Gastric decompression after surgery
Problem: Altered bowel elimination related to postoperative ileus
Study question: Is gastric decompression necessary after surgery?
Prophylactic nasogastric decompression after abdominal surgery
Nelson, R., Edwards, S., & Tse, B. (2007). Cochrane Database of Systematic Reviews, 3, 1-12.
This systematic review was performed to investigate the efficacy of routine nasogastric decompression after abdominal surgery. The time to the return of bowel function, pulmonary complications, incidence of anastomotic leakage, patient comfort, and hospital length of stay were measured. Studies including patients having abdominal surgery of any type, emergent or elective, who were randomized at the completion of the operation to receive a nasogastric tube and keep it in place until intestinal function returned versus those receiving either no tube or early tube removal (within 24 hours of surgery) were included in the analysis. The search terms were entered into three databases with publications from 1966 to 2006 included, and references were reviewed for each publication retrieved. In total, 33 studies fit the review criteria and included 5,240 patients (2,628 randomized to routine tube use and 2,612 randomized to selective or no tube use). Outcomes included time to flatus, pulmonary complications, wound infection, anastomotic leak, length of stay, death, nausea, vomiting, tube reinsertion, and subsequent ventral hernia. Patients without a nasogastric tube had a significantly earlier return of bowel function, a decrease in pulmonary complications, and an insignificant increase in the risk of wound infection and ventral hernia. Anastomotic leak was not significantly different between treatment groups. There was a reduced incidence of vomiting among those treated with a routine nasogastric tube but with increased levels of patient discomfort. Length of stay was reduced without the tube. No adverse events of tube insertion were reported.
The authors concluded that nasogastric decompression does not accomplish most of the intended goals of therapy, thus they recommended selective use of the nasogastric tube. For patients undergoing abdominal surgery, the outcomes were no better, and in some instances worse, than with gastric decompression. Future research is suggested to identify the patients and/or specific surgeries that have better outcomes with nasogastric decompression.
Systematic review of prophylactic nasogastric decompression after abdominal operations
Nelson, R., Tse, B., & Edwards, S. (2005). British Journal of Surgery, 92, 673-680.
This systematic review was undertaken to examine the effectiveness of nasogastric decompression after abdominal surgery. Effectiveness was measured by comparing the time to return of bowel function, rate of pulmonary complications, anastomotic leakage, patient comfort, and hospital stay among patients who received a nasogastric tube that was kept in place until intestinal function returned (routine use) and those who were selectively administered a nasogastric tube and had it removed early in the course of recovery. For the review, 28 studies fulfilled the eligibility criteria, which included patients with abdominal surgery of any type, emergent or elective. Overall, the 28 studies included 4,194 patients, with 2,108 randomized to routine gastric decompression and 2,087 randomized to selective or no tube. Analysis of the data demonstrated that those who did not have a nasogastric tube routinely inserted had a significantly earlier return of bowel function, a marginal decrease in pulmonary complications, and a marginal increase in wound infection and ventral hernia. The rate of anastomotic leakage was similar between the two groups. Due to the presentation of data between studies, the systematic review did not reveal data concerning length of stay between groups.
The authors concluded that nasogastric decompression does not accomplish any of its intended goals and should only be used selectively in those at high risk for postoperative ileus or with symptoms of gastric distention. For this review, the authors used a large amount of data from patients with various types of abdominal surgery. Considering this, the study provides compelling data that should make clinicians reconsider the routine use of nasogastric decompression after abdominal surgery. With patient comfort of primary importance, nasogastric decompression should be used selectively as a prophylactic intervention.
Nasogastric intubation after abdominal surgery: A meta-analysis of recent literature
Vermeulen, H., Storm-Versloot, M., Busch, O., & Ubbink, D. (2006). Archives of Surgery, 141(3), 307-314.
A meta-analysis was conducted to determine whether or not the same therapeutic outcomes were achieved among patients after abdominal surgery who did not receive nasogastric intubation and those who did. Randomized trials published between January 1990 and January 2005 were searched that reported outcome criteria, such as hospital stay, gastrointestinal function, and postoperative complications; 17 fit the study criteria. Data from the trials were analyzed collectively. The meta-analysis found that nasogastric intubation did not provide clinically relevant benefits for patients after abdominal surgery, such as faster recovery of gastrointestinal function or reduction in postoperative complications. Those with nasogastric intubation experienced discomfort and a later return to a liquid or a regular diet. Hospital length of stay was not shortened by nasogastric intubation.
The authors recommended avoiding the routine use of nasogastric intubation after abdominal surgery, as it does not improve outcomes and is uncomfortable. In addition, it does not consistently fulfill the goals of therapy, such as quicker recovery of gastrointestinal function, reducing postoperative complications, or shortening hospital length of stay. Selective use of nasogastric intubation for decompression should be reserved for those who have symptoms of abdominal distention or postoperative ileus.
Continuous gastric decompression for postoperative nausea and vomiting after coronary revascularization surgery
Burlacu, C. L., Healy, D., Buggy, D. J., Twomey, C., Veerasingam, D., Tierney, A., et al. (2005). Anesthesia and Analgesia, 100, 321-326.
A prospective, randomized, cohort study of 104 patients undergoing coronary revascularization surgery was conducted to determine whether or not gastric decompression during surgery until the time of extubation reduces the incidence of nausea and vomiting postoperatively. Patients with at least two Apfelī's risk factors for postoperative nausea and vomiting were assigned to receive a gastric tube on free gravity drainage after induction of anesthesia (52 patients) or to a control group (52 patients). The study findings indicated that postoperative nausea and vomiting were not significantly reduced with gastric decompression. The incidence of vomiting was 13.4% in patients with gastric decompression and 11.5% in the control group. Nausea, measured on a visual analog scale, was 32.7% with gastric decompression and 25% in the control group. Antiemetic administration was not statistically significant between groups and the use of opioids postoperatively was similar between the groups. Participants were followed for 48 hours postoperatively or until discharge from the intensive care unit.
The authors concluded that gastric decompression during coronary revascularization surgery until the time of endotracheal extubation does not reduce the incidence or severity of nausea and vomiting postoperatively. This well-designed and well-conducted study strengthens the case for using gastric decompression selectively for therapeutic use. Despite avoidance of prophylactic antiemetics in this study, the overall incidence of nausea and vomiting was low compared with findings of past research. The authors noted that pro-emetic anesthetic drugs such as nitrous oxide, neostigmine, and etomidate were avoided and that hemodynamic characteristics were carefully controlled to maintain normal organ perfusion pressure. Those who had tracheal extubation earlier (before 12 hours postoperatively) were less likely to experience nausea and vomiting. Gastric decompression did not alter this finding. It is suggested that the use of these measures could provide better control of postoperative nausea and vomiting than gastric decompression does.
Gastric decompression and enteral feeding through double-lumen gastrojejunostomy tube improves outcomes after pancreaticoduodenectomy
Mack, L. A., Kaklamanos, I. G., Livingstone, A. S., Levi, J. U., Robinson, C., Sleeman, D., et al. (2004). Annals of Surgery, 240(5), 845-851.
This study was conducted to assess the feasibility and safety of inserting a double-lumen gastrojejunostomy tube after pancreaticoduodenectomy and to evaluate postoperative outcomes. A randomized clinical trial was conducted among 36 patients with a periampullary tumor to receive the gastrojejunostomy tube (20 patients) or routine care by the operating surgeon (18 patients, control group). The experimental group received enteral feedings 24 to 48 hours after surgery beginning at 20 mL/hour. The infusion rate was increased at 20 mL per day as tolerated until a goal of 25 kcal/kg/day was achieved. Control participants received a nasogastric tube for decompression. Nutritional support was administered and the route determined by the surgeonī's routine practice. All patients were followed for at least 90 days postoperatively to monitor for complications. The two groups were similar in age and gender distribution, presence of jaundice and weight loss, and comorbidities. Prolonged gastroparesis occurred in 25% of control participants and in none of the patients with the gastrojejunostomy tube therapy. Complication rates were similar between groups. Mean postoperative length of stay was significantly longer and hospital costs significantly higher in controls compared with patients who received the gastrojejunostomy tube.
This study found that, for patients undergoing pancreaticoduodenectomy, the insertion of a gastrojejunostomy tube is safe and effective in improving outcomes. The use of the gastrojejunostomy tube was associated with a reduced length of stay and lower hospital costs. Since weight loss and cachexia are common in this patient population, the use of enteral feedings immediately (24 to 48 hours) following surgery appears to improve outcomes and should be considered. Further research is recommended to delineate the effect of gastric decompression on postoperative outcomes, as there was variability in the duration of gastric decompression within the experimental group. Future research should focus on identifying whether enteral feedings alone or enteral feedings with gastric decompression provide better outcomes for this patient population.
Evidence for early nasogastric tube removal after infrarenal aortic surgery: A randomized trial
Goueffic, Y., Rozec, B., Sonnard, A., Patra, P., & Blanloeil, Y. (2005). Journal of Vascular Surgery, 42(4), 654-659.
In this prospective, randomized controlled trial, the effects of discontinuing the nasogastric tube at the time of endotracheal extubation were evaluated for patients undergoing infrarenal aortic surgery. Of the 40 study participants, 20 had the nasogastric tube until the passage of flatus (control group) and 20 had the nasogastric tube removed at the time of tracheal extubation. The main dependent variable of the study was the development of nausea and vomiting. Preoperative and intraoperative data were similar in both groups. There was no statistical difference between groups regarding nausea and vomiting. In the control group, the occurrence of respiratory complications was more frequent compared with the early removal group. There was no significant difference in intensive care unit stay, but the hospital stay was shorter among those with early removal of the nasogastric tube. There were no differences in other adverse events.
This small-scale study did not identify a significant effect of early removal of the nasogastric tube on nausea and vomiting in patients undergoing open repair of the infrarenal aorta. However, an increased risk of respiratory complications and a longer hospital stay were found in the group that had the nasogastric tube retained until the time of flatus as compared with the early removal group. A limitation of the study is that it did not measure other outcomes, such as patient discomfort, return to normal diet, or return of bowel function. These findings suggest that early removal of the nasogastric tube after infrarenal aorta repair is not harmful and may be more beneficial than retaining the tube until the time of flatus. Research with a larger sample size would help support decision making related to this issue.
Randomized clinical trial evaluating the need for routine nasogastric decompression after elective hepatic resection
Pessaux, P., Regimbeau, J. M., Dondero, F., Plasse, M., Mantz, J., & Belghiti, J. (2007). British Journal of Surgery, 94(3), 297-303.
The purpose of this randomized controlled trial was to determine if patient outcomes are improved by using nasogastric decompression postoperatively as compared to no tube after hepatic resection. The 100 patients randomized to the control group received nasogastric decompression until the passage of flatus or stool. The experimental group of 100 patients had the nasogastric tube removed at the end of surgery. There were no significant preoperative or intraoperative differences between the control and experimental groups. The results of the study indicated that there were no differences between the two groups in surgical complications, medical morbidity, in-hospital mortality, duration of ileus, or length of hospital stay. Twelve patients randomized to no nasogastric decompression postoperatively required reinsertion of the tube. Previous abdominal surgery had no influence on the need for tube reinsertion. Severe discomfort was reported by 21 patients in the nasogastric decompression group and premature removal of the tube was required for 19. Pneumonia and atelectasis were significantly more common in the nasogastric decompression group.
This study suggests that routine nasogastric decompression after elective hepatectomy does not improve patient outcomes postoperatively. Despite 12% of the patients without nasogastric intubation requiring this therapy as part of their postoperative management, the extreme discomfort and higher risk of pulmonary complications in the routine nasogastric decompression group suggests that it should only be used for patients who need it. This supports the previous research on this topic.
Nasogastric decompression after total gastrectomy
Akbaba, S., Kayaalp, C., & Savkilioglu, M. (2004). Hepatogastroenterology, 51(60), 1881-1885.
Typically, nasogastric decompression is mandatory after total gastrectomy with esophagojejunostomy to protect the esophageal anastomosis. This prospective, randomized controlled trial was conducted to evaluate the outcomes of patients undergoing this procedure who had nasogastric decompression compared with those who did not. A convenience sample of patients undergoing gastrectomy with esophagojejunostomy was recruited to participate in the study. Sixty-six patients undergoing this procedure were randomized to receive nasogastric decompression or no tube. Postoperative complications and symptoms such as vomiting, distention, belching, hiccupping, and dysphagia were similar between groups. However, the nasogastric decompression group had a significantly higher rate of sore throat and nausea and a moderately significant increase in fever and pulmonary complications. Starting oral feedings and hospital stay were not significantly different between groups. These findings suggest that patients undergoing total gastrectomy with esophagojejunostomy do not require nasogastric decompression after surgery and, without it, might even have better outcomes with a lower incidence of fever and pulmonary complications along with improved comfort.
Although this study did not include a large sample, it found that nasogastric decompression after surgery caused a significant increase in sore throat and nausea and a higher incidence of fever and pulmonary complications than in those without the tube. These results correlate with other studies on the topic of nasogastric decompression after surgery and add to the evidence by demonstrating similar results in a patient population who had traditionally been exposed to the routine use of decompression postoperatively. Future research should focus on identifying those at high risk of requiring a nasogastric tube in the postoperative phase and possible preventive measures that can limit the need for decompression.
Early removing gastrointestinal decompression and early oral feeding improve patientsī' rehabilitation after colorectostomy
Zhou, T., Wu, X. T., Zhou, Y. J., Huange, X., Fan, W., & Li, Y. C. (2006). World Journal of Gastroenterology, 12(15), 2459-2463.
This randomized controlled trial was conducted to evaluate the safety and tolerance of discontinuing nasogastric decompression within 12 to 24 hours postoperatively. A total of 316 patients undergoing surgery for colorectal carcinoma was recruited and randomized; 158 had a nasogastric tube maintained after surgery until the time of the first passage of flatus and 161 had the nasogastric tube removed 12 to 24 hours postoperatively with subsequent oral feedings. Study variables included the time to the first passage of flatus, the time to the first passage of stool, hospital length of stay, and postoperative complications such as anastomotic leakage, acute dilation of the stomach, wound infection and dehiscence, fever, pulmonary infection, and pharyngolaryngitis. The results indicated that the group with early tube removal had a significantly shorter time to the first passage of flatus, the first passage of stool, and length of stay compared with the control group. Other complications, such as anastomotic leakage, acute dilation of the stomach, and wound complications were similar between groups. Fever, pulmonary infection, and pharyngolaryngitis were significantly reduced in the early tube removal group.
This study also supports discontinuing nasogastric decompression early in the course of recovery. However, the design of the study makes it difficult to determine whether it was the early removal of the nasogastric tube or the early oral feedings that produced better results in the experimental group. Future research should focus on whether early removal of the nasogastric tube or early removal and early feedings provide better outcomes for this patient population.
Is retention of a nasogastric tube after esophagectomy a risk factor for postoperative respiratory tract infection?
Sato, T., Takayama, T., So, K., & Murayama, I. (2007). Journal of Infection and Chemotherapy, 13, 109-113.
A retrospective review of 149 patients who underwent esophagectomy with thoracotomy was performed to compare the incidence of postoperative respiratory tract infection in patients who had a nasogastric tube with those who had a gastrostomy for decompression. Two time periods were compared, 1990 to 1997 during which postoperative nasogastric decompression was used routinely and 1998 to 2004 during which gastrostomy for decompression was routinely performed. In the study sample, there were more men than women, with an average age of 60 years for both groups. The groups were equal in their ratio of men and women and by age. The gastrostomy group (67 patients) had a significantly longer operation time and a lower mean hemorrhage volume than the nasogastric tube group (82 patients) had. In the nasogastric decompression group, more patients had anastomosis leakage. Postoperative respiratory tract infection developed significantly more in the nasogastric tube group than in the gastrostomy group. The frequency of respiratory tract infection was 41.5% in the nasogastric tube group (until 1998), which declined to 26.9% after routinely performing gastrostomy for decompression (after 1998).
Based on their findings, the authors concluded that gastrostomy decreases the risk of respiratory tract infection in this population and should be continued as a standard of care. Although this study is retrospective in design, the authors included an assessment of the impact of chemotherapy, radiation, and chemoradiation on patient outcomes; antibiotic use throughout the study period; bacteria detected from each infection site; and complications of surgery on the rate of respiratory tract infection. These co-variates were not shown to affect the association between the high rate of respiratory tract infection and nasogastric decompression. These findings support the use of gastrostomy for decompression in this population to reduce the risk of respiratory tract infection and mortality.
Does routine nasogastric tube placement after an operation for perforated appendicitis make a difference?
St. Peter, S. D., Valusek, P. A., Little, D. C., Snyder, C. L., Holcomb, G. W., & Ostlie, D. J. (2007). Journal of Surgical Research, 143(1), 66-69.
A retrospective analysis of children undergoing appendectomy for appendicitis with perforation was undertaken to evaluate the postoperative outcomes of those with a nasogastric tube compared to those without. Time to first oral feeding, length of hospitalization, and complications were compared between the two groups. Patients with a nasogastric tube maintained postoperatively (105 patients) were compared with those who did not receive a nasogastric tube (54 patients). The mean time to first oral feeding was significantly higher in the nasogastric tube group than in the no-tube group (3.8 days versus 2.2 days). Mean time to full feeding was significantly higher in the nasogastric tube group than in the no-tube group (4.9 days versus 3.3 days). Mean length of hospital stay was significantly higher in the nasogastric tube group compared with the no-tube group (6.0 days versus 5.6 days). These findings indicate that maintaining a nasogastric tube after surgery for appendicitis with perforation does not improve postoperative outcomes.
This retrospective study was novel in looking at the use of nasogastric intubation among children who underwent surgery for appendicitis with perforation. Although the findings indicate that longer-term outcomes were not significantly improved, the study would have been strengthened by reporting symptoms that warrant nasogastric intubation in the immediate postoperative phase, such as abdominal distention, vomiting, and ileus. However, the study supports previous findings that indicate that nasogastric intubation may lengthen the time to oral feeding and lengthen hospitalization.
Nasogastric decompression is not necessary after simultaneous pancreas-kidney transplant
Barth, R. N., Becker, Y. T., Odorico, J. S., & Sollinger, H. W. (2008). Annals of Surgery, 247(2), 350-356.
Most patients undergoing pancreas-kidney transplant have diabetes mellitus. Since diabetes is associated with gastroparesis, these patients routinely receive nasogastric decompression postoperatively. This retrospective review was performed to evaluate the effects of nasogastric decompression or no tube on hospital length of stay and complications after pancreas-kidney transplant. A total of 182 patients who underwent pancreas-kidney transplant between 2002 and 2005 were included in the analysis. Before 2004, patients routinely received a nasogastric tube with decompression for 5 days postoperatively. A diet was initiated 24 hours after tube removal as part of the protocol. In 2004, the surgical team eliminated routine nasogastric tube therapy postoperatively. The authors noted that the drug used for anesthetic induction was also changed during these two time frames. The study results indicate that there were no significant differences in complications or in graft or patient survival between groups. Patients managed without a nasogastric tube had a significantly shorter length of stay compared to those with a nasogastric tube (9.1 days versus 13.8 days). Six patients initially managed without a nasogastric tube required nasogastric intubation during their hospital stay.
The authors concluded that the use of nasogastric decompression for patients undergoing pancreas-kidney transplant does not improve outcomes and warrants an increased length of stay as compared with those without a tube. Although this study was a retrospective analysis, it provided important information concerning the lack of improvement in clinical outcomes when using nasogastric decompression after pancreas-kidney transplant. This therapy has been found in past studies and in different surgical populations to deter progression in the postoperative phase and to lengthen hospital stays. Thus, the findings are consistent with past research. However, the use of a different induction agent may have confounded the results, as past studies have indicated that pro-emetic drugs may cause more gastric symptoms. Even so, this study provides novel information about a patient population with a high rate of gastroparesis. A prospective clinical trial that also measures the degree of gastroparesis in this population may further support decision making in clinical practice.