A Procalcitonin-based Algorithm in Adhesion-related Small Bowel Obstruction (ALPROC)

Centre Hospitalier Universitaire, Amiens

Status: Enrolling

Conditions: Small Bowel Obstruction

Treatments: Diagnostic Test: algorithm

Study type: Interventional

Funder types: Other

Identifiers

NCT03905239

PI2018_843_0029

Details and patient eligibility

About

Adhesion-related small bowel obstruction is a common digestive emergency that can be managed either conservatively or surgically. However, the choice between these two approaches can be difficult due to the absence of specific signs. The objective of this study is to evaluate the clinical impact of a procalcitonin-based algorithm.

Full description

Acute adhesion-related small bowel obstruction (ASBO) is a common digestive emergency accounting for 1% to 3% of all digestive emergencies. It is associated with a mortality rate of between 2% and 8%, although this figure may be as high as 25% when surgical treatment is delayed. In 2013, the World Society of Emergency Surgery's working group on ASBO suggested two distinct approaches for the management of acute ASBO. Conservative management includes the use of a nasogastric tube (NGT), intravenous administration of fluids, and clinical and biochemical monitoring for 24 to 72 hours or surgical management. However, the efficacy of conservative management in this setting is a subject of debate, as it might delay the decision to perform surgery and increase the frequency of bowel resection (e.g. in the presence of bowel necrosis) or, in contrast, prompt an excessive number of unnecessary laparotomies. The efficacy of water-soluble contrast medium in this setting is also subject to debate, as data from a recent randomized clinical trial including 242 patients (ABOD study) combined with a meta-analysis in 2015 including 990 patients failed to demonstrate any value of gastrografin to reduce the surgery rate and length of stay. Three years ago, our team proposed the use of a marker of bacterial infection and bowel ischemia, procalcitonin (PCT), to help distinguish patients in whom conservative management is likely to be successful from those in whom surgical management was mandatory. Cutoffs of 0.2 µg/L (for failure of conservative management ) and 0.6 µg/L (for need for surgery) accurately identified more than 80% of patients. These cutoffs and data were confirmed in a second independent cohort, and were then used to propose an algorithm for the management of patients with ASBO. In this single-center, retrospective , case-control study, the investigators showed that introduction of this algorithm into patient management reduced i/ the time to surgery with no increase of the surgical management rate; ii/ the length of stay (with a 2-day difference). The investigators propose the hypothesis that introduction of the PCT-based algorithm improves the quality of management of patients with ASBO.

Enrollment: 488 estimated patients

Sex: All

Ages: 18+ years old

Volunteers: No Healthy Volunteers

Inclusion criteria

• Uncomplicated acute adhesion-related small bowel obstruction (ASBO)
• Adults
• Patients able to express consent
• Signed written informed consent form
• Covered by national health insurance

Exclusion criteria

• Disease-related criteria:
• Large bowel obstruction
• No previous abdominal surgery
• Signs of peritonitis or strangulation requiring emergency surgery)
• Obstruction within 4 weeks following previous surgery
• Ongoing or history of bowel cancer
• Ongoing or in history of inflammatory bowel disease
• History of abdominal radiotherapy
• Active infection
• Contraindication to contrast-enhanced CT scan
• Minors
• Patient deprived of liberty by administrative or judicial decision or placed under judicial protection (guardianship or supervision)
• Pregnancy or breastfeeding

Trial design

Primary purpose: Diagnostic

Allocation: Randomized

Interventional model: Parallel Assignment

Masking: None (Open label)

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488 participants in 2 patient groups

algorithm arm

Experimental group

Description:

Patient management is based on clinical examination and procalcitonin assessment. From 48 hours after initiation of conservative management in the case of absence of bowel function, operative management (adhesiolysis or bowel resection) will be performed. In the event of discordance between procalcitonin values and clinical examination, management will always be based on clinical examination.

Treatment:

Diagnostic Test: algorithm

no algorithm arm

No Intervention group

Description:

Patient management is based on clinical examination. Conservative management will be continued for 48 hours in the absence of signs of bowel ischemia (clinical and laboratory assessment other than procalcitonin, as procalcitonin will not be assayed in this arm). Gastrografin will not be used in this arm. Operative management (adhesiolysis or bowel resection) will be performed 48 hours after initiation of conservative management or in the case of absence of bowel function.