Review Br. J. Surg. 1992, Vol. 79, November, 1127-11 31
P. M. Sagar, G. Kruegener and J. MacFie Department of Surgery, Scarborough Hospital, Scalb y Road, Scarborough. North Yorkshire YO12 60L,UK Correspondence to: Mr J. MacFie
Nasogastric intubation and elective abdominal surgery The use of nasogastric tubes after elective abdominal surgery remains standard practice f o r many surgeons. Such tubes, however, cause much discomfort and are associated with signijicant morbidity. This paper reviews the argumentsfor and against nasogastric intubation, a n d j n d s little evidence to support its continued routine use.
Nasogastric intubation is used routinely by many surgeons after both elective and emergency abdominal surgery, for gastric decompression to prevent acute gastric dilatation and to treat ileus, to monitor upper gastrointestinal haemorrhage, to act as a guide to starting oral feeding, and to reduce tension on suture lines, thereby reducing the risk of anastomotic dehiscence. However, the use of nasogastric decompression may result in some morbidity. Respiratory complications, gastro-oesophageal reflux, fluid and electrolyte losses, injury to the vocal folds and, not least, discomfort to the patient are all well recognized problems. Some of these complications may even promote continued ileus. The potential advantages of nasogastric intubation must be weighed against the potential disadvantages in each case. In this paper the rationale for nasogastric decompression is reviewed and the value of nasogastric tubes in elective abdominal surgery reappraised.
History John Hunter is widely credited with the earliest use of nasogastric tubes. In 1790 he used eel skin stretched over whalebone to act as an enteral feeding tube in a patient with bulbar palsy who was unable to swallow'. However, 7 years later Alexander Munro claimed that 30 years previously his father had used a flexible tube of coiled wire covered with leather to effect decompression in cattle with excessive fermentation'. Such a tube was advocated by Philip Physick in 1800 to wash out the stomach of poisoned patients3. Decompression of the stomach with a nasogastric tube was described in 1884 by Kussmau14. Westerman in 1910advocated the use of siphon drainage when paralytic ileus had developed secondary to peritonitis5. Matas6 in 1924 and Meyer7 4 years later both used gastric tubes for aspiration and fluid administration. After Levin's description in 1921 of his design of nasogastric tube', Wangensteeng popularized the concept with a series ofexperiments on its use in small bowel obstruction reported in 1932. Partly because of the ease with which nasogastric tubes can be passed, compared with the construction of a gastrostomy which was a common practice at the time", and partly because of the esteem in which Wangensteen was held, nasogastric suction was used thereafter in almost all patients undergoing abdominal surgery. Many surgeons throughout the world continue to employ routine intestinal decompression after resection and primary anastomosis of the gastrointestinal tract' '. However, timehonoured surgical practices developed many decades ago are not necessarily appropriate today. Preparation of patients before operation, improved anaesthetic agents and techniques, awareness of the electrolytic and metabolic consequences of surgery, control of infection, and improved nursing care have all contributed to altering the nature of the postoperative period such that nasogastric tubes might now be reserved solely for a few specific indications.
ooO7-1323/92/111127-05
0 1992 Butterworth-Heinernann Ltd
Rationale for intestinal decompression Paralytic ileus Ileus is familiar to all surgeons: after abdominal operation there is a reduction in propulsive activity in the gastrointestinal tract; bowel sounds are diminished and abdominal distension with nausea and vomiting may occur. The condition may predispose to respiratory complications, wound dehiscence and anastomotic leakage. Previously considered to affect the entire gastrointestinal tract, it is now recognized that peristaltic activity is maintained in the small intestine and that diminished motility occurs to a significant degree only in the stomach and colon. In experimental animal models, activity of the small intestine returns to normal within a few hours; early return of motility has been shown in humans by means of radiotelemetry capsule^^^'^^'^. There is therefore no substantial period of paralysis of the small intestine after operation. Studies of the stomach have confirmed a period of paralysis that lasts 24-72 h according to the type of Colonic motility is also reduced for variable periods after abdominal surgery, and the sigmoid and rectum seem to recover last * '. The mechanism by which paralytic ileus occurs is unclear. Studies in animals have suggested that it is a consequence of sympathetic inhibition mediated by spinal reflexes, which are initiated by manipulation of the bowel during operation. The length of operation and degree of insult t o the bowel have long been held to be proportional to the duration of any subsequent paralytic ileus. However, recent studies suggest that these assumptions may be incorrect: in an investigation into postoperative bowel motility in humans, no relationship was found between duration of operation and severity of ileus15. It has been proposed that the afferent side of the reflex which initiates paralytic ileus originates in the parietal peritoneum rather than from afferent nerves in the gut or visceral peritoneum: this would explain prolonged paralytic ileus after retropubic prostatectomy or retroperitoneal trauma. It would also account for the absence of significant ileus after laparoscopic procedures. If confirmed, this concept would render nasogastric intubation after major excisional surgery illogical - at least on the basis of ileus prophylaxis. The intestinal tract may secrete up to 8.5 litres fluid every 24 h. The use of nasogastric tubes is not associated with the removal of a significant proportion of this volume. Therefore, the majority of these secretions must continue to be reabsorbed in the small intestine, even in the early period after operation. In the presence of an intact pyloric sphincter, a nasogastric tube is unlikely to decompress more than the stomach alone. The value of nasogastric intubation in preventing abdominal distension must consequently be related to removal of swallowed air. Significant amounts of air enter the gastrointestinal tract only with d e g l ~ t i t i o n ' ~ , ' and so gaseous distension should be most easily prevented by reduction of oral intake in the early postoperative period. Indeed, nasogastric intubation may itself promote aerophagia".
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Nasogastric tubes and abdominal surgery: P. M. Sagar et al.
Table 1 Studies on the tialue of nasogastric intubation after abdominal surgery
Upper, lower or mixed abdominal surgery
No. of
Reference
Year
patients
Type of study
Nathan and Painz1 Bauer et Dorairajan et
1991 1985 1985
197 200 20 1
Mixed elective Mixed
Argov et al.24
1980
300
Hendry”
1962
232
Miller et
1972
132
Prospective randomized Prospective randomized 198 patients with tube, three without 150 consecutive patients without tube, 150 consecutive patients with 114 Billroth I gastrectomy without tube, 118 vagotomy and pyloroplasty with Prospective randomized
Wolff et
Reasbeck et Racette er al.2s
1989 1984 1987
535 97 56
Prospective randomized Prospective randomized Prospective randomized
Lower Mixed Lower
Olesen et
1984
97
Prospective randomized
Lower
Meltvedt et a1.30
1985
118
Lower
Ibrahim et ~ 1 . ~ ’
1977
76
Lower
No difference in complications
Burg et
1978
137
Lower
No difference in complications
Cheadle et
1985
200
Retrospective non-randomized 53 consecutive patients with tube, 23 consecutive patients without Retrospective non-randomized Prospective randomized
Significantly fewer respiratory complications in ‘no tube’ group No difference in complications No difference in complications Significantly more abdominal distension without tube, but significantly more atelectasis with Flatus passed earlier without tube No difference in complications No difference in complications
Mixed
Colvin et af.34
1986
138
Prospective randomized
Increased time to flatus, length of stay and sore throat with tube but less vomiting No difference in complications
Acute gastric dilararion Acute gastric dilatation has long been considered a reason for routine use of a prophylactic nasogastric tube. The condition is common in patients after significant trauma; the reported incidence is 9 per cent”. In such patients, acute gastric dilatation may be complicated by gastric haemorrhage, pulmonary aspiration and prolonged ileus. Dilatation may also occur after an episode of acute pancreatitis, although much less commonly2’. However, acute gastric dilatation is very uncommon after elective abdominal surgery; of the 2716 patients described in Table 1 , none developed this condition.
Gastrostomy as an alternative Gastric decompression, via a nasogastric or gastrostomy tube, remains a useful procedure. Decompression of the acutely dilated stomach, conservative management of small bowel obstruction in the early stages, conservative treatment of a perforated peptic ulcer with localized minimal contamination, and management of upper gastrointestinal haemorrhage to assess rebleeding may all call for nasogastric intubation. Gastrostomy may be associated with fewer minor problems but major complications, including death, have been recorded in up to 6 per cent of patient^^'.^^. Gastrostomy also has problems related to removal of the tube and to its replacement if dislodged. Percutaneous endoscopic gastrostomy has, however, simplified the procedure. Gastrostomy is a good alternative to a nasogastric tube for patients at the extremes of life, in whom complications are more common with the latter. Chest infections are more frequent in patients over 60 years of age when nasogastric intubation is employed3’. Excessive salivation with subsequent aspiration pneumonitis is likely to occur with nasogastric tubes in the elderly and in young children.
1128
Upper
Comments (tube wrsus no tube) Increased sore throat and nausea with tube No difference in complications No difference in complications 15.0%pneumonia with tube, 1.5% without
No difference in complications
Upper
Lower
Gastrostomy has the advantages that it avoids nasopharyngeal pressure and irritation, the cardia is not compromised and patients find it more comfortable. It does, however, carry small risks of fistulation, peritonitis, haemorrhage from the gastrostomy wound, and wound infection if the tube is sited too close to a Iaparotomy incision26. It also represents an additional operation. A prospective trial examining 132 patients, who underwent truncal vagotomy and drainage and who were randomized to receive a nasogastric or gastrostomy tube or no tube at all, demonstrated a significantly greater risk ( P < 0.05) of wound infection in those with a gastrostomy than in either of the other two groups. Avoiding either type of tube resulted in a significant reduction ( P < 0.05) in the incidence of respiratory infection and was much preferred by the patients 2 6 . Tube management Nasogastric tubes may be left to drain freely, spigoted and aspirated at intermittent intervals, or a combination of free drainage and aspiration may be employed. Intermittent aspiration has the benefit that patency of the tube is tested regularly; the tube may be flushed if blocked or repositioned if displaced. If the tube is left spigoted, the chance of allowing escape of gas and decompression of the upper gastrointestinal tract is lost3. A drainage bag allows collection of large volumes of gas as well as fluid.
Clinical studies Upper gastroinrestinal surgerjt A retrospective study of 300 patients who underwent emergency or elective operations on the upper gastrointestinal tract, in
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Nasogastric tubes and abdominal surgery: P. M. Sagar et al.
which the first 150 received nasogastric intubation and the second 150 did not, demonstrated a tenfold increased risk of pneumonia (15.0 ciersus 1.5 per cent) in the former groupz4. Routine avoidance of nasogastric intubation in a series of 201 patients undergoing gastric drainage procedures alone, or with various forms of vagotomy, resulted in only three ( 1.5 per cent) subsequently needing a nasogastric tube because of abdominal distension and vomiting; the incidence of severe respiratory infection was only 1 per cent”. Low rates of gastric intubation had been reported previously, with an incidence of 3.4 per cent in 118 patients following vagotomy and pyloroplasty and none in 114 after Billroth I gastrectomy2’. Thus it would appear that a nasogastric tube is rarely required even after truncal vagotomy, a procedure that denervates the upper gastrointestinal tract. Furthermore, most practitioners of highly selective vagotomy do not use a nasogastric tube after operation (D. Johnston, personal communication). The influence of H,-receptor antagonists such as cimetidine on nasogastric intubation is interesting. Although a nasogastric tube is associated with a significant increase in the length of time to passage of flatus, bowel action and cessation of intravenous fluids, as well as a significantly greater incidence of postoperative discomfort, cimetidine has not been shown to reduce these p r ~ b i e m sThe ~ ~ .drug does, however, significantly increase the incidence of pneumonia, perhaps by an influence on gastric flora since bacterial overgrowth has been shown3’ to occur at pH > 4. The patient fasting after operation swallows about 2 litres recoverable air each day and about 600 ml salivary secretions accumulate in the stomach39. The fluid is accommodated without difficulty. The volume of air swallowed increases as fluid intake increases and, as long as the latter is restricted, the upper gastrointestinal tract should not be compromised by excessive gaseous intake. There is, therefore, no reason to drain this region. Apprehensive patients tend to be more aerophagic and so more at risk of nausea, vomiting and abdominal distension; some may require nasogastric decompression.
Lower grrstrointcs~inalsurgery The need for a nasogastric tube after elective colorectal surgery is even less convincing than in upper gastrointestinal operations. In a prospective randomized trial of 200 patients who underwent predominantly lower gastrointestinal operations with or without routine nasogastric aspiration”, no differences were observed in the frequency of complications between the two groups; there were no instances of aspiration pneumonia, anastomotic leakage or wound dehiscence. The rate at which the tube had to be inserted or reinserted was 6 per cent in the ‘no-tube’ group compared with 5 per cent in the ‘tube’ group. A retrospective non-randomized study or a consecutive series of 76 patients undergoing colorectal operations ( 5 3 with decompression, 23 without) also demonstrated no significant difference in postoperative morbidity rate and length of hospital stay after operation3’. A similar retrospective study of 1 18 patients showed not only no difference in mortality and morbidity rates and length of stay, but also that the tube did not reduce the degree of abdominal distension or hasten the time to recommencement of oral fluids or first bowel action”. Smaller prospective randomized studies have largely confirmed these results. In particular. nasogastric intubation is associated with increased risk of chest infection”. later passage offlatusZ9and an incidence of reintubation similar to that needed when an initial policy of non-aspiration is followed. The largest reported prospective randomized trial. from the Mayo Clinic, involved I391 patients who underwent eleclive colorectal operations”. A total of 535 patients were considered eligible for entry: 274 received nasogastric decompression and 261 did not. Abdominal distension, nausea and vomiting were significantly more common in patients with no tube ( P < 0.05) and the frequency of subsequent nasogastric decompression was 13 per cent compared with a frequency of reinsertion of
Br. J. Surg.. Vol. 79, No. 11, November 1992
5 per cent in those undergoing routine decompression ( P < 0.05). The incidence of major complications and length
of stay after operation were similar. The authors concluded that, despite the increased rate of minor complications. most patients do not require nasogastric intubation after colorectal surgery and that tube insertion should not be used as a routine procedure. There are no guidelines to predict which patients will require nasogastric decompression. It is possible that those with extensive adhesions, several previous operations or intraabdominal sepsis (who are often excluded from trials) are at increased risk, but this requires further study. The Mayo Clinic group” empirically recommended use of nasogastric decompression in patients with multiple (four or more) serosal tears, gross peritoneal contamination, intra-abdominal sepsis, extensive fibrotic adhesions or operating time > 6 h. They also suggested that nasogastric decompression was useful during operation to deflate the stomach if access was difficult, particularly if GoLytely solution (Seward Medical, London, U K ) had been used in preoperative cleansing of the bowel. This technique induces excess gas and fluid, which tend to accumulate in the stomach and duodenum and so be present at the start of the operation. Passage of long intestinal tubes on the day before surgery does not increase the extent of intestinal decompression, as assessed at operation, in terms of ease of packing of the small bowel. However, it may reduce pulmonary atelectasis. perhaps because of reduced abdominal distension after operation3”. No benefit from long tubes has been shown in terms of morbidity after operation.
Complications Nasogastric intubation is used at the cost of increased postoperative morbidity. The incidence of respiratory complications, such as atelectasis and pneumonia. is increased by tenfold in some series’“. Nasogastric tubes inhibit effective coughing, allow mucus plugs to accumulate and hence atelectasis and localized pneumonia to d e ~ e l o p “ ~The . likelihood of pneumonia associated with the use of nasogastric decompression increases with the age of the p t i e n t and duration of intubation. Nasogastric tubes are also unpleasant for the patient: most remember the uncomfortable sensation of ‘the tube in my throat’ long after they have forgotten other aspects of their operation. The vast majority of patients are unhappy with a nasogastric tube despite the use of mouth washes. nasal or pharyngeal sprays, lip swabs, ice cubes or changing the tube from one nostril to the other. A nasogastric tube may induce vomiting and is associated with nasopharyngeal soreness, otitis or sinusitis. As many as 50 per cent of patients undergoing nasogastric intubation develop radiological evidence of maxillary sinus inflammation and 75 per cent clinical evidence of rhinitis4I. A nasogastric tube may cause sudden lifethreatening bilateral vocal fold paralysis, possibly as a result of paresis of the posterior cricoarytenoid muscles, secondary to infection and ulceration over the posterior lamina of the cricoid. Diabetics who have undergone renal transplantation are particularly at risk4’. Intubation of the gastric cardia facilitates gastric reflux. It maintains acid in the lower oesophagus as long as there is sufficient gastric acid available to reflux (equivalent to 300 ml 0.1 mol/l HCI), the patient is supine, and the tube is actually in the stomach and not coiled up in the oesophagus‘.’. The mechanism of this reflux remains uncertain but interference with intrinsic sphincteric function, failure of the sphincter to close around the nasogastric tube. and the effects of posture in the recumbent patient all contribute. The tube renders the gastro-oesophageal sphincter incompetent and acts as a wick to encourage migration of gastric acid into the lower oesophagus, causing oesophagitis and even eventual stricture, The surface of the tube becomes covered with a thick amorphous biofilm consisting of microcolonies of bacteria within a matrix of exopolysaccharide glycocalyx. Although this
1129
Nasogastric tubes and abdominal surgery: P. M. Sagar et al.
matrix contains many dead and dying cells, many of the microcolonies are intact and the presence of yeast cells helps attachment to the tube. Such colonization occurs44 after the tube has been in place for only 1 day. The tube may become knotted45, making its removal difficult, dangerous or impossible. It may be incorrectly positioned even to the extent of an intracranial location46, placement in the sphenoidal sinus47 or trachea, despite the presence of an endotracheal tube. Suction connected to such a tube will evacuate gas from the lungs and prevent effective ventilation4’. The only sure test of correct placement of a nasogastric tube is the aspiration of gastric content. A tube may perforate the cervical oesophagus at the time of introduction, traverse the mediastinum and come to lie in the lesser sac49. Palpation of the tip of the tube by the surgeon at operation may give the mistaken impression that it is positioned in the stomach, but this can be confirmed only by positive gastric aspiration. The tube may become entrapped in a stapled gastrointestinal anastomosis; this preventable and infrequent complication can be managed successfully by endoscopic extraction5’. Finally, pneumothorax”, aorto-oesophageal fistula” and perforation of the n a ~ o p h a r y n x have ~ ~ all been reported as complications associated with nasogastric intubation.
4.
Kussmaul CA. Heilung von Ileus durch Magenausspulung.Berlin
5.
Westerman CWJ. Uber die Anwendung des Dauermagenhebers bei der Nachbehandlung schwerer Peritonitisfaln. Zentralbl Chir
6
Matas R. The continued intravenous ‘drip’. Ann Surg 1924; 79:
Hit? W O C ~ C W1884; S C ~ ~21: 669-85.
1910; 37: 356-7. 643-61. 7. 8.
Meyer W. Gastric intubation. Med J Rec 1928; 123: 304. Levin AI. A new gastroduodenal catheter. JAMA 1921; 76:
9.
Wangensteen OH. The early diagnosis of acute intestinal obstruction with comments on pathology and treatment: with a report of successful decompression of three cases of mechanical bowel obstruction by nasal catheter suction siphonage. Wesr J
10.
Schmidt ER. Forty-four cases of simple perforation of gastric and duodenal ulcers, with a simple method of surgical treatment.
1007-9.
Surg Obstet Gynecol 1932; 40: 1-17.
11.
12. 13. 14.
Other indications
15.
Nasogastric tubes have uses other than those already discussed. Recent evidence has highlighted the importance of maintaining the gut barrier to prevent translocation of bacteria. Enteral, as opposed to parenteral, feeding maintains this barrier function in the critically ill patient and fine-bore nasogastric tubes facilitate enteral nutrition in those unable to feed themselves adequately. Similarly, fine-bore nasogastric feeding of infants and small children on chronic ambulatory peritoneal dialysis awaiting renal transplantation will maintain or improve g r o ~ t h ~A ~nasogastric . ~ ~ . tube can permit oral administration of 1 3 ’ 1 and other medications to uncooperative patients. A probe can be incorporated into the tip of a nasogastric tube to monitor intragastric pH to permit titration against H, antagonists. This is particularly useful for patients in intensive therapy units who are at increased risk of haemorrhage from stress ulcerations6. A Salem sump nasogastric tube allows decompression of the distended small intestine during operation’ 7 .
16.
20.
Conclusions
25. 26.
17. 18. 19.
Acta Chir Scand 1922; 55: 313-17. Savassi-Rocha PR, Conceicao SA, Ferreira JT el al. Evaluation of the routine use of the nasogastric tube in digestive operation by a prospective controlled study. Surg Gynecol Obstet 1992; 174: 317-20. Valori R. Small intestinal motility. Curr Opin Gastroenteroll991; 7: 220-4. Ross R, Watson BW, Kay AW. Studies on the effect of vagotomy on small intestinal motility using radiotelemetring capsule. Gut 1963; 4 : 77-81.
Rothnie NG, Harper RAK, Catchpole BN. Early postoperative gastrointestinal activity. Lancet 1963; ii: 64-7. Wilson JP. Postoperative motility of the large intestine in man. Gut 1975; 16: 689-92. Soveri V. Der Verlauf der Luft durch den Verdaungskanal des Sauglings. Acta Paediatr Ups 1939; 23: 1-9. Gerber A, Rogers FA, Smith LL. The treatment of paralytic ileus without use ofgastrointestinalsuction.Surg Gynecol Obstet 1958; 107: 247-50.
Reasbeck PG, Rice ML, Herbison GP. Nasogastric intubation after intestinal resection.Surg Gynecol Obstet 1984; 158: 354-8. Jambor CR, Steedman DJ. Acute gastric dilatation after trauma. J R Coil Surg Edinb 1991; 36: 29-31.
21.
Murray WJ. Massive gastric distension in acute pancreatitis - a report of two cases. Postgrad Med J 1984; 60: 631-3. Nathan BN, Pain JA. Nasogastric suction after elective abdominal surgery: a randomised study. Ann R Coil Surg Engl 1991; 73: 291-4.
22.
Bauer JJ, Gerlernt IM, Salky BA, Kreel I. Is routine postoperative nasogastric decompression really necessary? Ann Surg 1985; 201: 233-6.
23. 24.
Dorairajan N, Kannan K, Venkataraman MS. No tube regimen in gastric surgery. J Postgrad Med 1985; 31: 102-4. Argot S, Goldstein I, Barzilai A. Is routine use of the nasogastric tube justified in upper abdominal surgery? Am J Surg 1980; 139: 849-50.
There are few prospective studies in the literature regarding routine nasogastric intubation in elective abdominal surgery. The use of tubes has been based on anecdotal evidence and the teachings of our forebears: surgeons as pre-eminent as W. J . Mayo and A. J. Ochsner have suggested that a nasogastric tube rather than a stethoscope should be carried around the neck of a resident. However, in contrast to the use of nasogastric tubes in acute conditions, their continued use in elective abdominal surgery is no longer justified. It is safe to omit intubation as long as oral fluids are restricted until flatus has been passed3’. A small proportion of patients will subsequently require intubation on the basis ofclinical signs such as persistent vomiting or abdominal distension. No harm should come to patients if they are allowed to select themselves, rather than be at the receiving end of a blanket policy.
27.
1989; 209: 670-5. 28.
1.
2.
Palmer JF. Complete Works of John Hunter. Philadelphia: Haswell. Barrington, Haswell, 1935: 622. Munro A. De Dysphagia Disp. Edinburgh: A Neil1 et Socii, 1797:
30. 31.
33.
Tinckler L. Nasogastric tube management. Br J Surg 1972; 59: 637-41.
1130
Olesen KL, Birch M, Bardam L, Burcharth F. Value of nasogastric tube after colorectal surgery. Acta Chir Scand 1984; 150: 251-3. Meltvedt R, Knecht B, Gibbons G, Stahler C, Stojowski A, Johansen K. Is nasogastric suction necessary after elective colon surgery? Am J Surg 1985; 149: 620-2. Ibrahim AA, Abrego D, Issiah IA, Smith DW. Is postoperative
proximal decompression a necessary complement to elective colon resection? South Med J 1977; 70: 1070-1. Burg R, Geigle CF, Faso JM, Theuerkauf FJ. Omission of routine gastric decompression. Dis Colon Rectum 1978; 21: 98-100. Cheadle WG, Vitale GC, Mackie CR, Cuschieri A. Prophylactic postoperative nasogastric decompression. Ann Surg 1985; 202: 361-6.
34.
1.
3.
Racette DL, Chang FC, Trekell ME, Farha GJ. Is nasogastric intubation necessary in colon operations? Am J Surg 1987; 154: 640-2.
29.
32.
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Hendry WG. Tubeless gastric surgery. B M J 1962; i: 1736-7. Miller DF, Mason JR, McArthur J, Gordon I. A randomised prospective trial comparing three established methods of gastric decompression. Br J Surg 1972; 59: 605-8. Wolff BG, Pemberton JH, van Heerden JA et al. Elective colon and rectal surgery without nasogastric decompression.Ann Surg
Colvin DB, Lee W, Eisenstat TE, Rubin RJ, Salvati EP. The role of nasointestinal intubation in elective colonic surgery. Dis Colon Rectum 1986; 29: 295-9.
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gastrostomy in infants and children: 15 year review of 240 cases. Ann Surg 1966; 164: 284-90. Senter KL. Complications of temporary tube gastrostomy. Arch Surg 1960; 81: 103-6. Grant GN, Elliott DW, Frederick PL. Postoperative decompression by temporary gastrostomy or nasogastric tube. Arch Surg 1962; 85: 844-51. Murcroft TJ, Youngs DJ, Burdon DW, Keighley MRB. Cimetidine and the risk of postoperative sepsis. Br J Surg 1981; 68: 557-9. Mehnert JH, Brown MJ, Woodward B, Paetkeu E, Donovan PB. A clinical evaluation of postoperative gastric suction. Surg Gynecol Obstet 1959; 109: 607-12. Schenkler JD, Charles A. The pathogenesis of postoperative atelectasis. Arch Surg 1973; 107: 846. Desmond P, Raman R, Idikula J. Effect of nasogastric tubes on the nose and maxillary sinus. Crit Care Med 1991; 19: 509-11. Sofferman RA, Haisch CE, Kirchner JA, Hardin NJ. The nasogastric tube syndrome. Laryngoscope 1990; 100: 962-8. Nagler R, Spiro HM. Persistent gastroesophageal reflux induced during prolonged gastric intubation. N Engl J Med 1963; 269: 495-500. Marrie TJ, Sung JY, Costerton JW. Bacterial biofilm formation on nasogastric tubes. J Gastroenterol Hepatol 1990; 5 : 503-6. Dasani B, Sahdev P. Knotting ofa nasogastric tube: a case report. Am J Emerg Med 1991; 9: 565. Hande A, Nagpal R. Intracranial malposition of nasogastric tube following transnasal transsphenoidal operation. Br J Neurosurg 1991; 5 : 205-7. Violaris NS. A nasogastric tube in the sphenoid sinus. BMJ 1987; 295: 1653. Wood G , Milne B, Spjeda V, Lewis J. Ventilatory failure due to
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an improperly placed nasogastric tube. Can J Anaesth 1990; 37: 587-8. Hecker RB, Harris S, Robert J, Otchy D. Intra-abdominal palpation of a nasogastric tube in the stomach does not assure appropriate placement. Sourh Med J 1990; 83: 1223-5. Urschel JD, Stockburger HJ. Endoscopic extraction of an entrapped nasogastric tube. A m Surg 1990; 56: 730-2. Duke GJ, Harding J. Pneumothorax from a nasogastric tube. Anaestlz Intensive Care 1990; 18: 265 (Letter). Lewandrowski KB, Southern JF, Medeiros LJ, Jacobs M. Aortoesophageal fistula arising as a complication of prolonged nasogastric placement. Hum Pathol 1989; 20: 709-1 1. Patow CA, Pruet CW, Fetter TW, Rosenberg SA. Nasogastric tube perforation of the nasopharynx. South Med J 1985; 78: 1362-5. Brewer ED. Growth of small children managed with chronic peritoneal dialysis and nasogastric tube feedings: 203 month experience in 14 patients. Ado Perit Dial 1990; 6: 269-72. Warady BA, Kriley M, Belden B, Hellerstein S, Alan U. Nutritional and behavioural aspects of nasogastric tube feeding in infants receiving chronic peritoneal dialysis. Adu Perit Dial 1990; 6 : 265-8. Lowry PA, Semenkovich JW, Scott LD, Zeck OF, Desai A, Lavis VR. Administration of 13’1 capsule via nasogastric tube in an uncooperative patient with Graves’ disease. AJR Am J Roentgen01 1990; 155: 611-12. Gimmon Z. Advantageous use of Salem sump nasogastric tube for intraoperative decompression of distended intestine. Surg Gynecol Obstef 1985; 161: 69-70.
Paper accepted 1 June 1992
1131
P. M. Sagar, G. Kruegener and J. MacFie Department of Surgery, Scarborough Hospital, Scalb y Road, Scarborough. North Yorkshire YO12 60L,UK Correspondence to: Mr J. MacFie
Nasogastric intubation and elective abdominal surgery The use of nasogastric tubes after elective abdominal surgery remains standard practice f o r many surgeons. Such tubes, however, cause much discomfort and are associated with signijicant morbidity. This paper reviews the argumentsfor and against nasogastric intubation, a n d j n d s little evidence to support its continued routine use.
Nasogastric intubation is used routinely by many surgeons after both elective and emergency abdominal surgery, for gastric decompression to prevent acute gastric dilatation and to treat ileus, to monitor upper gastrointestinal haemorrhage, to act as a guide to starting oral feeding, and to reduce tension on suture lines, thereby reducing the risk of anastomotic dehiscence. However, the use of nasogastric decompression may result in some morbidity. Respiratory complications, gastro-oesophageal reflux, fluid and electrolyte losses, injury to the vocal folds and, not least, discomfort to the patient are all well recognized problems. Some of these complications may even promote continued ileus. The potential advantages of nasogastric intubation must be weighed against the potential disadvantages in each case. In this paper the rationale for nasogastric decompression is reviewed and the value of nasogastric tubes in elective abdominal surgery reappraised.
History John Hunter is widely credited with the earliest use of nasogastric tubes. In 1790 he used eel skin stretched over whalebone to act as an enteral feeding tube in a patient with bulbar palsy who was unable to swallow'. However, 7 years later Alexander Munro claimed that 30 years previously his father had used a flexible tube of coiled wire covered with leather to effect decompression in cattle with excessive fermentation'. Such a tube was advocated by Philip Physick in 1800 to wash out the stomach of poisoned patients3. Decompression of the stomach with a nasogastric tube was described in 1884 by Kussmau14. Westerman in 1910advocated the use of siphon drainage when paralytic ileus had developed secondary to peritonitis5. Matas6 in 1924 and Meyer7 4 years later both used gastric tubes for aspiration and fluid administration. After Levin's description in 1921 of his design of nasogastric tube', Wangensteeng popularized the concept with a series ofexperiments on its use in small bowel obstruction reported in 1932. Partly because of the ease with which nasogastric tubes can be passed, compared with the construction of a gastrostomy which was a common practice at the time", and partly because of the esteem in which Wangensteen was held, nasogastric suction was used thereafter in almost all patients undergoing abdominal surgery. Many surgeons throughout the world continue to employ routine intestinal decompression after resection and primary anastomosis of the gastrointestinal tract' '. However, timehonoured surgical practices developed many decades ago are not necessarily appropriate today. Preparation of patients before operation, improved anaesthetic agents and techniques, awareness of the electrolytic and metabolic consequences of surgery, control of infection, and improved nursing care have all contributed to altering the nature of the postoperative period such that nasogastric tubes might now be reserved solely for a few specific indications.
ooO7-1323/92/111127-05
0 1992 Butterworth-Heinernann Ltd
Rationale for intestinal decompression Paralytic ileus Ileus is familiar to all surgeons: after abdominal operation there is a reduction in propulsive activity in the gastrointestinal tract; bowel sounds are diminished and abdominal distension with nausea and vomiting may occur. The condition may predispose to respiratory complications, wound dehiscence and anastomotic leakage. Previously considered to affect the entire gastrointestinal tract, it is now recognized that peristaltic activity is maintained in the small intestine and that diminished motility occurs to a significant degree only in the stomach and colon. In experimental animal models, activity of the small intestine returns to normal within a few hours; early return of motility has been shown in humans by means of radiotelemetry capsule^^^'^^'^. There is therefore no substantial period of paralysis of the small intestine after operation. Studies of the stomach have confirmed a period of paralysis that lasts 24-72 h according to the type of Colonic motility is also reduced for variable periods after abdominal surgery, and the sigmoid and rectum seem to recover last * '. The mechanism by which paralytic ileus occurs is unclear. Studies in animals have suggested that it is a consequence of sympathetic inhibition mediated by spinal reflexes, which are initiated by manipulation of the bowel during operation. The length of operation and degree of insult t o the bowel have long been held to be proportional to the duration of any subsequent paralytic ileus. However, recent studies suggest that these assumptions may be incorrect: in an investigation into postoperative bowel motility in humans, no relationship was found between duration of operation and severity of ileus15. It has been proposed that the afferent side of the reflex which initiates paralytic ileus originates in the parietal peritoneum rather than from afferent nerves in the gut or visceral peritoneum: this would explain prolonged paralytic ileus after retropubic prostatectomy or retroperitoneal trauma. It would also account for the absence of significant ileus after laparoscopic procedures. If confirmed, this concept would render nasogastric intubation after major excisional surgery illogical - at least on the basis of ileus prophylaxis. The intestinal tract may secrete up to 8.5 litres fluid every 24 h. The use of nasogastric tubes is not associated with the removal of a significant proportion of this volume. Therefore, the majority of these secretions must continue to be reabsorbed in the small intestine, even in the early period after operation. In the presence of an intact pyloric sphincter, a nasogastric tube is unlikely to decompress more than the stomach alone. The value of nasogastric intubation in preventing abdominal distension must consequently be related to removal of swallowed air. Significant amounts of air enter the gastrointestinal tract only with d e g l ~ t i t i o n ' ~ , ' and so gaseous distension should be most easily prevented by reduction of oral intake in the early postoperative period. Indeed, nasogastric intubation may itself promote aerophagia".
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Table 1 Studies on the tialue of nasogastric intubation after abdominal surgery
Upper, lower or mixed abdominal surgery
No. of
Reference
Year
patients
Type of study
Nathan and Painz1 Bauer et Dorairajan et
1991 1985 1985
197 200 20 1
Mixed elective Mixed
Argov et al.24
1980
300
Hendry”
1962
232
Miller et
1972
132
Prospective randomized Prospective randomized 198 patients with tube, three without 150 consecutive patients without tube, 150 consecutive patients with 114 Billroth I gastrectomy without tube, 118 vagotomy and pyloroplasty with Prospective randomized
Wolff et
Reasbeck et Racette er al.2s
1989 1984 1987
535 97 56
Prospective randomized Prospective randomized Prospective randomized
Lower Mixed Lower
Olesen et
1984
97
Prospective randomized
Lower
Meltvedt et a1.30
1985
118
Lower
Ibrahim et ~ 1 . ~ ’
1977
76
Lower
No difference in complications
Burg et
1978
137
Lower
No difference in complications
Cheadle et
1985
200
Retrospective non-randomized 53 consecutive patients with tube, 23 consecutive patients without Retrospective non-randomized Prospective randomized
Significantly fewer respiratory complications in ‘no tube’ group No difference in complications No difference in complications Significantly more abdominal distension without tube, but significantly more atelectasis with Flatus passed earlier without tube No difference in complications No difference in complications
Mixed
Colvin et af.34
1986
138
Prospective randomized
Increased time to flatus, length of stay and sore throat with tube but less vomiting No difference in complications
Acute gastric dilararion Acute gastric dilatation has long been considered a reason for routine use of a prophylactic nasogastric tube. The condition is common in patients after significant trauma; the reported incidence is 9 per cent”. In such patients, acute gastric dilatation may be complicated by gastric haemorrhage, pulmonary aspiration and prolonged ileus. Dilatation may also occur after an episode of acute pancreatitis, although much less commonly2’. However, acute gastric dilatation is very uncommon after elective abdominal surgery; of the 2716 patients described in Table 1 , none developed this condition.
Gastrostomy as an alternative Gastric decompression, via a nasogastric or gastrostomy tube, remains a useful procedure. Decompression of the acutely dilated stomach, conservative management of small bowel obstruction in the early stages, conservative treatment of a perforated peptic ulcer with localized minimal contamination, and management of upper gastrointestinal haemorrhage to assess rebleeding may all call for nasogastric intubation. Gastrostomy may be associated with fewer minor problems but major complications, including death, have been recorded in up to 6 per cent of patient^^'.^^. Gastrostomy also has problems related to removal of the tube and to its replacement if dislodged. Percutaneous endoscopic gastrostomy has, however, simplified the procedure. Gastrostomy is a good alternative to a nasogastric tube for patients at the extremes of life, in whom complications are more common with the latter. Chest infections are more frequent in patients over 60 years of age when nasogastric intubation is employed3’. Excessive salivation with subsequent aspiration pneumonitis is likely to occur with nasogastric tubes in the elderly and in young children.
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Upper
Comments (tube wrsus no tube) Increased sore throat and nausea with tube No difference in complications No difference in complications 15.0%pneumonia with tube, 1.5% without
No difference in complications
Upper
Lower
Gastrostomy has the advantages that it avoids nasopharyngeal pressure and irritation, the cardia is not compromised and patients find it more comfortable. It does, however, carry small risks of fistulation, peritonitis, haemorrhage from the gastrostomy wound, and wound infection if the tube is sited too close to a Iaparotomy incision26. It also represents an additional operation. A prospective trial examining 132 patients, who underwent truncal vagotomy and drainage and who were randomized to receive a nasogastric or gastrostomy tube or no tube at all, demonstrated a significantly greater risk ( P < 0.05) of wound infection in those with a gastrostomy than in either of the other two groups. Avoiding either type of tube resulted in a significant reduction ( P < 0.05) in the incidence of respiratory infection and was much preferred by the patients 2 6 . Tube management Nasogastric tubes may be left to drain freely, spigoted and aspirated at intermittent intervals, or a combination of free drainage and aspiration may be employed. Intermittent aspiration has the benefit that patency of the tube is tested regularly; the tube may be flushed if blocked or repositioned if displaced. If the tube is left spigoted, the chance of allowing escape of gas and decompression of the upper gastrointestinal tract is lost3. A drainage bag allows collection of large volumes of gas as well as fluid.
Clinical studies Upper gastroinrestinal surgerjt A retrospective study of 300 patients who underwent emergency or elective operations on the upper gastrointestinal tract, in
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Nasogastric tubes and abdominal surgery: P. M. Sagar et al.
which the first 150 received nasogastric intubation and the second 150 did not, demonstrated a tenfold increased risk of pneumonia (15.0 ciersus 1.5 per cent) in the former groupz4. Routine avoidance of nasogastric intubation in a series of 201 patients undergoing gastric drainage procedures alone, or with various forms of vagotomy, resulted in only three ( 1.5 per cent) subsequently needing a nasogastric tube because of abdominal distension and vomiting; the incidence of severe respiratory infection was only 1 per cent”. Low rates of gastric intubation had been reported previously, with an incidence of 3.4 per cent in 118 patients following vagotomy and pyloroplasty and none in 114 after Billroth I gastrectomy2’. Thus it would appear that a nasogastric tube is rarely required even after truncal vagotomy, a procedure that denervates the upper gastrointestinal tract. Furthermore, most practitioners of highly selective vagotomy do not use a nasogastric tube after operation (D. Johnston, personal communication). The influence of H,-receptor antagonists such as cimetidine on nasogastric intubation is interesting. Although a nasogastric tube is associated with a significant increase in the length of time to passage of flatus, bowel action and cessation of intravenous fluids, as well as a significantly greater incidence of postoperative discomfort, cimetidine has not been shown to reduce these p r ~ b i e m sThe ~ ~ .drug does, however, significantly increase the incidence of pneumonia, perhaps by an influence on gastric flora since bacterial overgrowth has been shown3’ to occur at pH > 4. The patient fasting after operation swallows about 2 litres recoverable air each day and about 600 ml salivary secretions accumulate in the stomach39. The fluid is accommodated without difficulty. The volume of air swallowed increases as fluid intake increases and, as long as the latter is restricted, the upper gastrointestinal tract should not be compromised by excessive gaseous intake. There is, therefore, no reason to drain this region. Apprehensive patients tend to be more aerophagic and so more at risk of nausea, vomiting and abdominal distension; some may require nasogastric decompression.
Lower grrstrointcs~inalsurgery The need for a nasogastric tube after elective colorectal surgery is even less convincing than in upper gastrointestinal operations. In a prospective randomized trial of 200 patients who underwent predominantly lower gastrointestinal operations with or without routine nasogastric aspiration”, no differences were observed in the frequency of complications between the two groups; there were no instances of aspiration pneumonia, anastomotic leakage or wound dehiscence. The rate at which the tube had to be inserted or reinserted was 6 per cent in the ‘no-tube’ group compared with 5 per cent in the ‘tube’ group. A retrospective non-randomized study or a consecutive series of 76 patients undergoing colorectal operations ( 5 3 with decompression, 23 without) also demonstrated no significant difference in postoperative morbidity rate and length of hospital stay after operation3’. A similar retrospective study of 1 18 patients showed not only no difference in mortality and morbidity rates and length of stay, but also that the tube did not reduce the degree of abdominal distension or hasten the time to recommencement of oral fluids or first bowel action”. Smaller prospective randomized studies have largely confirmed these results. In particular. nasogastric intubation is associated with increased risk of chest infection”. later passage offlatusZ9and an incidence of reintubation similar to that needed when an initial policy of non-aspiration is followed. The largest reported prospective randomized trial. from the Mayo Clinic, involved I391 patients who underwent eleclive colorectal operations”. A total of 535 patients were considered eligible for entry: 274 received nasogastric decompression and 261 did not. Abdominal distension, nausea and vomiting were significantly more common in patients with no tube ( P < 0.05) and the frequency of subsequent nasogastric decompression was 13 per cent compared with a frequency of reinsertion of
Br. J. Surg.. Vol. 79, No. 11, November 1992
5 per cent in those undergoing routine decompression ( P < 0.05). The incidence of major complications and length
of stay after operation were similar. The authors concluded that, despite the increased rate of minor complications. most patients do not require nasogastric intubation after colorectal surgery and that tube insertion should not be used as a routine procedure. There are no guidelines to predict which patients will require nasogastric decompression. It is possible that those with extensive adhesions, several previous operations or intraabdominal sepsis (who are often excluded from trials) are at increased risk, but this requires further study. The Mayo Clinic group” empirically recommended use of nasogastric decompression in patients with multiple (four or more) serosal tears, gross peritoneal contamination, intra-abdominal sepsis, extensive fibrotic adhesions or operating time > 6 h. They also suggested that nasogastric decompression was useful during operation to deflate the stomach if access was difficult, particularly if GoLytely solution (Seward Medical, London, U K ) had been used in preoperative cleansing of the bowel. This technique induces excess gas and fluid, which tend to accumulate in the stomach and duodenum and so be present at the start of the operation. Passage of long intestinal tubes on the day before surgery does not increase the extent of intestinal decompression, as assessed at operation, in terms of ease of packing of the small bowel. However, it may reduce pulmonary atelectasis. perhaps because of reduced abdominal distension after operation3”. No benefit from long tubes has been shown in terms of morbidity after operation.
Complications Nasogastric intubation is used at the cost of increased postoperative morbidity. The incidence of respiratory complications, such as atelectasis and pneumonia. is increased by tenfold in some series’“. Nasogastric tubes inhibit effective coughing, allow mucus plugs to accumulate and hence atelectasis and localized pneumonia to d e ~ e l o p “ ~The . likelihood of pneumonia associated with the use of nasogastric decompression increases with the age of the p t i e n t and duration of intubation. Nasogastric tubes are also unpleasant for the patient: most remember the uncomfortable sensation of ‘the tube in my throat’ long after they have forgotten other aspects of their operation. The vast majority of patients are unhappy with a nasogastric tube despite the use of mouth washes. nasal or pharyngeal sprays, lip swabs, ice cubes or changing the tube from one nostril to the other. A nasogastric tube may induce vomiting and is associated with nasopharyngeal soreness, otitis or sinusitis. As many as 50 per cent of patients undergoing nasogastric intubation develop radiological evidence of maxillary sinus inflammation and 75 per cent clinical evidence of rhinitis4I. A nasogastric tube may cause sudden lifethreatening bilateral vocal fold paralysis, possibly as a result of paresis of the posterior cricoarytenoid muscles, secondary to infection and ulceration over the posterior lamina of the cricoid. Diabetics who have undergone renal transplantation are particularly at risk4’. Intubation of the gastric cardia facilitates gastric reflux. It maintains acid in the lower oesophagus as long as there is sufficient gastric acid available to reflux (equivalent to 300 ml 0.1 mol/l HCI), the patient is supine, and the tube is actually in the stomach and not coiled up in the oesophagus‘.’. The mechanism of this reflux remains uncertain but interference with intrinsic sphincteric function, failure of the sphincter to close around the nasogastric tube. and the effects of posture in the recumbent patient all contribute. The tube renders the gastro-oesophageal sphincter incompetent and acts as a wick to encourage migration of gastric acid into the lower oesophagus, causing oesophagitis and even eventual stricture, The surface of the tube becomes covered with a thick amorphous biofilm consisting of microcolonies of bacteria within a matrix of exopolysaccharide glycocalyx. Although this
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Nasogastric tubes and abdominal surgery: P. M. Sagar et al.
matrix contains many dead and dying cells, many of the microcolonies are intact and the presence of yeast cells helps attachment to the tube. Such colonization occurs44 after the tube has been in place for only 1 day. The tube may become knotted45, making its removal difficult, dangerous or impossible. It may be incorrectly positioned even to the extent of an intracranial location46, placement in the sphenoidal sinus47 or trachea, despite the presence of an endotracheal tube. Suction connected to such a tube will evacuate gas from the lungs and prevent effective ventilation4’. The only sure test of correct placement of a nasogastric tube is the aspiration of gastric content. A tube may perforate the cervical oesophagus at the time of introduction, traverse the mediastinum and come to lie in the lesser sac49. Palpation of the tip of the tube by the surgeon at operation may give the mistaken impression that it is positioned in the stomach, but this can be confirmed only by positive gastric aspiration. The tube may become entrapped in a stapled gastrointestinal anastomosis; this preventable and infrequent complication can be managed successfully by endoscopic extraction5’. Finally, pneumothorax”, aorto-oesophageal fistula” and perforation of the n a ~ o p h a r y n x have ~ ~ all been reported as complications associated with nasogastric intubation.
4.
Kussmaul CA. Heilung von Ileus durch Magenausspulung.Berlin
5.
Westerman CWJ. Uber die Anwendung des Dauermagenhebers bei der Nachbehandlung schwerer Peritonitisfaln. Zentralbl Chir
6
Matas R. The continued intravenous ‘drip’. Ann Surg 1924; 79:
Hit? W O C ~ C W1884; S C ~ ~21: 669-85.
1910; 37: 356-7. 643-61. 7. 8.
Meyer W. Gastric intubation. Med J Rec 1928; 123: 304. Levin AI. A new gastroduodenal catheter. JAMA 1921; 76:
9.
Wangensteen OH. The early diagnosis of acute intestinal obstruction with comments on pathology and treatment: with a report of successful decompression of three cases of mechanical bowel obstruction by nasal catheter suction siphonage. Wesr J
10.
Schmidt ER. Forty-four cases of simple perforation of gastric and duodenal ulcers, with a simple method of surgical treatment.
1007-9.
Surg Obstet Gynecol 1932; 40: 1-17.
11.
12. 13. 14.
Other indications
15.
Nasogastric tubes have uses other than those already discussed. Recent evidence has highlighted the importance of maintaining the gut barrier to prevent translocation of bacteria. Enteral, as opposed to parenteral, feeding maintains this barrier function in the critically ill patient and fine-bore nasogastric tubes facilitate enteral nutrition in those unable to feed themselves adequately. Similarly, fine-bore nasogastric feeding of infants and small children on chronic ambulatory peritoneal dialysis awaiting renal transplantation will maintain or improve g r o ~ t h ~A ~nasogastric . ~ ~ . tube can permit oral administration of 1 3 ’ 1 and other medications to uncooperative patients. A probe can be incorporated into the tip of a nasogastric tube to monitor intragastric pH to permit titration against H, antagonists. This is particularly useful for patients in intensive therapy units who are at increased risk of haemorrhage from stress ulcerations6. A Salem sump nasogastric tube allows decompression of the distended small intestine during operation’ 7 .
16.
20.
Conclusions
25. 26.
17. 18. 19.
Acta Chir Scand 1922; 55: 313-17. Savassi-Rocha PR, Conceicao SA, Ferreira JT el al. Evaluation of the routine use of the nasogastric tube in digestive operation by a prospective controlled study. Surg Gynecol Obstet 1992; 174: 317-20. Valori R. Small intestinal motility. Curr Opin Gastroenteroll991; 7: 220-4. Ross R, Watson BW, Kay AW. Studies on the effect of vagotomy on small intestinal motility using radiotelemetring capsule. Gut 1963; 4 : 77-81.
Rothnie NG, Harper RAK, Catchpole BN. Early postoperative gastrointestinal activity. Lancet 1963; ii: 64-7. Wilson JP. Postoperative motility of the large intestine in man. Gut 1975; 16: 689-92. Soveri V. Der Verlauf der Luft durch den Verdaungskanal des Sauglings. Acta Paediatr Ups 1939; 23: 1-9. Gerber A, Rogers FA, Smith LL. The treatment of paralytic ileus without use ofgastrointestinalsuction.Surg Gynecol Obstet 1958; 107: 247-50.
Reasbeck PG, Rice ML, Herbison GP. Nasogastric intubation after intestinal resection.Surg Gynecol Obstet 1984; 158: 354-8. Jambor CR, Steedman DJ. Acute gastric dilatation after trauma. J R Coil Surg Edinb 1991; 36: 29-31.
21.
Murray WJ. Massive gastric distension in acute pancreatitis - a report of two cases. Postgrad Med J 1984; 60: 631-3. Nathan BN, Pain JA. Nasogastric suction after elective abdominal surgery: a randomised study. Ann R Coil Surg Engl 1991; 73: 291-4.
22.
Bauer JJ, Gerlernt IM, Salky BA, Kreel I. Is routine postoperative nasogastric decompression really necessary? Ann Surg 1985; 201: 233-6.
23. 24.
Dorairajan N, Kannan K, Venkataraman MS. No tube regimen in gastric surgery. J Postgrad Med 1985; 31: 102-4. Argot S, Goldstein I, Barzilai A. Is routine use of the nasogastric tube justified in upper abdominal surgery? Am J Surg 1980; 139: 849-50.
There are few prospective studies in the literature regarding routine nasogastric intubation in elective abdominal surgery. The use of tubes has been based on anecdotal evidence and the teachings of our forebears: surgeons as pre-eminent as W. J . Mayo and A. J. Ochsner have suggested that a nasogastric tube rather than a stethoscope should be carried around the neck of a resident. However, in contrast to the use of nasogastric tubes in acute conditions, their continued use in elective abdominal surgery is no longer justified. It is safe to omit intubation as long as oral fluids are restricted until flatus has been passed3’. A small proportion of patients will subsequently require intubation on the basis ofclinical signs such as persistent vomiting or abdominal distension. No harm should come to patients if they are allowed to select themselves, rather than be at the receiving end of a blanket policy.
27.
1989; 209: 670-5. 28.
1.
2.
Palmer JF. Complete Works of John Hunter. Philadelphia: Haswell. Barrington, Haswell, 1935: 622. Munro A. De Dysphagia Disp. Edinburgh: A Neil1 et Socii, 1797:
30. 31.
33.
Tinckler L. Nasogastric tube management. Br J Surg 1972; 59: 637-41.
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Olesen KL, Birch M, Bardam L, Burcharth F. Value of nasogastric tube after colorectal surgery. Acta Chir Scand 1984; 150: 251-3. Meltvedt R, Knecht B, Gibbons G, Stahler C, Stojowski A, Johansen K. Is nasogastric suction necessary after elective colon surgery? Am J Surg 1985; 149: 620-2. Ibrahim AA, Abrego D, Issiah IA, Smith DW. Is postoperative
proximal decompression a necessary complement to elective colon resection? South Med J 1977; 70: 1070-1. Burg R, Geigle CF, Faso JM, Theuerkauf FJ. Omission of routine gastric decompression. Dis Colon Rectum 1978; 21: 98-100. Cheadle WG, Vitale GC, Mackie CR, Cuschieri A. Prophylactic postoperative nasogastric decompression. Ann Surg 1985; 202: 361-6.
34.
1.
3.
Racette DL, Chang FC, Trekell ME, Farha GJ. Is nasogastric intubation necessary in colon operations? Am J Surg 1987; 154: 640-2.
29.
32.
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Paper accepted 1 June 1992
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