obstruction from other causes
of small-bowel dilatation. AJR Am J Roentgenol 1994;
162:43.
24. Fukaya T, Hawes DR, Lu CC, Chang PJ, Barloon TJ. CT diag-
nosis of small bowel obstruction: efficacy in 60 patients. AJR
Am J Roentgenol 1992;158:765-9.
25. Chen SC, Chang KJ, Lee PH, Wang SM, Chen KM, Lin FY.
Oral Urografin in postoperative small bowel obstruction.
World J Surg 1999;23:1051-4.
 ARTICLE IN PRESS
8 Mori et al
26. Onoue S, Katoh T, Shibata Y, Matsuo K, Suzuki M, Chigira H.
The value of contrast radiology for postoperative adhesive small
bowel obstruction. Hepatogastroenterology 2002;49:1576-8.
27. Lee JF, Meng WC, Leung K, Yu SC, Poon C, Lau W. Water
soluble contrast follow-through in the management of ad-
hesive small bowel obstruction: a prospective randomized
trial. Ann Coll Surg HK 2004;8:120-6.
28. Zer M, Kazenelson D, Feigenberg Z, Dintsman M. The vakus of
Gastrografin in the differential diagnosis of paralytic ileus and
mechanical obstruction. Dis Colon Rectum 1977;20:573-9.
29. Thompson JS. Contrast radiography and intestinal obstruc-
tion. Ann Surg 2002;236:7-8.
Surgery
j 2017
30. Sakakibara T, Harada A, Yaguchi T, Koike M, Fujiwara M,
Kodera Y, et al. The indicator for surgery in adhesive small
bowel obstruction patient managed with long tube. Hepato-
gastroenterology 2007;54:787-90.
31. Chen JH, Hsieh CB, Chao PC, Liu HD, Chen CJ, Liu YC,
et al. Effect of water-soluble contrast in colorectal surgery:
a prospective randomized trial. World J Gastroenterol
2005;11:2802-5.
32. Aquina CT, Becerra AZ, Probst CP, Xu Z, Hensley BJ,
Iannuzzi JC, et al. Patients with adhesive small bowel
obstruction should be primarily managed by a surgical
team. Ann Surg 2016;264:437-47.