Nasogastric Tube - Yes or No

Rick Nelson

Powerpoint File

For the past 300 years tubes have been inserted into the stomach via the nose or mouth for the purpose of evacuating gas and liquid. The reason to perform such an activity may be either therapeutic, as in patients with distention and vomiting from bowel obstruction, diagnostic, as in the case of gastrointestinal bleeding or peptic ulcer disease, or prophylactic, as in patients having major abdominal surgery.

The prophylactic use of nasogastric tubes after abdominal operations, flexible tubes inserted through the nose, pharynx, oesophagus and into the stomach, has happened only in the last century, becoming so prevalent that it has been variously described up to 2002 as "the standard of care" [1],"traditionally used by most surgeons" [2], "common practice" [3-5], "unquestioned" [6], and "routine" [7]. What is to be achieved by this prophylaxis is gastric decompression, decreased likelihood of nausea and vomitting, decreased distention, less chance of pulmonary aspiration and pneumonia, less chance of wound separation and infection, less chance of fascial dehiscence and hernia, earlier return of bowel function, and earlier hospital discharge. Many studies have been published that assess the efficacy of this intervention. Evidence was gathered and assessed regarding prophylactic nasogastric decompression after abdominal surgery with the following objectives and results[8]:

Objectives

To investigate, in a meta-analysis of published studies, the efficacy of routine nasogastric decompression after abdominal surgery in achieving each of the above goals.

Search strategy

Search terms were “nasogastric, tubes, randomised,” using MEDLINE, EMBASE, Cochrane Controlled Trials Register, and references of included studies.

Selection criteria

Patients having abdominal operations of any type, emergency or elective, who were randomised prior to the completion of the operation to receive a nasogastric tube and keep it in place until intestinal function had returned, versus those receiving early tube removal.

Results

28 studies fulfilled eligibility criteria, encompassing 4194 patients, 2108 randomised to routine tube use, and 2087 randomised to selective or No Tube use. Patients not having routine tube use had an earlier return of bowel function (p<0.00001), a marginal decrease in pulmonary complications (p=0.07) and a marginal increase in risk of wound infection (p=0.08) and ventral hernia (0.09). Anastomotic leak was no different between groups (p=0.70).

Conclusions

Routine nasogastric decompression does not accomplish any of its intended goals and so should be abandoned in favor of selective use of the nasogastric tube.

References

1 Montgomery, R.C., Bar-natan, M.F., Thomas, S.E. & Cheadle, W.G. Postoperative nasogastric decompression; a prospective randomized trial. in Southern Medical J. 1996;89: 1063-1066

2 Lee, J.H., Hyung, W.J. & Noh, S.H. Comparison of gastric cancer surgery th versus without nasogastric decompression. in Yonsei Med J 2002;43: 451-456.

3 Cunningham, J., Temple, W.J., Langevin, J.M. & Kortbeek, J. A prospective randomized trial of routine postoperative nasogastric decompression in patients with bowel anastomosis. in Can J Surg 1992;35: 629-631.

4 Sakamandis, A.K., Ballas, K.D. & Kabaroudis, A.G. Role of nasogastric intubation in major operations: a prospective study. in Med. Sci Res. 1999;27: 789-791.

5 Manning, B.J., Winter, D.C., McGreal, G., Kirwan, W.O. & Redmond, H.P. Nasogastric intubation causes gastroesophagel reflux in patients undergoing elective laparotomy. in Surgery 2001;130: 788-791.6

6 Savassi-Rocha, P.R., Conceicao, S.A., Ferreira, J.T. et al. Evaluation of the routine use of the nasogastric tube in digestive operation by a prospective controlled study. in Surgery, Gynecology & Obstetrics 1992;174: 317-320.

7 Wolff, B.G., Pemberton, J.H., van Heerden, J.A. et al. Elective colon and rectal surgery without nasogastric decompression. in Ann. Surg. 1989;209: 670-673.

8 Nelson RL, Edwards S, Tse B. Prophylactic nasogastric decompression after abdominal operations. Brit J Surg. 2005 Jun;92(6):673-80. Review. PMID: 15912492