Prophylactic nasogastric decompression after abdominal surgery: Cochrane systematic review

Abstract

Background

Routine use of nasogastric tubes after abdominal operations is intended to hasten the return of bowel function, prevent pulmonary complications, diminish the risk of anastomotic leakage, increase patient comfort and shorten hospital stay.

Objectives

To investigate the efficacy of routine nasogastric decompression after abdominal surgery in achieving each of the above goals.

Search methods

Search terms were nasogastric, tubes, randomised, using MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (Central) and references of included studies, from 1966 through Sep 2009.

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 either no tube or early tube removal, in surgery, in recovery or within 24 hours of surgery. Excluded will be randomised studies involving laparoscopic abdominal surgery and patient groups having gastric decompression through gastrostomy.

Data collection and analysis

Data were abstracted onto a form that assessed study eligibility, as defined above, quality related to randomizations, allocation concealment, study size and dropouts, interventions, including timing and duration of intubation, outcomes that included time to flatus, pulmonary complications, wound infection, anastomotic leak, length of stay, death, nausea, vomit ting, tube reinsertion, subsequent ventral hernia.

Main results

37 studies fulfilled eligibility criteria, encompassing 5711 patients, 2866 randomised to routine tube use, and 2845 randomised to selective or No Tube use. Patients not having routine tube use had an earlier return of bowel function (p<0.00001), a decrease in pulmonary complications (p=0.09) and an insignificant trend toward increase in risk of wound infection (p=0.39) and ventral hernia (0.09). Anastomotic leak was no different between groups (p=0.70). Vomiting seemed to favour routine tube use, but with increased patient discomfort. Length of stay was shorter when no tube was used but the heterogeneity encountered in these analyses make rigorous conclusion difficult to draw for this outcome. No adverse events specifically related to tube insertion (direct tube trauma) were reported. Other outcomes were reported with insufficient frequency to be informative.

Authors' conclusions

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

Author(s)

Verma Rashmi, Nelson Richard L

Summary

Nasogastric decompression used routinely after abdominal surgery does not speed recovery.

This systematic review of 37 trials showed that routine use of nasogastric tube decompression after abdominal operations, rather than speeding recovery, may slow recovery down and increase the risk of some postoperative complications. On the other hand routine use may decrease the risk of wound infection and subsequent ventral hernia.

Reviewer's Conclusions

Implications for practice

Prophylactic nasogastric decompression following abdominal operations was undertaken with the intent of:
1 Hastening return of bowel function
2 By emptying the stomach, easing respiration and diminishing the risk of aspiration of gastric contents and therefore decreasing the risk of pulmonary complications
3 Increasing patient comfort, by lessening abdominal distension
4 Protect intestinal anastomoses and prevent anastomotic leakage
5 Shortening hospital stay
This review has shown that the intervention is ineffective in achieving any of these goals, and in fact significant benefit may be obtained by avoidance of prolonged intubation and only selective tube insertion when needed to relieve gastric symptoms.
Wound infection (and one of its most common sequellae, incisional hernia (Bucknall 1983; Yahchouchy 2003)) may be more common when routine intubation is avoided. The reasons for this are not clear.
Many surgeons already avoid routine intubation. Those that don't, probably should.

Implications for research

What don't we know? Not much. Routine use of the nasogastric tube for prophylaxis in the post-operative period hase been abandoned in many institutions. The previous update added 5 more studies in a broad range of surgical specialties and none of them supported the routine use of a nasogastric tube. This second update added 4 more studies and none of them have shown any benefit of routine use of nasogastric tube.
In regard to the primary benefits claimed for routine nasogastric decompression in the post operative laparotomy patient, this is an intervention that can, with this amount of data, be rightly abandoned.
The reasons for a possible increase in wound complications without routine nasogastric decompression need to be investigated further:
what specific aspects of intubation diminish these risks and what other measures might achieve the same goals, thus avoiding the adverse consequences of routine intubation.

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