Ann Otol Rhinal Laryngol99: 1990
USE OF THE NASOGASTRIC TUBE AFTER TOTAL LARYNGECTOMY: IS IT TRULY NECESSARY? FLAVIa APRIGLIANO, MD RIO DE JANEIRO, BRAZIL The nasogastric tube has been routinely used to feed the patient during the first postoperative days after a total laryngectomy. In the last 21 years the author has performed 625 total laryngectomies without using the feeding tube. With this procedure oral feeding could be started during the third postoperative day, making the patient more comfortable and confident. In addition, the hospital stay was shortened. It was also observed that the incidence of pharyngeal fistulas (9 0/0) was comparable to that of other reports in the literature. KEY WORDS -
intubation, laryngectomy, nasogastric tube, pharyngeal fistula.
reason some of them would pull out their tubes during the first 24 hours after the operation. This group of patients was closely watched, and it was noticed that they could swallow saliva without much difficulty. Since 1968, as a result of these observations, we have discontinued the use of the nasogastric tube, feeding the patient by mouth from the third postoperative day on.
In spite of all efforts to establish an early diagnosis and to preserve the larynx, total laryngectomy is still the most frequent operation for the treatment of laryngeal cancer. In the surgical technique of total laryngectomy the routine procedure is, after the removal of the larynx, to insert a nasogastric or nasoesophageal tube just before the closure of the pharynx. The purpose of this tube is to secure the patient's proper nutrition during the first 8 to 10 postoperative days, leaving the pharyngeal suture at rest. The nasogastric tube is also believed to decrease the occurrence of the pharyngocutaneous fistula, the most common complication of totallaryngectomy. A recent literature review I indicates that this fistula is present in 15 % to 30 % of cases.
Nothing unusual was added to the surgical technique of total laryngectomy in order to abolish the use of a feeding tube. The closure of the pharyngeal mucosa was performed according to the usual method. With 3-0 chromic catgut suture material and an atraumatic needle a continuous inverted suture was made upward, in a straight line. A reinforcement suture was placed over the first one, and the inferior constrictor muscle was closed over it. A hemovac-type drain was placed on each side of the wound. If not enough mucosa was available the suture was done in a T shape.
In the early days of laryngectomy, just after Billroth showed its feasibility, the nutrition of patients during the first postoperative days was provided through a rectal enema. This practice proved to be inefficient, since it was very difficult for the patients and also because most of the nutrients were expelled soon after introduction.
On the third postoperative day the patients were fed 150 mL of tea every 3 hours. The following day milk and fruit juices were added. If the patients did not complain of pain a soft diet was started on the third feeding day. On the average the patients remained in the hospital for only 7 to 8 days, returning to the outpatient clinic for dressing and suture removal.
Probably the first surgeon to use and suggest the use of a nasoesophageal tube was Chevalier Jackson. In a 1904 publication he wrote, "Feeding should be by esophageal tube for a few days until swallowing is easy.'? In 1914 Gluck and Soerensen3 ( p 34 ) also mentioned the use of a nasogastric tube. Alonso" wrote that in "narrow field" laryngectomy, when the suture of the pharynx could be easily done, he did not use a nasogastric tube and started oral feeding on the second or third postoperative day. On the other hand, several surgeons have adopted intravenous feeding on the basis that the nasogastric tube interferes with healing. I
Over the last 21 years 625 total laryngectomies were done without the use of any type of feeding tube. All patients were fed by mouth starting on the third or fourth postoperative day. In this group of patients there was a total of 57 fistulas. Of these only 3 fistulas had to be surgically closed. The remaining 54 spontaneously closed between 5 and 38 days after operation. Of these 625 patients, 52 had undergone radiotherapy for curative purposes before operation. This group of patients had a higher per-
Throughout a period of several years we observed that the majority of patients complained of the nasogastric tube as being very unpleasant. For this
From the Department of Laryngo-Broncho-Esophagology, Hospital de Bonsucesso, Instituto Nacional de Assistencia Medicae PrevidenciaSocial, Riode Janeiro, Brazil. Dr Aprigliano is also Privatdozent of Bronchoesophagology, Federal University of Rio de Janeiro Medical School. Presented at the meeting of the American Laryngological Association, Palm Beach, Florida, April 28-29, 1990. REPRINTS - Flavio Aprigliano, MD, Rua Teresina 19, 20240 Rio de Janeiro, RJ, Brazil.
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Aprigliano, Nasogastric Tube After Total Laryngectomy
centage of fistulas: 8 of 52 patients (15.3%), versus 49 of 573 (8.5 %) in the group without radiotherapy.
In conclusion, our experience indicates that the
nasogastric tube is not necessary after a totallaryngectomy. Without this tube oral feeding of the patients starts sooner in the postoperative period. For this reason patients become more confident and their hospital stay is shortened.
REFERENCES 1. Kleinsasser O. Tumors of the larynx and the hypopharynx. New York, NY: Thieme Medical Publishers, 1988:1956. 2. Jackson C. Primary malignant disease of the larynx. Laryngoscope 1904;14:590-618. 3. Gluck, Soerensen. Die Ressektion und Exstirpation des
Larynx, Pharynx und Osophagus. In: Katz L, Preysing H, Blumenfeld F, eds. Handbuch der Speziellen Chirurgie des Ohres und der Oberen Luftwege. Vol 4. Wurzburg: Verlag Von Curt Kabitzsch, 1914:1-58. 4. Alonso JM. Cancer laringeo. Madrid, Spain: Editorial Paz Montalvo, 1954.
THE FIRST INTERNATIONAL LARYNGOTRACHEAL RECONSTRUCTION SYMPOSIUM The Cleveland Clinic Foundation is sponsoring a continuing education program entitled The First International Laryngotracheal Reconstruction Symposium, to be held August 24-27, 1991, at Stouffer Tower City Plaza Hotel in Cleveland, Ohio. For further information, contact The Cleveland Clinic Educational Foundation, Department of Continuing Education, 9500 Euclid Avenue, TT31, Cleveland, OH 44195-5241; 444-5696 (local), (800) 762-8172 (Ohio), (800) 762-8173 (outside Ohio).
Downloaded from aor.sagepub.com at East Carolina University on June 5, 2016
USE OF THE NASOGASTRIC TUBE AFTER TOTAL LARYNGECTOMY: IS IT TRULY NECESSARY? FLAVIa APRIGLIANO, MD RIO DE JANEIRO, BRAZIL The nasogastric tube has been routinely used to feed the patient during the first postoperative days after a total laryngectomy. In the last 21 years the author has performed 625 total laryngectomies without using the feeding tube. With this procedure oral feeding could be started during the third postoperative day, making the patient more comfortable and confident. In addition, the hospital stay was shortened. It was also observed that the incidence of pharyngeal fistulas (9 0/0) was comparable to that of other reports in the literature. KEY WORDS -
intubation, laryngectomy, nasogastric tube, pharyngeal fistula.
reason some of them would pull out their tubes during the first 24 hours after the operation. This group of patients was closely watched, and it was noticed that they could swallow saliva without much difficulty. Since 1968, as a result of these observations, we have discontinued the use of the nasogastric tube, feeding the patient by mouth from the third postoperative day on.
In spite of all efforts to establish an early diagnosis and to preserve the larynx, total laryngectomy is still the most frequent operation for the treatment of laryngeal cancer. In the surgical technique of total laryngectomy the routine procedure is, after the removal of the larynx, to insert a nasogastric or nasoesophageal tube just before the closure of the pharynx. The purpose of this tube is to secure the patient's proper nutrition during the first 8 to 10 postoperative days, leaving the pharyngeal suture at rest. The nasogastric tube is also believed to decrease the occurrence of the pharyngocutaneous fistula, the most common complication of totallaryngectomy. A recent literature review I indicates that this fistula is present in 15 % to 30 % of cases.
Nothing unusual was added to the surgical technique of total laryngectomy in order to abolish the use of a feeding tube. The closure of the pharyngeal mucosa was performed according to the usual method. With 3-0 chromic catgut suture material and an atraumatic needle a continuous inverted suture was made upward, in a straight line. A reinforcement suture was placed over the first one, and the inferior constrictor muscle was closed over it. A hemovac-type drain was placed on each side of the wound. If not enough mucosa was available the suture was done in a T shape.
In the early days of laryngectomy, just after Billroth showed its feasibility, the nutrition of patients during the first postoperative days was provided through a rectal enema. This practice proved to be inefficient, since it was very difficult for the patients and also because most of the nutrients were expelled soon after introduction.
On the third postoperative day the patients were fed 150 mL of tea every 3 hours. The following day milk and fruit juices were added. If the patients did not complain of pain a soft diet was started on the third feeding day. On the average the patients remained in the hospital for only 7 to 8 days, returning to the outpatient clinic for dressing and suture removal.
Probably the first surgeon to use and suggest the use of a nasoesophageal tube was Chevalier Jackson. In a 1904 publication he wrote, "Feeding should be by esophageal tube for a few days until swallowing is easy.'? In 1914 Gluck and Soerensen3 ( p 34 ) also mentioned the use of a nasogastric tube. Alonso" wrote that in "narrow field" laryngectomy, when the suture of the pharynx could be easily done, he did not use a nasogastric tube and started oral feeding on the second or third postoperative day. On the other hand, several surgeons have adopted intravenous feeding on the basis that the nasogastric tube interferes with healing. I
Over the last 21 years 625 total laryngectomies were done without the use of any type of feeding tube. All patients were fed by mouth starting on the third or fourth postoperative day. In this group of patients there was a total of 57 fistulas. Of these only 3 fistulas had to be surgically closed. The remaining 54 spontaneously closed between 5 and 38 days after operation. Of these 625 patients, 52 had undergone radiotherapy for curative purposes before operation. This group of patients had a higher per-
Throughout a period of several years we observed that the majority of patients complained of the nasogastric tube as being very unpleasant. For this
From the Department of Laryngo-Broncho-Esophagology, Hospital de Bonsucesso, Instituto Nacional de Assistencia Medicae PrevidenciaSocial, Riode Janeiro, Brazil. Dr Aprigliano is also Privatdozent of Bronchoesophagology, Federal University of Rio de Janeiro Medical School. Presented at the meeting of the American Laryngological Association, Palm Beach, Florida, April 28-29, 1990. REPRINTS - Flavio Aprigliano, MD, Rua Teresina 19, 20240 Rio de Janeiro, RJ, Brazil.
513
Downloaded from aor.sagepub.com at East Carolina University on June 5, 2016
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Aprigliano, Nasogastric Tube After Total Laryngectomy
centage of fistulas: 8 of 52 patients (15.3%), versus 49 of 573 (8.5 %) in the group without radiotherapy.
In conclusion, our experience indicates that the
nasogastric tube is not necessary after a totallaryngectomy. Without this tube oral feeding of the patients starts sooner in the postoperative period. For this reason patients become more confident and their hospital stay is shortened.
REFERENCES 1. Kleinsasser O. Tumors of the larynx and the hypopharynx. New York, NY: Thieme Medical Publishers, 1988:1956. 2. Jackson C. Primary malignant disease of the larynx. Laryngoscope 1904;14:590-618. 3. Gluck, Soerensen. Die Ressektion und Exstirpation des
Larynx, Pharynx und Osophagus. In: Katz L, Preysing H, Blumenfeld F, eds. Handbuch der Speziellen Chirurgie des Ohres und der Oberen Luftwege. Vol 4. Wurzburg: Verlag Von Curt Kabitzsch, 1914:1-58. 4. Alonso JM. Cancer laringeo. Madrid, Spain: Editorial Paz Montalvo, 1954.
THE FIRST INTERNATIONAL LARYNGOTRACHEAL RECONSTRUCTION SYMPOSIUM The Cleveland Clinic Foundation is sponsoring a continuing education program entitled The First International Laryngotracheal Reconstruction Symposium, to be held August 24-27, 1991, at Stouffer Tower City Plaza Hotel in Cleveland, Ohio. For further information, contact The Cleveland Clinic Educational Foundation, Department of Continuing Education, 9500 Euclid Avenue, TT31, Cleveland, OH 44195-5241; 444-5696 (local), (800) 762-8172 (Ohio), (800) 762-8173 (outside Ohio).
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