International Surgery Journal Goudar BV et al. Int Surg J. 2017 Jan;4(1):229-232 http://www.ijsurgery.com pISSN 2349-3305 | eISSN 2349-2902

DOI: http://dx.doi.org/10.18203/2349-2902.isj20164424 Original Research Article Early removal versus conventional removal of nasogastric tube after abdominal surgery: a prospective randomized controlled study

Bhimanagouda Venkanagouda Goudar*, Eshwar B. Kalburgi, Hanumaraddi L. Giraddi, Mohammedgouse Abdulsattar Karikazi

Department of Surgery, S. N. Medical College and HSK, Research Centre, Bagalkot, Karnataka, India

Received: 23 November 2016 Accepted: 05 December 2016

*Correspondence: Dr. Bhimanagouda Venkanagouda Goudar, E-mail: [email protected]

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Post-operative nasogastric decompression was introduced by Levin’s in 1926 and is intended to drain secretions and gas from the upper gastro-intestinal tract, thereby reducing vomiting, abdominal distension, abdominal discomfort, to prevent anastamotic leak and wound dehiscence. Methods: The current study was carried among all patients of abdominal surgeries that were conducted in S.N. Medical College and H.S.K. Hospital and Research Centre, Bagalkot, Karnataka, India. Among the total sample of 100 cases, patients undergoing abdominal surgeries nasogastric output, absence of emesis and no increasing abdominal discomfort were randomized into two groups. Results: In the current study majority of the patients (79%) were in the age group of 21 - 60 years and male to female ratio is 2.3:1. The patients in study group tolerated the first feed earlier as compared to the control group. The mean duration of hospital stay was 8 days for study group and 10.5 days for control group (p=<0.0001). Conclusions: That it is safe to remove nasogastric tube early (within 24 hours) in patients undergoing abdominal surgeries. Early nasogastric tube removal and early oral feeding thus follows the principle of achieving anatomical and physiological continuity heralding early recovery.

Keywords: Early removal, Late removal, Nasogastric tube

INTRODUCTION The loss or reduction of motility is common after abdominal surgery. The period of hypomotility varies Post-operative nasogastric decompression was introduced from few hours to five days, depends on segment of by Levin’s in 1926 and is intended to drain secretions and gastrointestinal tract is involved.4 gas from the upper gastro-intestinal tract, thereby reducing vomiting, abdominal distension, abdominal The purpose of this study is to determine whether early discomfort, to prevent anastomotic leak and wound (less than 24 hours) removal of nasogastric tube is safe dehiscence.1,2 But prolonged nasogastric intubation is and to compared with conventional removal in terms of associated with complications like basal atelectasis due to time of return of bowel sounds, time of passing flatus, poor cough reflex, aspiration pneumonia, nasal septum acceptance of first feed, post-operative complication and necrosis and loss of electrolytes. So now reserved solely hospital stay. for a specific indications.3

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METHODS RESULTS

The current study was carried among all patients of In the current study majority of the patients (79%) were abdominal surgeries that were conducted in S.N. Medical in the age group of 21 - 60 years and male to female ratio College and H.S.K. Hospital and Research Centre, is 2.3:1. In the current study, most of the patients (64%) Bagalkot, Karnataka, India from December 2013 to June passed the flatus early post operatively. In study group 36 2015. This is single blind prospective randomized study (72%) patients nasogastric tube was removed in 24 hours involving elective and emergency abdominal surgeries. after surgery, majority of patients felt better and were This work was approved by Ethical Committee of the allowed clear fluids fallowed by soft diet. One (2%) institute and informed consent was obtained. After developed vomiting, in whom nasogastric tube was following inclusion and exclusion criteria a total of 100 reinserted. In 14 (28%) patients tube was not inserted cases were taken for the study. since from the beginning. In controlled group tube kept from 3 days to 7 days based on clinical assessment, in 27 Inclusion criteria (54%) patients tube was removed in 48 hours and in rest of the patients after 48 hours.  Adult patients and both sexes were included  All patients who underwent abdominal surgery  Gastro duodenal surgery  Colorectal surgery  Biliary surgery 40 36  Intestinal obstruction with or without resection and 27 23 anastamosis 30  Perforative peritonitis  Abdominal trauma. 20 14 10 0 0 Exclusion criteria 0 0 Controls 0 Cases  Laparoscopic surgery No < 24 24-48 > 48 Ryles hrs hrs hrs  Gynecological operations Cases 14 36 0 0  Other lower abdominal surgery. Controls 0 0 27 23

Among the total sample of 100 cases, patients undergoing abdominal surgeries nasogastric output, absence of emesis and no increasing abdominal discomfort were Figure 1: Distribution of study subjects based on randomized into two groups. In study group (Group A) duration of nasogastric decompression (p = 0.001). the nasogastric tube was removed within 24 hours after the operation and started oral feeding. In control group (Group B) of the nasogastric tube was maintained until 60 Cases the passage of flatus per rectum, return of bowel sounds 45 Controls by auscultation, decreasing nasogastric aspiration. 40 16 16 Details of cases were recorded including history, clinical 12 examination; investigations, surgical procedure, 20 2 4 3 anesthesia type and analgesic used were recorded. The 0 1 0 1 0 study requires no specific/special investigations. This 0 study based on clinical assessment return of bowel sounds, release of flatus and passing of stool, postoperative complication and hospital stay were noted.

Date were entered and analyzed in Microsoft Excel 2013 and with Open Epi. Categorical data were presented as frequencies and analyzed using Pearson's chi square test. In case, if the cell count was less than 5 in more than 20% of the cells in a table, then Fischer's exact test was Figure 2: Distribution of study subjects based on applied. P value of <0.05 was considered statistically complications among cases and controls (p >0.10). significant.

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The rationale of nil by mouth is to prevent postoperative 14 nausea and vomiting and to protect the anastomotic, 12 allowing time to heal before being stressed by food. It is, however, unclear whether deferral of enteral feeding is 10 beneficial. Contrary to widespread opinion, evidence from clinical studies and animal experiments suggest that 8 initiating feeding early is advantageous. 13.04 6 The benefits of early enteral feeding are contributed by 8.88 the trophic support of gut mucosa as well as by the 4 improved maintenance of gut metabolic and immunologic 6 2 function during the hypercatabolic phase.

0 Also the early mobility of the patient due to nasogastric Study Subjects Controls tube removal, thus preventing any thrombotic complications. Early oral feed decreased the requirement of IV fluids, injectable, antibiotics and nursing care thus Figure 3: Mean duration of hospital stay (p= 0.0001). reducing the treatment cost, patients with non-traumatic intestinal perforation and peritonitis.

The patients in study group tolerated the first feed earlier The widespread practice of keeping nasogastric tube till as compared to the control group. The mean duration of passage of flatus and appearance of bowel sounds and hospital stay was 8 days for study group and 10.5 days keeping patient 'nil by mouth', after gastrointestinal for control group (p=<0.0001). The incidence of upper surgery has been challenged by recent studies. Further, respiratory tract infection, pulmonary complications like the apparently beneficial effects of early removal of pneumonia, pleural, effusion, pneumonitis, surgical site nasogastric tube and oral feeding definitely reduce the infection and incisional hernia was higher as compared to infection rates, length of stay and cast in hospital is study group (p >0.10). compelling arguments in favor of a change in clinical practice. DISCUSSION This study has shown that prolonged nasogastric Since the 1930s routine use of the nasogastric tube to decompression in ineffective in achieving many of these achieve postoperative gastric decompression has enjoyed goals and in fact significant benefit may be obtained by widespread acceptance, and for decades patients' avoidance of prolonged intubation and only selective tube complaints were not taken into consideration by insertion when needed to relieve gastric symptoms. anaesthesiologists and surgeons. This strong consensus was based on a traditionally held view, namely that Surgical and anaesthetic practice has changed, such that postoperative ileus should be reduced by nasogastric surgery has become less 'stressful' and patients recover decompression, although the different specialties had from anesthesia much faster. So when combined with their own reasons to endorse this approach. Stomach improved postoperative analgesia and attention to fluid emptying is impaired for about 24 hours after and electrolyte balance, defiantly hastened patients early laparotomy. mobilization and recover.7-9 Thus, patients today may be much more able to tolerate early oral feeding than was In contrast, the motility and the capacity of absorption of seen in previous studies. Patients had less pulmonary the small intestine are normal within a few hours after complications, tolerated better oral feeds, shorten the surgery. The small bowel, although mobile, contains little duration of hospital stay and better wound healing as fluid or gas and therefore does not generate bowel sounds compared to control group.10,11 until the stomach resumes activity after 24 hours, pushing swallowed air and fluid into the gut. Any gas that reaches CONCLUSION the small intestine is rapidly passed on into the caecum. However, the colon remains insertia for a long time, with That it is safe to remove nasogastric tube early (within 24 differences in times needed for activity in caecum (48 hours) in patients undergoing abdominal surgeries. Early hours) and sigmoid colon (72 hours), with the passage of nasogastric tube removal and early oral feeding thus 5 flatus or stool as a marker. The autonomic nervous follows the principle of achieving anatomical and system undoubtedly plays an important role in POI, with physiological continuity heralding early recovery. perioperative stimuli inducing an increase in tonic inhibitory sympathetic control, as indicated by the Funding: No funding sources inhibition of bowel function that occurs following Conflict of interest: None declared surgery not involving the peritoneum. Ethical approval: The study was approved by the institutional ethics committee

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