reduce operative rates and hospital length of stay [7,8]. Pediatric ASBO differs in etiology and physiology. Children often present with fewer comorbidities but have narrower reserves for prolonged obstruction. Single-center pediatric studies have reported high predictive accuracy of enteral contrast transit for non-operative resolution, but mixed findings on therapeutic benefit [9–11]. Only recently have multicenter pediatric studies emerged. These suggest WSCA protocols are feasible and safe, but the effect on surgery avoidance and length of stay is less certain [12,13]. Given variability in protocols and patient selection across institutions, prospective multicenter data are needed to clarify the role of enteral contrast in pediatric ASBO. This study aimed to evaluate, prospectively, the safety, diagnostic performance, and potential therapeutic impact of a standardized enteral contrast protocol for pediatric ASBO across multiple pediatric surgical centers

Study design and setting This was a 24-month prospective, multicenter observational study involving nine tertiary pediatric surgical centers with established pediatric acute care surgery services. Participants Consecutive pediatric patients aged 1–17 years presenting with clinical and radiologic suspicion of ASBO were screened. Inclusion criteria:  Stable hemodynamics  Absenceofperitonitis or sepsis  Noradiologic evidence of bowel perforation or closed-loop obstruction  Prior abdominal surgery (presumed adhesive etiology) Exclusion criteria:  Knownallergy to iodinated contrast  Severe dehydration uncorrected at presentation  High aspiration risk (e.g., uncontrolled vomiting with altered sensorium)  Previous enrollment in study within 12 months Intervention: Enteral contrast protocol After nasogastric decompression for at least 2 hours and adequate fluid/electrolyte resuscitation, a standardized dose of water-soluble contrast (Gastrografin® diluted 1:3 with sterile water) was administered via NG tube at 2 mL/kg (maximum 100 mL). The NG tube was clamped for 2 hours post-administration, then returned to low intermittent suction. Abdominal radiographs were obtained at 8 and 24 hours to assess contrast progression. Cecal transit within 24 hours was defined as a positive challenge. Outcomes Primary outcome:  Need for operative intervention during index admission. Secondary outcomes:  Diagnostic accuracy of cecal transit for predicting successful non-operative resolution  Length of hospital stay (LOS)  Timetofull enteral feeds  Adverse events attributable to contrast Data collection and analysis Each center used a standardized case report form. Data included demographics, prior surgery type, presenting symptoms, radiologic findings, contrast transit times, operative findings if applicable, and complications. Continuous variables were summarized as means (SD) or medians (IQR) and compared using t-test or Mann–Whitney U as appropriate. Categorical variables were compared with χ² or Fisher’s exact test. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of cecal transit were calculated.

Table 1. Baseline characteristics of enrolled patients (n=142) Variable Value Age, median (IQR), years 11 (7–14) Sex, male (%) 87 (61.3) Weight, mean (SD), kg 34.6 (12.2) Common prior surgery (%) Median time since last abdominal surgery, months Appendectomy (34), bowel resection (21), congenital anomaly repair (29), other (16) 18 (7–34) Presenting symptoms (%) Abdominal pain (94), vomiting (88), distension (76), constipation (54) Initial imaging (%) Contrast transit and outcomes Cecal transit within 24 hours occurred in 91/142 cases (64.1%). Non-operative resolution was achieved in 88/91 (96.7%) of positive transit cases versus 14/51 (27.5%) of negative transit cases. Sensitivity of cecal transit for predicting non operative success was 86.3% (95% CI 78.5 92.0%), specificity 89.8% (95% CI 79.2–96.2%), PPV 96.7%, and NPV 72.5%. Table 2 shows diagnostic accuracy metrics. Table 2. Diagnostic accuracy of cecal transit for predicting non-operative success Metric Value (95% CI) Sensitivity 86.3% (78.5–92.0) Specificity 89.8% (79.2–96.2) PPV 96.7% NPV 72.5% Operative intervention Overall, 49/142 patients (34.5%) required surgery during the index admission. The most common operative findings were single adhesive band (59%), dense matted adhesions (31%), and ischemic segment requiring resection (10%). Median LOS was 3.8 days (IQR 3–5) in non operative cases and 6.9 days (IQR 5–9) in operative cases. Time to full feeds was 2.1 days vs 4.8 days, respectively. Table 3 compares operative and non-operative cases. Table 3. Comparison of operative and non-operative cases Variable Non-operative (n=93) Operative (n=49) Age, median (IQR), years 11 (7–14) 10 (6–14) 0.54 LOS, median (IQR), days 3.8 (3–5) 6.9 (5–9) <0.001 Time to full feeds, median (IQR), days 2.1 (1.5–3) 4.8 (3.5 6.2) Readmission within 30 days (%) Safety outcomes 5.4 Abdominal radiograph (100), ultrasound (42), CT (18) No episodes of aspiration pneumonitis, allergic reaction, or significant electrolyte disturbance were reported. Mild, transient diarrhea occurred in 9 patients (6.3%), resolving without intervention. Table 4 summarizes safety findings. Table 4. Adverse events related to enteral contrast Event Frequency (%) Severity Aspiration pneumonitis 0 — Allergic reaction 0 — Electrolyte disturbance 0 — Transient diarrhea 9 (6.3) Mild, self-limiting

when proper exclusion criteria and NG decompression are applied [5,7,9]. Our study’s strengths include prospective data collection, multicenter participation, standardized protocol, and comprehensive follow-up. Limitations include lack of a randomized control arm, potential inter-center variability in supportive care, and reliance on plain radiographs for transit assessment, which may underestimate partial progress. Future research should focus on randomized trials comparing WSCA protocols to optimized non operative care without contrast, with standardized dosing, timing, and operative decision criteria. Incorporating cost-effectiveness analysis and patient-centered outcomes (e.g., comfort, parental satisfaction) could further guide adoption.

In this prospective multicenter study, enteral water-soluble contrast in pediatric ASBO was safe and demonstrated high predictive accuracy for successful non-operative management. While it did not significantly reduce the overall operative rate, it facilitated confident, timely decision making and was associated with shorter feeding times in non-operative cases. Standardized, time bound protocols are recommended for optimal use.

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