Distal gastrectomy for cancer is one of the most common procedures performed in Japan. In that setting, many studies have been conducted and great experience has been gained. One point evaluated is the use or not use of postoperative nasogastric tube (NGT) decompression. Surgeons classically advocate the use of NGT decompression to prevent gastric dilation, avoid anastomotic leakage, and for intraluminal postoperative bleeding surveillance.
However, and according to past studies, leaving a NGT for several days after distal gastrectomy or pylorus-preserving gastrectomy (PPG) is not necessary. In fact, Yang et al. concluded that anastomotic leak rate was similar with or without a postoperative NGT decompression. Respiratory complications like aspiration pneumonia are linked to NGT. Additionally, complications related to the NGT have been reported, namely: nasal septum necrosis, laryngeal injury, perforation of oesophagus.
Even though, many surgeons in Japan keep using a one-day NGT decompression protocol after distal gastrectomy or PPG, to monitor anastomotic bleeding or prevent vomiting. Is it necessary?
"... Japan and Korea continue to use a 1-day NGT decompression (...) to monitor postoperative anastomotic bleeding or prevent vomiting."
Kimura et al.
Yutaka Kimura et al. from five different surgery departments from Japan, published in 2017 the first prospective trial to compare outcomes between a one-day NGT decompression group and a no-NGT group. They collected a total of 233 oncologic patients submitted to distal gastrectomy or PPG between 2005 and 2009. Two groups were studied: one-day NGT (119 patients) and no-NGT (114 patients). As primary outcomes the authors included postoperative surgery-related and respiratory complications, and set as second outcomes patient complaints.
The only clinical and statistically difference found between the groups was nasopharyngeal discomfort.
Surgery-related and respiratory complications were similar in both groups, with an overall complications rate of 24,3% and 22,8% for NGT group and no-NGT group, respectively (p=0,88). Mean passage of flatus of 3 days and mean oral intake of 5 days for both groups were found. No difference in vomiting was noted (p>0,9999). The only clinical and statistically difference found between the groups was nasopharyngeal discomfort. In NGT group 20% (24/119) patients had nasopharyngeal complains, and in three patients NGT was removed because of discomfort. Surprisingly, a postoperative in-hospital length of stay of 19 days was reported for both groups.
From the data presented by Yutaka Kimura et al. the one-day NGT decompression does not reduce morbidity or mortality. The risk of vomiting is not decreased by the NGT, which will only bring discomfort to the patient. As stated before, one reason for what many surgeons keep using NGT decompression is intraluminal bleeding surveillance. Well, the authors found only one patient who had a 8 ml blood volume drained. Was this helpful? For the authors it was not. NGT was not useful to evaluate the postoperative bleeding.
In several studies, 40% of patients with NGT for a few days complain of nasopharyngeal discomfort. The authors concluded that removing NGT in the morning after surgery was responsible for the lower rate of discomfort found in their study.
"Ultimately, the NGT appeared to offer no benefit to the patient or to the medical staff."
Kimura et al.
The authors concluded that there is no benefit for the patient to use one-day NGT decompression after distal gastrectomy or PPG. Morbidity is not reduced with a NGT. Only a good surgical practice will reduce complications' rate, I think. From these data we will probably have to think about our surgical practice and the use of NGT. However, to avoid its use and promote a fast patient recovery by mean of a enhance recovery program, more doctors and nurses are necessary than the ones available in Portuguese hospitals. But that is another story...
Link to PubMed:
Dr. Carlos Eduardo Costa Almeida
General Surgeon