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The role of nasogastric tube after elective abdominal surgery
Abstract
Nasogastric tube (NGT) is routine employed after abdominal surgery still in our country and abroad too, but the patients' discomfort is severe and several serious complications were referred as related to its use. The aim of this study was to evaluate the pros and cons of routine use of NGT in elective uncomplicated abdominal surgery.
In order to evaluate the routine use of NGT we performed a prospective randomized trial on 100 patients who had elective uncomplicated abdominal surgery: 50 subjects had the early removal of NGT and in 50 patients it was maintained until passage of flatus/feces.
The relevant differences between the two groups were the earlier passage of flatus and feces and the lower incidence of postoperative gastrectasy in the group where NGT was early removed. No statistical difference was recorded concerning the occurrence of postoperative nausea, vomiting, abdominal distension, complications and day of clinical release.
The routine application of NGT in elective abdominal surgery could be omitted if the surgeon and nursing team are willing to renounce a useful tool in providing informations about the resolution of postoperative intestinal atony to the patient's benefit: in fact a severe discomfort due to the NGT was recorded in the 70% of our series.
... In a study conducted in Greece, no statistically significant difference was recorded with and without nasogastric decompression concerning the occurrence of postoperative nausea, vomiting and abdominal distension. 16 Tube decompression of the stomach does not relieve intestinal paralysis after digestive operations. 17 In this study, there was no difference in time required for onset of bowel sounds and start of oral sips after operation between two groups. ...
... 22 Another randomized research report showed that 70% of severe upsets were caused by gastrointestinal decompression. 16 This study also demonstrated that gastrointestinal decompression could not effectively prevent severe postoperative complications such as anastomotic leakage and instead resulted in an increased incidence rate of pharyngolaryngitis. ...
... Conservative treatment is often successful in the ileum after surgery and contractility may return, especially if electrolyte and water balance can be restored. Recently, several studies on endotracheal intubation have called into question its effectiveness in upper digestive surgery [21]. ...
... Fluid lost during intubation is predominantly alkaline, which leads to acidosis. Therefore, intravenous physiological saline infusion should be supplemented with lactate or carbonate or balanced saline solution (Ringer's or Hartmann's solution) [20,21]. It is important to remember when calculating daily fluid balance that these patients will need fluids to replace not only ongoing losses (eg, nasogastric aspiration) and basic daily requirements, but also fluid deficiency. ...
The study aims to summarize the updated evidence regards, epidemiology, causes, clinical manifestations, and management of paralytic ileus. Lower abdominal surgical procedure, particularly big open cuts and increased bowel operations, is linked with an increased hazard of bowel obstruction. Though, numerous risk issues have been revealed to upsurge the probability and resistance of intestinal obstruction, such as prolonged abdominal / pelvic surgery, lower gastrointestinal (GI) surgery, open surgery, retroperitoneal spine surgery, opioid use, cancer peritoneal, intra-abdominal inflammation (sepsis / peritonitis), delayed enteral nutrition or nasogastric (NG) tube placement, and hypokalemia. Signs of intestinal obstruction are tachycardia caused by any interruption of movement, absence of abdominal pain, abdominal distention and tenderness, shortness of breath, and hypovolemia. Bowel sounds disappear and flatulence is not Mini-review Article Alahmari et al.; JPRI, 33(42B): 61-66, 2021; Article no.JPRI.73129 62 discharged, leading to gastric stasis, which can cause hiccups, discomfort, and easy vomiting. Preventive measures include avoiding unnecessary exposure and over-processing of the intestine or traction of the mesentery. Treatment is conservative, as this condition is mostly self-limited. Pharmacologic Therapy have little place, but there are some exceptions of adequate values.
... In a study conducted in Greece, no statistically significant difference was recorded with and without nasogastric decompression concerning the occurrence of postoperative nausea, vomiting and abdominal distension. 16 Tube decompression of the stomach does not relieve intestinal paralysis after digestive operations. 17 In this study, there was no difference in time required for onset of bowel sounds and start of oral sips after operation between two groups. ...
... 22 Another randomized research report showed that 70% of severe upsets were caused by gastrointestinal decompression. 16 This study also demonstrated that gastrointestinal decompression could not effectively prevent severe postoperative complications such as anastomotic leakage and instead resulted in an increased incidence rate of pharyngolaryngitis. ...
... In the traditional surgical treatment method for esophageal cancer, to fully heal the anastomotic stoma, patients should routinely fast for 7 days and decompress their gastrointestinal tract for 5-7 days after surgery. Some studies found that gastrointestinal decompression tubes can make 70% of patients feel very uncomfortable (21). The results of a meta-analysis also show that gastrointestinal decompression did not reduce the complications of abdominal surgery (22). ...
... The two groups (study & control) showed statically homogenecity of their baseline characteristics, which is similar to the study conducted by D Koukouras 14 , in a slightly different study conducted by H.G. Vinary 10 , for elective bowel surgery with or without prophylactic nasogastric decompression also had similar demographic groups. Nasogastric tube intolerance was common complaint noted by Michele Tanguy 8 which is also the chief complaint in control group in our study. ...
Objectives: To compare early return of bowel movements in patients withelective stoma closure with or without nasogastric tube. Place and Duration: Single surgicalunit, Civil Hospital, Karachi, from January 2015-August 2016. Methods: This prospective doubleblind randomized control trial of 114 patients for elective stoma (Ileostomy, colostomy) closurein which lottery method was used to divide the patients into control group (with nasogastrictube) and study group (without nasogastric tube). Post operatively total duration from thesurgery till the patient passed first flatus was recorded in hours between the control and studygroups. Result: Comparison between two groups, the passage of first flatus after reversal ofstoma a mean difference of 19.7 was observed in hours between the control and study groups.Conclusion: Prophylactic nasogastric decompression in stoma closure patients can be omittedfrom routine postoperative period without any management problem.
... Recently, several studies on nasogastric intubation questioned its efficacy in upper gastrointestinal surgery. 30,31,32 The insertion of a nasogastric tube could postpone the return of bowel sounds and increase the incidence of nausea and patient discomfort, but it does not affect the incidence of postoperative ileus. 30 The fluid lost by intubation is predominantly alkaline and this leads to acidosis. ...
Paralytic ileus is the condition where the motor activity of the bowel is impaired, usually not associated with a mechanical cause. Although the condition may be self-limiting, it is serious and if prolonged and untreated will result in death in much the same way as in acute mechanical obstruction. Management of paralytic ileus depends on the knowledge of the most likely cause and the perceived chance of resolution without operation. Postoperative ileus is the single largest factor influencing length of hospital stay after bowel resection, and has great implications for patients and resource utilization. Early diagnosis and correct management is essential in reducing complications. This article briefly outlined the plausible pathophysiological mechanisms and clinical implications of paralytic ileus.
... Koukouras et al in his study published in 2001 proposed the same thought. 15 Upper respiratory tract infection was the main complications of prolonged naso gastric intubation as shown by our control group (55.45%) compared to the study group where it was significantly less (14.67%). Our study like many other published articles, showed higher frequency of upper respiratory tract infection in prolong naso gastric intubation. ...
Background: Nasogastric (NG) decompression and delayed oral feeding after bowel anastomosis is conventional and years old practice. The aim of the present study was to evaluate the advantages and disadvantages of early removal of naso gastric tube (<24 hrs) and delayed feeding, compared with delayed removal and delayed enteral feeding in patients undergoing bowel anastomosis.Methods: It is a single blind, prospective randomized study involving patients with bowel anastomosis from December 2016- November 2018 at a tertiary care hospital. In study group naso gastric tube was removed within 24 hours. After 12 hours of surgery patients were allowed sips of water, then free liquids followed by semisolid and normal diet in calculated way. In control group naso gastric tube was retained till passage of flatus and orally allowed only after passage of stool.Results: A total of 241 patients were enrolled. In study group bowel sound returned after 30.57±31.19 hours of surgery and in control group 46.90±48.65 hours and this difference was significant (p<0.002). In study group first free liquid was allowed on 38.14±38.50 hours in post operative period, as compared to the control group where free liquids were allowed after 50.09±51.80 hours this difference was significant (p<0.04). Total hospital stay in the study group was significant (p<0.02).Conclusions: Early removal of naso gastric tube and early feeding is better than the conventional practice.
... Gastrointestinal decompression makes about 70% of patients feel unwell. A recent meta-analysis also showed that gastrointestinal decompression could not reduce the complications of abdominal surgery [12,13]. Accumulated evidence has suggested that early oral feeding after colorectal surgery, gynecologic surgery and gastrectomy was safe and effective [14][15][16]. ...
Purpose:
To prospectively compare the early and late postoperative oral feeding of operated gastric cancer patients on the gastrointestinal function recovery.
Methods:
198 gastric cancer patients treated in our hospital from June 2015 to June 2017 were enrolled. Patients were randomized into two groups, early feeding group and late feeding group. All patients underwent the same surgical procedure, which was laparoscopic radical gastrectomy. Time of the first postoperative exhaust and defecation was recorded. Fasting venous blood samples were collected on the day of surgery and 1, 3, and 5 days after surgery. Serum levels of gastrin and motilin were assessed.
Results:
Time of the first postoperative exhaust and defecation in the early feeding group was 2.05±0.71 days and 3.58±0.92 days, respectively. In the late feeding group they were 2.50±0.91 days and 5.17±1.0 days, respectively (p=0.008, p=0.002). Serum levels of gastrin and motilin in the early feeding group were remarkably higher than those of the late feeding group on the 3rd and 5th postoperative day. Univariate analysis showed that time of the first postoperative feeding, operation time and postoperative gastrin level on the 3rd day were factors remarkably affecting the time of the first postoperative exhaust (p=0.003, p=0.043, p=0.032, respectively). Multivariate analysis revealed that the time of postoperative feeding was an independent factor affecting the time of the first postoperative exhaust (Odds ratio/OR=0.986, 95%CI=0.974-0.997, p=0.027).
Conclusions:
Early oral feeding promotes the recovery of postoperative gastrointestinal function in gastric cancer patients, and doesn't increase the incidence of related complications and adverse events.
... The two groups (study & control) showed statically homogenecity of their baseline characteristics, which is similar to the study conducted by D Koukouras 14 , in a slightly different study conducted by H.G. Vinary 10 , for elective bowel surgery with or without prophylactic nasogastric decompression also had similar demographic groups. Nasogastric tube intolerance was common complaint noted by Michele Tanguy 8 which is also the chief complaint in control group in our study. ...
... The use of the nasogastric tube (NGT) during the postoperative period is still controversial, although data describes disturbance of water, electrolyte, and acid base, and more digestive fluid reflux using nasogastric tube, which can increase pulmonary morbidity [71]. Some studies also show that NGT can delay normal gastrointestinal function [72]. Removal of NGT in the immediate postoperative period promotes early oral diet introduction that has some physiological advantages: decreases bacterial translocation, ensures function of intestinal mucosal cells, activates digestive secretory system, reduces postoperative infection, and accelerates organ recovery [73]. ...
... In China at present, 97.5% of surgeons routinely place and keep the nasogastric tube until the passage of gas through anus after excision and anastomosis of lower digestive tract, while 2.5% of surgeons discard gastrointestinal decompression 2-3 d after operation before the passage of gas through anus [7] . Indeed, the nasogastric tube can cause moderate to severe discomfort in 88%, severe discomfort in 70% of the patients and significantly delay the return of normal gastrointestinal function [8,9] . Recently, a meta-analysis shows that routine nasogastric decompression does not accomplish any of its intended goals. ...
AIM: To evaluate the feasibility, safety, and tolerance of early removing gastrointestinal decompression and early oral feeding in the patients undergoing surgery for colorectal carcinoma.
METHODS: Three hundred and sixteen patients submitted to operations associated with colorectostomy from January 2004 to September 2005 were randomized to two groups: In experimental group (n = 161), the nasogastric tube was removed after the operation from 12 to 24 h and was promised immediately oral feeding; In control group (n = 155), the nasogastric tube was maintained until the passage of flatus per rectum. Variables assessed included the time to first passage of flatus, the time to first passage of stool, the time elapsed postoperative stay, and postoperative complications such as anastomotic leakage, acute dilation of stomach, wound infection and dehiscense, fever, pulmonary infection and pharyngolaryngitis.
RESULTS: The median and average days to the first passage of flatus (3.0 ± 0.9 vs 3.6 ± 1.2, P < 0.001), the first passage of stool (4.1 ± 1.1 vs 4.8 ± 1.4 P < 0.001) and the length of postoperative stay (8.4 ± 3.4 vs 9.6 ± 5.0, P < 0.05) were shorter in the experimental group than in the control group. The postoperative complications such as anastomotic leakage (1.24% vs 2.58%), acute dilation of stomach (1.86% vs 0.06%) and wound complications (2.48% vs 1.94%) were similar in the groups, but fever (3.73% vs 9.68%, P < 0.05), pulmonary infection (0.62% vs 4.52%, P < 0.05) and pharyngolaryngitis (3.11% vs 23.23%, P < 0.001) were much more in the control group than in the experimental group.
CONCLUSION: The present study shows that application of gastrointestinal decompression after colorectostomy can not effectively reduce postoperative complications. On the contrary, it may increase the incidence rate of fever, pharyngolaryngitis and pulmonary infection. These strategies of early removing gastrointestinal decompression and early oral feeding in the patients undergoing colorectostomy are feasible and safe and associated with reduced postoperative discomfort and can accelerate the return of bowel function and improve rehabilitation.
Keywords: Gastrointestinal decompression, Feeding, Colorectostomy
Citation: Zhou T, Wu XT, Zhou YJ, Huang X, Fan W, Li YC. Early removing gastrointestinal decompression and early oral feeding improve patients' rehabilitation after colorectostomy. World J Gastroenterol 2006; 12(15): 2459-2463
... This study also demonstrated that gastrointestinal decompression could not effectively prevent severe postoperative complications such as anastomotic leakage. 11 In our study, the frequency of atelectasis remained 15% and 35% between the two groups with a p value of 0.01. Another study showed that selective (as opposed to routine) nasogastric decompression is effective in preventing postoperative pulmonary complications like atelectasis. ...
Objective: To determine the clinical significance of postoperative routine versus selective gastrointestinal decompression in operations on the lower digestive tract in terms of frequency of complications and post-op hospital stay. Place & Duration: Benazir Bhutto Hospital (Surgical Unit – 1). Duration: From July 2007 to June 2008. Materials and Methods: One hundred and twenty patients with resection and anastomosis of intestinal tract were selected by consecutive sampling for a Randomized. They were divided into two groups by Random Allocation (Lottery method), i.e. the group with routine postoperative gastrointestinal decompression and the group with selective postoperative gastrointestinal decompression. Clinical therapeutic outcome and frequency of complications were compared between two groups. Results: The complications such as pneumonia, atelectasis, aspiration, fever, and nausea were higher in routine decompression group than in selective decompression group. There was no significant difference (p< 0.45) between two groups regarding the length of hospitalization after operation. Fever, atelectasis, and pneumonia were significantly less common (p<0.03) and the number of days to first oral intake was significantly fewer in patients treated without nasogastric tubes (p< 0.04). Conclusion: Application of routine gastrointestinal decompression after resection and anastomosis of lower digestive tract cannot effectively reduce gastrointestinal tract pressure. Selective decompression is associated with fewer wound complications (infection and dehiscence) and a shorter length of hospital stay.
... Some studies demonstrated that forgoing gastrointestinal decompression might be a momentous step for faster functional restoration of the gastrointestinal tract and decrease of the postoperative hospital stay. Studies show that the nasogastric tube gave 88% of the patients discomfort and 70% patients even more severe feelings of discomfort, and normal gastrointestinal functions were markedly delayed [14,15]. A recent study showed that the nasogastric tube had not reduced the complications of gastrointestinal surgery [16]. ...
OBJECTIVES The aim of this study was to evaluate the safety and effectiveness of a fast-track surgery (FTS) protocol on patients undergoing
minimally invasive oesophagectomy.
... The results of the study by Gerber and Robert (1958) showed that routine use of the nasogastric tube after surgical operations is unnecessary, and it increases patient's stress and discomfort [3]. Recently, several studies on nasogastric intubation questioned its efficacy in upper gastrointestinal surgeries [4, 5] . Data from the study by Wittbrodt demonstrated that patients with no nasogastric tube after the operation had a shorter length of hospital stay [6]. A. Jangjoo : M. Mehrabi Bahar : M. Aliakbarian (*) : ...
It is the practice of many surgeons to use the routine nasogastric tube after biliary operations, but its usefulness has been questioned. This study was designed to determine the effect of postoperative nasogastric intubation on gastrointestinal function in patients with obstructive jaundice. In this randomized clinical trial, 40 patients who underwent choledochoduodenostomy or hepaticojejunostomy were randomly divided into two groups. Patients in the experimental group did not have the nasogastric tube, and in the control group the nasogastric tube was routinely applied after surgery. Gastrointestinal function was compared in these two groups. Patients with no nasogastric intubation did not show any postoperative complications or prolonged hospital stay. On the contrary, nasogastric tube insertion postponed return of bowel function and increased the incidence of nausea and vomiting, while it did not affect the incidence of postoperative ileus. Routine use of the nasogastric tube after choledochoduodenostomy or hepaticojejunostomy can delay normal gastrointestinal function and increase postoperative discomfort.
... [2][3][4][5][6][7][8] Studies have repudiated the routine use of nasogastric tubes in elective gastrointestinal surgery and touted the safety of early postop-erative feeding. [9][10][11][12] Some have demonstrated a reduction in length of stay with early enteral feeding and note that most patients tolerate early feeding without and increase in morbidity; thereby suggesting that early enteral support is safe. 3,6 Furthermore, data presented at the annual meeting of the Southern California Chapter of the American College of Surgeons also confirmed the safety of early postoperative feeding. 2 There are conflicting studies attesting to earlier discharge in patients offered early postoperative feeding, with limited studies evaluating the economic impact this approach may have. ...
Early postoperative oral feeding has been demonstrated to be safe and not increase postoperative morbidity. There are conflicting reports about its effect on postoperative length of stay. Some patients will fail attempts at early postoperative feeding and may be relegated to a longer postoperative course. Few studies to date have attempted to identify cost savings associated with early oral support, and those identified address nasoenteric support only. Fifty-one consecutive patients were randomized into either a traditional postoperative feeding group or an early postoperative feeding group after their gastrointestinal surgery. Length of hospital stay, hospital costs (excluding operating room costs), morbidity, and time to tolerance of a diet were compared. There was a tendency toward increased nasogastric tube use in the early feeding arm, but the morbidity rates were similar. Length of hospital stay and costs were similar in both arms. Early postoperative enteral support does not reduce hospital stay, nursing workload, or costs. It may come at a cost of higher nasogastric tube use, however, without an increase in postoperative morbidity.
Background: Routine use of nasogastric tubes (NGTs) after abdominal surgeries aims to reduce
Background: Routine use of nasogastric tubes (NGTs) after abdominal surgeries aims to reduce
Background
Nasogastric tube (NT) is commonly used following abdominal surgeries with a belief that it will decompress the bowel and prevent complications such as abdominal distension and post-operative nausea and vomiting. However, many studies have now reported that the use of a NT after abdominal surgery is not only unnecessary but also can be harmful to the patient.
Methods
This was a prospective and interventional randomised comparative study where patients undergoing elective ileostomy reversal (n = 120) were randomly divided into two groups: patients with (Group A), and without (Group B) the placement of the NT in the post-operative period ( n = 60 each). Post-operative parameters like time to pass first flatus and stool, the first appearance of bowel sounds, length of hospital stay, post-operative hospital stay, post-operative complications such as pneumonia, fascial dehiscence, anastomotic leak, nausea, vomiting and need for tube insertion/reinsertion were recorded.
Results
Mean time (post-operative days) for appearance of first bowel sounds ( P < 0.0001), passing first flatus ( P < 0.0001) and first stool ( P < 0.0001) were significantly higher in Group A as compared to Group B ( P < 0.0001). The mean duration of hospital stay (days) was also significantly higher in Group A compared to Group B (8.8 ± 1.5 Vs 5.5 ± 1). The proportion of patients who developed a chest infection in both Groups A and B was comparable.
Conclusions
Use of a NT during the post-operative period after ileostomy reversal surgery does not provide any additional benefit and may be harmful in terms of early patient recovery.
Background: Gum-chewing has been listed as one of many factors that contribute to enhancing recovery after laparotomy due to its effects on postoperative ileus. Objectives: The aim of the study was to compare gum-chewing against controls on the reduction of postoperative ileus among patients undergoing elective laparotomy. Methodology: Consenting patients who had elective laparotomy with gut anastomosis in the Surgical wards of Nnamdi Azikiwe University Teaching Hospital(NAUTH), Nnewi were randomised into Gum-chewing group and Control/ traditional delayed feeding group. In the first Group patients’ Naso gastric tubes(NGT) were left insitu as they chewed gum 3 times a day from 1DPO. Patients in the second group were used as controls and were managed in the traditional way-nil by mouth until passage of flatus or faeces. Assessed outcome measure was time from completion of surgery to passage of flatus and faeces. Results: During the study period, December 2014 to November 2016 (2 years), 70 consenting patients who had elective laparotomy in the Surgical wards were randomised into the two groups- Group 1 (n=34) and group 2 (n=36). The groups were similar in terms of gender, age, surgical procedures, and co morbidity. The age range was 20-81 years. The time from completion of surgery to first passage of flatus was 3.07days for Group 1 and 3.92days for Group 2. Time from completion of surgery to first passage of stool was 4.00days for Group1 and 4.76days for Group2. Time to flatus and faeces was significantly shorter in the Gum-chewing group compared to Controls (p0.05 for both). There were no significant differences noted in the complication rates among the groups. Conclusion: Gum-chewing reduced the length of postoperative ileus significantly
Background: Early oral feeding has been listed as one of many factors that contribute to enhancing recovery after laparotomy due to its effect on postoperative ileus. Objectives: The aim of the study was to compare early feeding against controls on the reduction of postoperative ileus among patients undergoing elective laparotomy. Methodology: Consenting patients who had elective laparotomy with gut anastomosis in the Surgical wards of NAUTH Nnewi were randomised into Early feeding group and Control/ traditional delayed feeding group. In the Early feeding group, patients’ NGTs were removed within first 24 hours and graded oral intake was commenced. In the Delayed feeding group, patients were used as controls and were managed in the traditional way-nil by mouth until passage of flatus or faeces. Assessed outcome measure was time from completion of surgery to passage of flatus and faeces. Results: During the study period, December 2014 to November 2016 (2 years), 72 consenting patients who had elective laparotomy in the Surgical wards were randomised into the two groups- Group1 (n=36); Group 2 (n=36). The groups were similar in terms of gender, age, surgical procedures, and co morbidity. The age range was 20-81 years. The time from completion of surgery to first passage of flatus was 3.85days for Group1 and 3.92days for Group 2. Time from completion of surgery to first passage of stool was 4.57days for Group 1 and 4.76days for Group2. The time to flatus and faeces was shorter in early feeding compared to Controls but did not reach statistical significance (p0.115, p0.116 respectively). There were no significant differences noted in the complication rates among the groups. Conclusion: There was no statistically significant difference in the time to passage of flatus and faeces between the Early oral feeding group and controls.
Background: Routine use of nasogastric tubes, after abdominal operations, is intended to
AIM: To discuss the clinical significance of postoperative gastrointestinal decompression in operation on lower digestive tract.
METHODS: Three hundred and sixty-eight patients with excision and anastomosis of lower digestive tract were divided into two groups, i.e. the group with postoperative gastrointestinal decompression and the group without postoperative gastrointestinal decompression. Clinical therapeutic outcome and incidence of complication were compared between two groups. Furthermore, an investigation on application of gastrointestinal decompression was carried out among 200 general surgeons.
RESULTS: The volume of gastric juice in decompression group was about 200 mL every day after operation. Both groups had a lower girth before operation than every day after operation. No difference in length of the first passage of gas by anus and defecation after operation was found between two groups. The overall incidence of complications was obviously higher in decompression group than in non-decompression group (28% vs 8.2%, P < 0.001). The incidence of pharyngolaryngitis was up to 23.1%. There was also no difference between two groups regarding the length of hospitalization after operation. The majority (97.5%) of general surgeons held that gastrointestinal decompression should be placed till passage of gas by anus, and only 2.5% of surgeons thought that gastrointestinal decompression should be placed for 2-3 d before passage of gas by anus. Nobody (0%) deemed it unnecessary for placing gastrointestinal compression after operation.
CONCLUSION: Application of gastrointestinal decompression after excision and anastomosis of lower digestive tract cannot effectively reduce gastrointestinal tract pressure and has no obvious effect on preventing postoperative complications. On the contrary, it may increase the incidence of pharyngolaryngitis and other complications. Therefore, it is more beneficial to the recovery of patients without undergoing gastrointestinal decompression.
Nasogastric decompression used routinely after abdominal surgery does not speed recovery.This systematic review of 28 trials showed that routine use of nasogastric tube decompression after abdominal operations, rather than speeding recovery, may slow recovery down and increase the risk of some postoperative complications. Routine use may decrease the risk of wound infection and subsequent ventral hernia.
To determine advantages and disadvantages of postoperative nasogastric intubation after small bowel anastomosis.
Quasi experimental.
Surgical Unit-I, Holy Family Hospital, Rawalpindi, from December 2003 to December 2006.
A total of 112 patients, undergoing small bowel anastomosis were equally divided in group I and II with and without postoperative nasogastric intubation respectively. Variables compared were number of patients having episodes of vomiting, change in abdominal girth, the time for onset of bowel sounds, time to begin per oral fluids, length of hospitalization and postoperative complications.
In group-I, nasogastric tube was removed on an average after 3.1 days. Average postoperative nasogastric output was 357, 154 and 64 ml/day for day 1, 2 and 3 respectively. There was no statistically significant difference between two groups in abdominal girth before and after operation, frequency of vomiting, time taken for onset of bowel sounds and start of oral sips after operation, frequency of wound infection, anastomotic leak and mortality (p>0.05). Length of postoperative hospital stay and frequency of postoperative respiratory complications were more in group-I as compared to group-II (p<0.05).
Nasogastric decompression does not provide added advantage after small bowel anastomosis.
To investigate the feasibility of fast track clinical pathway for esophageal tumor resections.
One hundred and fourteen patients with esophageal carcinoma who underwent esophagogastrectomy from January 2006 to October 2007 in our department were studied. Fast track clinical pathway included analgesia control, fluid infusion volume control, early ambulation and enteral nutrition. Nasogastric tube was removed 3 d after operation and chest tube was removed 4 d after operation as a routine, and full liquid diet 5 d after operation.
Among 114 patients (84 men and 30 women), 26 patients underwent fast track surgery, including 17 patients over 65 years old and 9 under 65 (P=0.014); 18 patients who had preoperative complications could not bear fast track surgery (P<0.001). No significant differences in tolerance of fast track surgery were attributed to differences in gender, differentiated degree or stage of tumor, pathological type of tumor, or operative incision. The median length of hospital stay was 7 d (5-28 d), 4% patients were readmitted to hospital within 30 d of discharge. Three patients died and postoperative mortality was 2.6%. All 3 patients had no determinacy to fast track surgery approach.
The majority of patients with esophageal carcinoma can tolerate fast track surgery. Patients younger than 65 or who have no preoperative diseases have the best results. Median length of hospital stay has been reduced to 7 d.
Intestinal obstruction is common in patients with malignant disease; Surgical intervention should always be considered; Intravenous hydration and nasogastric suction are rarely useful or necessary; Constipation is a common reversible cause of obstruction; Analgesic and antiemetic drugs can be given by continuous subcutaneous infusion.
To discuss the clinical significance of postoperative gastrointestinal decompression in operation on lower digestive tract.
Three hundred and sixty-eight patients with excision and anastomosis of lower digestive tract were divided into two groups, i.e. the group with postoperative gastrointestinal decompression and the group without postoperative gastrointestinal decompression. Clinical therapeutic outcome and incidence of complication were compared between two groups. Furthermore, an investigation on application of gastrointestinal decompression was carried out among 200 general surgeons.
The volume of gastric juice in decompression group was about 200 mL every day after operation. Both groups had a lower girth before operation than every day after operation. No difference in length of the first passage of gas by anus and defecation after operation was found between two groups. The overall incidence of complications was obviously higher in decompression group than in non-decompression group (28% vs 8.2%, P<0.001). The incidence of pharyngolaryngitis was up to 23.1%. There was also no difference between two groups regarding the length of hospitalization after operation. The majority (97.5%) of general surgeons held that gastrointestinal decompression should be placed till passage of gas by anus, and only 2.5% of surgeons thought that gastrointestinal decompression should be placed for 2-3 d before passage of gas by anus. Nobody (0%) deemed it unnecessary for placing gastrointestinal compression after operation.
Application of gastrointestinal decompression after excision and anastomosis of lower digestive tract cannot effectively reduce gastrointestinal tract pressure and has no obvious effect on preventing postoperative complications. On the contrary, it may increase the incidence of pharyngolaryngitis and other complications. Therefore, it is more beneficial to the recovery of patients without undergoing gastrointestinal decompression.
Routine use of nasogastric tubes after abdominal operations is intended to hasten the return of bowel function, prevent pulmonary complications, diminish the risk of anastomotic leakage, increase patient comfort and shorten hospital stay. This meta-analysis of published studies examines the efficacy of this practice after abdominal surgery in achieving each of these goals.
Search terms were 'nasogastric, tubes, randomized', using Medline, Embase, the Cochrane Controlled Trials Register and references from included studies. Eligible studies included patients having abdominal operations of any type, emergency or elective, who were randomized before completion of the operation to receive a nasogastric tube and keep it in place until intestinal function had returned or to selective use of a tube with early removal.
Twenty-eight studies fulfilled the eligibility criteria. These included 4194 patients, 2108 randomized to routine tube and 2087 randomized to selective or no tube. Those not having a nasogastric tube routinely inserted experienced an earlier return of bowel function (P < 0.001), a marginal decrease in pulmonary complications (P = 0.07), and a marginal increase in wound infection (P = 0.08) and ventral hernia (P = 0.09). Anastomotic leakage was similar in the two groups (P = 0.70).
Routine nasogastric decompression does not accomplish any of its intended goals and so should be abandoned in favour of selective use of the nasogastric tube.
To determine whether refraining from nasogastric intubation (NGI) in patients after abdominal surgery will result in the same therapeutic effectiveness as using NGI. Data Source We identified randomized trials from the Cochrane Central Register of Controlled Trials published between January 1990 and January 2005.
Two of us independently selected trials based on randomization, abdominal surgery in patients, early vs late removal of the NGI, and reporting at least 1 of the following end points: hospital stay, gastrointestinal function, and postoperative complications.
Two of us independently performed trial quality assessment and data extraction. Trials were judged using a structured list that included factors relating to internal and external validity. Data were entered and analyzed by means of dedicated software from the Cochrane Collaboration.
Seventeen randomized trials met the inclusion criteria. Meta-analysis showed that NGI does not offer any clinically relevant benefits for patients after abdominal surgery, such as recovery of gastrointestinal function or reduction of postoperative complications (relative risk, 1.18; 95% confidence interval, 0.98-1.42). Moreover, NGI showed some undesired effects, such as discomfort (in 60% of the NGI patients) and a later return to a liquid diet (weighted mean difference, 0.65 days; 95% confidence interval, 0.38-0.92 days) or a regular diet, whereas hospital stay was not shortened.
Routine NGI seems to serve no beneficial purpose and may even be harmful in patients after modern abdominal surgery; also, it is uncomfortable. Therefore, NGI is recommended only as a therapeutic approach.
To evaluate the feasibility, safety, and tolerance of early removing gastrointestinal decompression and early oral feeding in the patients undergoing surgery for colorectal carcinoma.
Three hundred and sixteen patients submitted to operations associated with colorectostomy from January 2004 to September 2005 were randomized to two groups: In experimental group (n=161), the nasogastric tube was removed after the operation from 12 to 24 h and was promised immediately oral feeding; In control group (n=155), the nasogastric tube was maintained until the passage of flatus per rectum. Variables assessed included the time to first passage of flatus, the time to first passage of stool, the time elapsed postoperative stay, and postoperative complications such as anastomotic leakage, acute dilation of stomach, wound infection and dehiscense, fever, pulmonary infection and pharyngolaryngitis.
The median and average days to the first passage of flatus (3.0+/-0.9 vs 3.6+/-1.2, P<0.001), the first passage of stool (4.1+/-1.1 vs 4.8+/-1.4, P<0.001) and the length of postoperative stay (8.4+/-3.4 vs 9.6+/-5.0, P<0.05) were shorter in the experimental group than in the control group. The postoperative complications such as anastomotic leakage (1.24% vs 2.58%), acute dilation of stomach (1.86% vs 0.06%) and wound complications (2.48% vs 1.94%) were similar in the groups, but fever (3.73% vs 9.68%, P<0.05), pulmonary infection (0.62% vs 4.52%, P<0.05) and pharyngolaryngitis (3.11% vs 23.23%, P<0.001) were much more in the control group than in the experimental group.
The present study shows that application of gastrointestinal decompression after colorectostomy can not effectively reduce postoperative complications. On the contrary, it may increase the incidence rate of fever, pharyngolaryngitis and pulmonary infection. These strategies of early removing gastrointestinal decompression and early oral feeding in the patients undergoing colorectostomy are feasible and safe and associated with reduced postoperative discomfort and can accelerate the return of bowel function and improve rehabilitation.
Few data are available concerning the frequency of bacteremia after diagnostic EUS or EUS-guided FNA. This study was undertaken to provide these data and to determine whether present guidelines for prophylactic administration of antibiotics to prevent endocarditis during upper endoscopy are applicable to EUS and EUS-guided FNA.
A total of 100 patients who were to undergo diagnostic EUS of the upper-GI tract and 50 who were to have upper-GI EUS-guided FNA were enrolled in this prospective study. Blood cultures were obtained before and within 5 minutes after the conclusion of the procedure. In case of bacterial growth, patients were observed for at least 3 days for signs of infection.
After diagnostic EUS, significant bacteremia was found in two patients with esophageal carcinoma (2%: 95% CI[0%, 4.8%]) and after EUS-guided FNA in two patients (4%: 95% CI[0%, 9.6%]). The difference was not statistically significant. None of these patients developed clinical signs of infection. Risk factors predisposing to bacteremia could not be identified.
The frequency of bacteremia after EUS, with and without FNA, is within the range of that for diagnostic upper endoscopy. Therefore, the same recommendations for prophylactic administration of antibiotics to prevent endocarditis may be applied in patients undergoing EUS and EUS-guided FNA. The role of esophageal cancer as a predisposing factor to EUS-associated infection remains uncertain.
Routine use of nasogastric tubes after abdominal operations is intended to hasten the return of bowel function, prevent pulmonary complications, diminish the risk of anastomotic leakage, increase patient comfort and shorten hospital stay.
To investigate the efficacy of routine nasogastric decompression after abdominal surgery in achieving each of the above goals.
Search terms were nasogastric, tubes, randomised, using MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (Central), and references of included studies, from 1966 through 2006.
Patients having abdominal operations of any type, emergency or elective, who were randomised prior tot he completion of the operation to receive a nasogastric tube and keep it in place until intestinal function had returned, versus those receiving either no tube or early tube removal, in surgery, in recovery or within 24 hours of surgery. Excluded will be randomised studies involving laparoscopic abdominal surgery and patient groups having gastric decompression through gastrostomy.
Data were abstracted onto a form that assessed study eligibility, as defined above, quality related to randomizations, allocation concealment, study size and dropouts, interventions, including timing and duration of intubation, outcomes that included time to flatus, pulmonary complications, wound infection, anastomotic leak, length of stay, death, nausea, vomiting, tube reinsertion, subsequent ventral hernia.
33 studies fulfilled eligibility criteria, encompassing 5240 patients, 2628 randomised to routine tube use, and 2612 randomised to selective or No Tube use. Patients not having routine tube use had an earlier return of bowel function (p<0.00001), a decrease in pulmonary complications (p=0.01) and an insignificant trend toward increase in risk of wound infection (p=0.22) and ventral hernia (0.09). Anastomotic leak was no different between groups (p=0.70). Vomiting seemed to favour routine tube use, but with increased patient discomfort. Length of stay was shorter when no tube was used but the heterogeneity encountered in these analyses make rigorous conclusion difficult to draw for this outcome. No adverse events specifically related to tube insertion (direct tube trauma) were reported. Other outcomes were reported with insufficient frequency to be informative.
Routine nasogastric decompression does not accomplish any of its intended goals and so should be abandoned in favour of selective use of the nasogastric tube.
Of the many hollow tubes which serve the body economy, the alimentary canal is the only one which communicates with the surface at both origin and termination. Advantage has long been taken of this arrangement in dealing with the distended intestinal tube by intubation, when the distention was of other than mechanical origin. The rectal tube and gastric lavage are old and well established therapeutic procedures. It is now twenty-four years since Westermann1 first used the duodenal tube in the relief of postoperative distention of peritonitis. With the introduction of the smooth tipped duodenal tube for nasal intubation by Levin2 in 1921 and satisfactory demonstration of the source of gas in postoperative distention by McIver and his associates3 in 1926 as being largely swallowed air, the relief of postoperative distention through employment of the duodenal tube has become a matter of general practice.From observations made on
Gastric emptying was measured in healthy, trained, unanesthetized dogs before and after surgical manipulation of the intestine and/or treatment with bretylium. Gastric content was found to decline exponentially with time. The pattern of emptying could be defined by the volume remaining in the stomach 10 minutes after the start of feeding and by the slope of the exponential decline in volume of the contents (the rate of gastric emptying). Laparotomy with intestinal manipulation induced gastric retention, but laparotomy alone (sham operation) did not change the rate of gastric emptying. Bretylium, an adrenergic blocking drug, suppressed the postoperative gastric ileus without significantly altering gastric emptying in control animals. Our observations support the classical assumption of a sympathetic hyperactivity during postoperative ileus and suggest that adrenergic blocking agents may be useful in the treatment of paralytic ileus.
Wangensteen OH. The early diagnosis of acute intestinal obstruction with comments on pathology and treatment. Dis Colon Rectum 1982;25:65-78. ALL cases of bowel obstruction at the onset, with the exception of primary thrombosis or embolism of the mesenteric vessels, may be regarded as instances of simple obstruction. Release of the obstruction before the anatomic changes consequent upon prolonged interference with the blood supply of the segment have occurred obviates the necessity of dealing with a non-viable bowel. Many types of bowel obstruction are potentially instances of strangulation obstruction from the beginning, in which the nutrition of the bowel is compromised as well as its lumen obstructed. Strangulated external hernias, intussusception, and volvulus constitute well known examples of this. In adhesive types of obstruction, encirclement of the bowel may eventuate in strangulation such as may also occur in kinking with secondary volvulus, the adhesive band serving as a fulcrum for the torsion. A number of instances of adhesive obstruction continue as simple obstruction throughout their course. Most cases of narrowing of the lumen of the bowel, whether due to an intrinsic lesion in the bowel wall, such as a benign or malignant stricture, or an obturatire type of obstruction, due to a lesion within the lumen such as a gallstone; or narrowing due to compression from without upon a relatively fixed portion of the bowel, such as the pelvic colon by a carcinomatous mass in the pelvis--most of these, as well as most instances of bowel stasis due to nervous causes, whether inhibitive (paralytic) or spastic, remain instances of simple obstruction. An obvious exception is carcinoma of the colon, and especially carcinoma of the sigmoid flexure, in which a signet-ring type of constriction in the presence of a competent ileocolic sphincter eventuates in enormous distension, deprivation of blood supply, gangrene and perforation, and usually in the cecum, the most distensible portion of the bowel. With this single exception, however, mere narrowing of the lumen of the bowel with resultant distension of the proximal gut rarely eventuates in strangulation obstruction. Not uncommonly, however, local effects in the bowel wall at the site of pressure may become manifest, as directly over a large gallstone incarcerated within the lumen of the ileum.
Gastric aspiration alone utilizing either a Levin-type nasogastric tube or a gastrostomy tube is inefficient. The esophagus proved to be a more efficient supplemental site for aspiration of a swallowed bolus. For thirty-one patients, esophagogastric aspiration proved to be approximately twelve times as efficient as aspiration via a Levin-type tube for twenty-four patients or a gastrostomy tube in five patients (residual activity, of 3,35, and 42 per cent, respectively). Radiographic studies of a volunteer swallowing barium with each type of nasogastric tube in place showed efficient removal of the contrast agent by esophageal aspiration. With the Levin-type tube, the bolus promptly traversed the stomach and entered the duodenum along parallel channels remote from the x-ray -visualized gastric tube. Efficient postoperative exclusion of swallowed air clinically and experimentally by esophageal aspiration permits more rapid return of gastrointestinal function and full nutrition and perhaps shortened hospitalization.
We report two complications of nasoenteral tubes. A nasogastric tube became knotted during gastric intubation in a patient with a small gastric remnant, created during gastric surgery for morbid obesity. A clogged Dobbhoff tube ruptured while it was being flushed manually with a syringe containing normal saline under great pressure. To retrieve the knotted tube, we grasped the distal knotted part visible in the oropharynx with forceps, pulled it out of the mouth, and cut it. To retrieve the broken tube, we snared the intragastric fragment at endoscopy. These case reports suggest that a small gastric remnant may be a risk factor for nasogastric tube coiling and knot formation and that flushing a clogged tube at high pressure may rupture it. To prevent these complications, a nasogastric tube should be carefully passed just into the stomach in a patient with a small gastric remnant, and a clogged feeding tube should be flushed with only moderate pressure. Failure to clear a blocked tube by flushing with normal saline at moderate pressure should lead to tube removal and not to use of excessive pressure.
Aortoesophageal fistula is a rare disorder that may result from many causes. In this report, we describe the unique case of a 71-year-old woman who developed an aortoesophageal fistula following prolonged placement of a nasogastric tube. The presence of dense fibrous adhesions between the aorta and esophagus may have facilitated the development of aortoesophageal fistula in this patient.
Fifty-six patients undergoing elective colonic resection were prospectively randomized into two groups either with or without postoperative nasogastric decompression. The results demonstrated only minimal differences between the two groups. Postoperative abdominal distention was more common in patients without nasogastric tubes, whereas pulmonary complications were more common in patients with nasogastric tubes. Other morbidity and mortality and hospital stay were the same in both groups. We conclude that in elective colon operations, the routine use of postoperative nasogastric decompression is unnecessary and can safely be omitted.
Atelectasis was determined by auscultation in 151 patients after abdominal surgery. The roentgenographic findings correlated well with auscultatory evidence of atelectasis. A carefully taken respiratory history was as helpful as pulmonary function tests in predicting postoperative atelectasis. The incidence of atelectasis was related to duration of surgery but not to age or obesity. Temperature elevation on the first postoperative day was directly related to the degree of atelectasis, but the white blood cell count (WBC) elevation was inversely related. No correlation was found between the bacteriologic state of the lower respiratory tract at the time of surgery, determined by an endotracheal aspirate culture, and the incidence of postoperative atelectasis, temperature, or WBC elevation. On the basis of this study, atelectasis is shown not to be related to an infectious process.
Perforation of the hypopharynx, esophagus, and stomach complicated the insertion of flexible tubes in 11 adults. Nasogastric suction tubes were responsible for 5 instances of gastric perforation. Palliative intubation of obstructive carcinomas of the distal esophagus resulted in delayed perforation of the esophagus and stomach in 2 cases. The use of a Linton tube for decompression of bleeding varices caused esophageal rupture in 1 patient whereas 2 others developed pharyngoesophageal perforation due to misplaced endotracheal tubes. The remaining 1 case demonstrated penetration of a chest tube into the esophageal lumen. The radiographic features and mechanisms of these iatrogenic injuries are described and the pertinent literature is reviewed.
Despite some evidence that gastric decompression may be unnecessary after some abdominal operations and in the treatment of paralytic ileus, the use of nasogastric suction after extensive abdominal operations, particularly intestinal resection, remains a subject of some debate. In a randomized prospective trial, 52 patients with suture lines constructed in the gastrointestinal tract received no postoperative nasogastric drainage unless acute gastric dilation or copious vomiting developed postoperatively, while 45 similar patients were allocated to receive routine postoperative nasogastric aspiration. Only 12 patients in the nonintubated group required subsequent insertion of a nasogastric tube, while in the remaining 40, nasogastric drainage was avoided completely. Postoperative loss of fluid from the intestine was significantly greater in the patients undergoing routine nasogastric drainage, although the requirement for intravenous fluid therapy was the same in both groups. There were no significant differences between the two groups in the incidence of postoperative complications. Routine nasogastric aspiration after gastric or intestinal resection does not confer significant advantages to outweigh its discomfort and potential morbidity for patients and should be replaced by selective intubation when required postoperatively.
This article has no abstract; the first 100 words appear below.
PROLONGED gastric intubation may be a factor in the development of peptic esophagitis and stricture in some patients, but whether acid reflux into the esophagus is the primary mechanism is uncertain. A previous study utilizing cineradiographic technics showed no reflux of barium into the esophagus during short-term gastric intubation.¹ In contrast, this study of simultaneously recorded intraluminal esophageal pressures and pH reports that gastric acid is refluxed and maintained in the distal esophagus during prolonged gastric intubation under certain conditions. Methods and Results Three water-filled polyethylene catheters, each with an internal diameter of 1.5 mm., were fastened together and sealed . . .
*Supported in part by grants (AM-04759 and AM-05100) from the United States Public Health Service.
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NEW HAVEN, CONNECTICUT
† Instructor in medicine, Yale University School of Medicine; former address, 23 Green Street, Huntington, New York.
‡ Associate professor of medicine, Yale University School of Medicine.