Early Nasogastric Tube Removal Research Articles

Enhanced Recovery Protocol after Radical Cystectomy for Bladder Cancer

Enhanced recovery after surgery protocols aim to improve patient care and decrease complications and hospital stay. We evaluated our enhanced recovery after surgery protocol, focusing on length of stay, early complication and readmission rates after radical cystectomy for bladder cancer. From May 2012 to July 2013 a perioperative protocol was applied in 126 consecutive patients who underwent open radical cystectomy and urinary diversion. Nonconsenting patients (2), those with previous diversion (2) and prolonged postoperative intubation (3), and those who underwent additional surgery (9) were excluded from study. The protocol focuses on avoiding bowel preparation and nasogastric tube, early feeding, nonnarcotic pain management and the use of cholinergic and μ-opioid antagonists. Outcomes were compared to those in matched controls from our bladder cancer database. A total of 110 patients with a median age of 69 years were included in analysis, of whom 68% underwent continent urinary diversion. Of the patients 82% had a bowel movement by postoperative day 2. Median length of stay was 4 days. The 30-day minor and major complication rates were 64% and 14%, respectively. The most common minor complication was anemia requiring transfusion in 19% of patients, urinary tract infection in 13% and dehydration in 10%. The latter 2 complications were the most common etiologies for readmission. The 30-day readmission rate was 21% (23 patients). Patients 75 years old or older had a longer length of stay (5 vs 4 days, p = 0.03) and a higher minor complication rate (72% vs 51%, p = 0.04) than younger patients. Our enhanced recovery after surgery protocol expedites bowel function recovery and shortens hospital stay after RC and urinary diversion without an increase in the hospital readmission rates.

Guidelines for perioperative care after radical cystectomy for bladder cancer: Enhanced Recovery After Surgery (ERAS®) society recommendations

Enhanced recovery after surgery (ERAS) pathways have significantly reduced complications and length of hospital stay after colorectal procedures. This multimodal concept could probably be partially applied to major urological surgery. The primary objective was to systematically assess the evidence of ERAS single items and protocols applied to cystectomy patients. The secondary objective was to address a grade of recommendation to each item, based on the evidence and, if lacking, on consensus opinion from our ERAS Society working group. A systematic literature review was performed on ERAS for cystectomy by searching EMBASE and Medline. Relevant articles were selected and quality-assessed by two independent reviewers using the GRADE approach. If no study specific to cystectomy was available for any of the 22 given items, the authors evaluated whether colorectal guidelines could be extrapolated. Overall, 804 articles were retrieved from electronic databases. Fifteen articles were included in the present systematic review and 7 of 22 ERAS items were studied. Bowel preparation did not improve outcomes. Early nasogastric tube removal reduced morbidity, bowel recovery time and length of hospital stay. Doppler-guided fluid administration allowed for reduced morbidity. A quicker bowel recovery was observed with a multimodal prevention of ileus, including gum chewing, prevention of PONV and minimally invasive surgery. ERAS has not yet been widely implemented in urology and evidence for individual interventions is limited or unavailable. The experience in other surgical disciplines encourages the development of an ERAS protocol for cystectomy.

Perioperative outcomes in radical cystectomy

To define the incidence of perioperative morbidity following contemporary radical cystectomy and identify preoperative, intraoperative, and postoperative strategies to reduce complications. When complications are methodically and systematically recorded, 64% of patients will sustain a complication within 90 days of radical cystectomy. Various preoperative, postoperative, and intraoperative strategies have been identified to reduce morbidity. Prior to surgery, patients should have reversible medical conditions treated, mechanical bowel preparation can be omitted if using small bowel for reconstruction, venous thromboembolism and antimicrobial infection prophylaxis should be initiated, nutrition should be optimized, and patient education should be provided. During surgery, complications can be attenuated by utilizing meticulous surgical technique, minimizing blood loss, fluid management can be guided by transesophageal cardiovascular Doppler, and lower extremity repositioning should be performed as soon as feasible. After surgery, early mobilization, incentive spirometry, early nasogastric tube removal, alvimopan usage, and judicious jejunostomy tube feeding, or total parenteral nutrition usage may reduce morbidity. Morbidity is common following radical cystectomy, but careful attention to preoperative, intraoperative, and postoperative details can help reduce this risk.

Initial Experiences of an Enhanced Recovery Protocol in Esophageal Surgery

A recent development in gastrointestinal surgery is the implementation of enhanced recovery after surgery (ERAS) programs. Evidence regarding the benefit of these programs in patients undergoing esophageal surgery is scarce. We investigated the feasibility and possible benefit of a perioperative ERAS program in patients undergoing esophagectomy for malignant disease. The ERAS program was initiated in 2009. Patients who underwent esophagectomy and were treated according to the ERAS program were included. Items of ERAS included preoperative nutrition, early extubation, early removal of nasogastric tube, and early mobilization. Primary outcome parameters were hospital stay and the incidence of postoperative complications. Outcome parameters in the ERAS cohort were compared to a cohort of patients who underwent surgical resection in the year prior to the implementation of the ERAS protocol. A feasibility analysis was performed among a sample of ERAS patients to determine the number of achieved items per patient. Between 2008 and August 2010, 181 patients in our department underwent esophagectomy. Of these, 103 patients were included in the ERAS program (ERAS+ group) and were compared to 78 patients who had undergone an esophagectomy in 2008 (ERAS- group). Overall hospital stay was 14 days versus 15 days (ERAS+ and ERAS-, respectively; p = 0.013). There were no significant differences in the incidence of postoperative complications in either group. The percentage of achieved items varied between 42 and 93 % per item. The implementation of an ERAS program in esophageal surgery was feasible and resulted in a small but significant reduction in overall hospital stay, whereas overall morbidity was not affected.

The feasibility and safety of early removal of nasogastric tube after total gastrectomy for gastric cancer.

To evaluate the feasibility and safety of early removal of nasogastric tube after total gastrectomy for gastric cancer. Data of 142 gastric cancer patients who underwent total gastrectomy from January 2011 to March 2012 were retrospectively collected and analyzed. Early removal ER group n=57 of nasogastric tube was defined as removal within postoperative 48 h, and conventional placement CP group n=85 of nasogastric tube was defined as removal till flatus and less than 300 cc gastric juice drainage. Outcome measures included postoperative temperature, hospital stay length, days to passage of flatus, days to semi-liquid diet, postoperative complications and mortality. No statistically significant difference was found between the ER group and the CP group in postoperative highest temperature p=0,456 the incidence of temperature over 38.5C p=0,772 postoperative hospital stay length p=0,102 and time to flatus p=0,163 There was no death or reoperation in patients of both groups. There were no significant differences in postoperative complications between the two groups 22,8% vs 30,6%, p=0,309 There was no anastomotic leakage, hemorrhage or stenosis. There was a trend of decreased risk of postoperative pneumonia in the ER group 10,5% vs 21,2% despite no significance p=0,097 CONCLUSIONS: The early removal of nasogastric tube within postoperative 48 h after total gastrectomy is feasible and safe in common practice and might also have a potential benefit in preventing postoperative pneumonia.

Effect of Short-term vs Prolonged Nasogastric Decompression on Major Postesophagectomy Complications

Controversy exists over the need for prolonged nasogastric decompression after esophagectomy. We hypothesized that early removal of the nasogastric tube would not adversely affect major pulmonary complications and anastomotic leak rates. Single-center, parallel-group, open-label, randomized (1:1) trial. A tertiary referral cancer center with high esophagectomy volume. One hundred fifty patients undergoing esophagectomy with gastric tube reconstruction. Either conventional nasogastric decompression for 6 to 10 days (75 patients) or early removal (48 hours) of nasogastric tube (75 patients) with stratification for pyloric drainage and anastomotic technique. The primary (composite) end point was the occurrence of major pulmonary complications and anastomotic leaks. Secondary end points were the need for nasogastric tube reinsertion and patient discomfort scores. Analysis was performed on an intent-to-treat basis. No significant differences were seen in the occurrence of the composite primary end point of major pulmonary and anastomotic complications between the delayed (14 of 75 patients [18.7%]) and early (16 of 75 patients [21.3%]) removal groups, respectively (P = .84). Nasogastric tube reinsertion was required more often (23 of 75 patients [30.7%] vs 7 of 75 patients [9.3%]) in the early group (P = .001). Mean patient discomfort scores were significantly higher in the delayed (+1.3; 95% CI, 0.4-2.2; P = .006) than in the early removal group. Significantly more patients in the delayed removal group (26 of 75 patients [34.7%] vs 10 of 75 patients [13.3%] in the early removal group; P = .002) identified the nasogastric tube as the tube causing the most discomfort. Early removal of nasogastric tubes does not increase pulmonary or anastomotic complications after esophagectomy. Patient discomfort can be significantly reduced by early removal of the nasogastric tube. Clinical Trials Registry of India Identifier: CTRI/2010/091/003023.

Value of nasogastric decompression tube in patients with gastric cancer

To evaluate the effect of nasogastric decompression tube after gastric cancer operation on the postoperative recovery. A total of 174 patients with gastric cancer were prospectively enrolled from December 2009 to March 2011 and randomly divided into non-nasogastric tube control group(n=88) and nasogastric tube group(n=86). Postoperative symptoms, complications, recovery time, and quality of life during hospital stay were compared between the two groups. The incidences of nausea(14.8% vs. 47.7%, P<0.01), sore throat(6.8% vs. 38.4%, P<0.01), bucking and foreign body sensation(3.4% vs. 20.9%, P<0.01), expectoration obstruction(36.4% vs. 55.8%, P<0.05) were significantly lower in nasogastric tube group than those in the control group. The intervals to ambulation and flatus were(1.46±0.58) d and(3.11±0.77) d in the non-nasogastric tube group, significantly shorter those in nasogastric tube group[(1.68±0.61) d and(3.75±1.03) d]. There was no anastomotic leak or bowel obstruction. The difference in bleeding was not statistically significant[3.4%(3/88) vs. 5.8%(5/86), P>0.05] between the two groups. The quality of life differed between the two groups(mean score, 3.36 vs. 2.78, P<0.01). Early removal of nasogastric decompression tube is safe and reasonable and can improve the quality of life during hospital stay.

Early removal of nasogastric tube is beneficial for patients undergoing radical cystectomy with urinary diversion

Examine the beneficial effect of early nasogastric tube (NGT) removal in patients undergoing radical cystectomy with urinary diversion. 43 consecutive patients underwent radical cystectomy with urinary diversion and were randomized into 2 groups. In the intervention group (n = 22), the NGT was removed 12 hours after the operation. Comparatively, in the control group (n = 21), the NGT remained in place until the appearance of the first flatus. The appearance of ileus, patient ambulation, time to regular diet, and hospital discharge of the two patient groups were assessed. Patient discomfort due to the NGT was also recorded. The 2 groups showed statistical homogeneity of their baseline characteristics. Two patients (9.09%) from the intervention and 3 patients (14.3%) from the control group developed postoperative ileus and were treated conservatively. No significant differences in intraoperative, postoperative, bowel outcomes or other complications were found between the two groups. All patients preferred the NGT to be removed first in comparison to their other co-existing drains. This is the first randomized, prospective study, to our knowledge, to assess early NGT removal after radical cystectomy. We advocate early removal, independently of the selected type of urinary diversion, since it is not correlated with ileus and is advantageous in terms of patient comfort and earlier ambulation.

Radical Cystectomy for Bladder Cancer: Morbidity of Laparoscopic Versus Open Surgery

We compared the morbidity and mortality of laparoscopic vs open surgery in radical cystectomy for bladder cancer. This prospective, nonrandomized study was conducted between January 2003 and July 2007 in 68 patients (7 women and 61 men) who underwent radical cystectomy for bladder cancer. A total of 38 cystectomies were performed laparoscopically and 30 by open surgery. Mean patient age was 68.0 +/- 9.0 years. Median preoperative American Society of Anesthesiologists score was 2 (range 1 to 3) in both groups. Intraoperative blood loss and transfusion rate were significantly lower in the laparoscopic surgery group. Postoperatively the incidence of minor complications and mortality were also significantly lower. Postoperative opioid consumption was significantly less in the laparoscopic surgery group in amount and duration. Resumption of oral fluid and solid intake as well as return to normal bowel function were significantly more rapid in the laparoscopic surgery group, and mean hospital stay was significantly shorter. Mean patient followup was 30.5 +/- 17.2 months. Laparoscopic radical cystectomy for bladder cancer has a lower morbidity rate than cystectomy by open surgery. It allows more rapid resumption of oral fluid and solid intake as well as return to normal bowel function and shorter hospital stay.

Early Removal of Nasogastric Tube After Cystectomy With Urinary Diversion: Does Postoperative Ileus Risk Increase?

Early Removal of Nasogastric Tube After Cystectomy With Urinary Diversion: Does Postoperative Ileus Risk Increase?

The duration of postoperative ileus after elective colectomy is correlated to surgical specialization

Postoperative ileus is an important factor of complications following gastrointestinal procedures. Its pathophysiology and the parameters, which may impact on its duration, remain unclear. The aim of this study was to measure the role of various clinical determinants on restoration of intestinal function after elective colorectal surgery. From July 2002 to September 2003, all patients who underwent laparotomy for colectomy (laparoscopic resections excluded) with either an ileotransverse, colocolic, or high colorectal anastomosis were entered in this prospective study. The intervals in hours between the end of the surgical procedure and passing of flatus (PG) and passing of stool (PS) were recorded by an independent investigator. PG and PS were eventually correlated with the following parameters: type of colectomy, early removal of nasogastric tube (NGT), mechanical bowel preparation (MBP), type of underlying disease, systemic administration of opiates, and surgical training (colorectal fellowship or other). One hundred twenty-four patients were entered in this study. Four patients (3.2%) developed septic complications (3 anastomotic leaks and 1 intraabdominal abscess) and were excluded from the analysis. Median age in this population was 68 (range 30-95) years. Mean duration of postoperative ileus was 70+/-28 h (PG) and 99+/-34 h (PS). The type of colectomy, underlying disease, MBP, and early NGT removal failed, in univariate analysis, to correlate with the duration of postoperative ileus. By contrast, time intervals PG and PS were statistically shorter in the group of patients treated by a colorectal surgeon [56+/-23 vs 74+/-28 h (PG); 82+/-26 vs 103+/-35 h (PS), p=0.004], as well as in patients who received systemic opiates for less than 2 days [64+/-27 vs 75+/-28 h (PG), p=0.04; 88+/-32 vs 108+/-33 h (PS), p=001]. Restoration of normal intestinal function after elective open colectomy takes 3 (PG) to 4 (PS) days. In our series, specialized training in colorectal surgery has a positive impact on the duration of postoperative ileus. Surgical specialization should be considered an important parameter in future clinical trials aiming to minimize postoperative ileus.

Evidence for early nasogastric tube removal after infrarenal aortic surgery: A randomized trial

Nasogastric tube (NGT) decompression after abdominal surgery is still largely used to prevent nausea and vomiting. However, indications are based more on practice than on studies. Moreover, prolonged NGT decompression can lead to complications. In this prospective and randomized study, we evaluated the effects of early withdrawal of NGTs in patients undergoing surgery of the infrarenal aorta. Between October 2001 and May 2002, consecutive patients underwent scheduled infrarenal aortic operations. Patients were prospectively randomised into two groups: group 1, NGT maintenance until the passage of flatus; and group 2, NGT removal at the time of tracheal extubation. Preoperative and perioperative data were collected. The main end point was the occurrence of nausea and vomiting. Secondary end points were tolerance of NGT withdrawal and postoperative complications. Criteria were compared between groups by using Mann-Whitney or Fisher exact tests. Forty-six patients underwent aortic operations. Six patients were subsequently excluded from the study. Of the 40 randomized subjects, 20 patients were included in each group. Preoperative and intraoperative data were similar in both groups. There was no statistical difference between groups regarding nausea and vomiting. In group 1, the occurrence of respiratory complications was more frequent compared with group 2 (5 vs 0 complications; P = .023). There was no significant difference in intensive care unit stay, but the hospital stay was shorter in group 2 (mean, 9 +/- 3 days vs 15 +/- 9 days; P = .016). There were no differences in other adverse events. This study does not support a significant effect of early removal of NGTs on nausea and vomiting in patients undergoing open repair of the infrarenal aorta. However, these findings suggest that NGT maintenance increases the risk of respiratory complications and the length of hospital stay.

Early removal of nasogastric tube after cystectomy with urinary diversion: Does postoperative ileus risk increase?

Objectives To examine the risk factors of postoperative ileus and investigate whether the duration of postoperative nasogastric tube (NGT) use affects the rate of postoperative ileus in patients undergoing radical cystectomy with urinary diversion. Methods A total of 101 patients underwent radical cystectomy with urinary diversion from 1999 to 2003. We examined the demographic and perioperative variables of the patients who did and did not develop postoperative ileus. We divided the patients into two groups—those who had the NGT removed within 24 hours and those who had the NGT removed at first flatus. We compared the two groups for the incidence of ileus and clinical variables. Results Postoperative ileus was observed in 23 patients (23%). The demographic data of both groups were not different in terms of age or American Society of Anesthesiologists score. Also, the operative time, estimated blood loss, type of diversion, and postoperative complication rate were not significantly different between the two groups ( P >0.05). However, the risk of postoperative ileus was significantly greater in those who took polyethylene glycol for bowel preparation than in those who took sodium phosphate (40% versus 18%, respectively, P = 0.02). No significant difference in the prevalence of ileus was found between the patients whose NGT was removed within 1 day and those in whom it was removed after 2 days (25% versus 22%, respectively, P >0.05). Conclusions The results of our study suggest that the use of sodium phosphate for bowel preparation may reduce the incidence of postoperative ileus and that early NGT removal after cystectomy is not correlated with ileus.

Reducing time to oral diet and hospital discharge in patients undergoing radical cystectomy using a perioperative care plan

Objectives To outline our current perioperative treatment of patients undergoing radical cystectomy and urinary diversion, which uses advancements in perioperative care to allow for early institution of an oral diet and early hospital discharge, and thereby overall improvement in patient recovery and outcome after this procedure. Methods Forty consecutive patients underwent radical cystectomy and urinary diversion with curative intent from 2001 to 2002. A care plan was followed for all patients and included improvements in preoperative, intraoperative, and postoperative care. The preoperative care included limited outpatient bowel preparation with sodium phosphate solution and patient education. Operative modifications included reduced incision length, initial preperitoneal dissection, and the use of internal surgical stapling devices. The postoperative care included the use of prokinetic agents, early nasogastric tube removal, the use of non-narcotic analgesics, and early institution of an oral diet. The outcomes with regard to time to institution of an oral diet, tolerance of a regular diet, and hospital discharge were assessed. Results The mean surgical time was 3.9 hours, and the mean estimated blood loss was 573 mL. The mean time to the institution of a clear liquid diet was 2.0 days and to a regular diet was 4.2 days. The mean time to hospital discharge was 5.1 days. No statistically significant differences were found in the time to resumption of a regular diet or to discharge between patients undergoing ileal conduits versus orthotopic ileal neobladders. Only 1 patient had any gastrointestinal dysfunction (ileus), and this patient was discharged on postoperative 7. No patient had any delayed complications involving problems with diet intolerance or other gastrointestinal dysfunction. The results of the current series were compared with those of historical controls. Conclusions Advancements in preoperative, intraoperative, and postoperative management have together been successfully used in our patient population to reduce morbidity and improve recovery with regard to the early institution of an oral diet and early hospital discharge.

Editorial comment

With improvements in perioperative care, surgical technique, and anesthetic management, the morbidity associated with radical cystectomy and urinary diversion has decreased significantly. More recently, economic pressures and emphasis on quality-of-life concerns have contributed to a push toward shorter hospitalization for surgical patients. The authors should be applauded for their efforts in critically reviewing their experience and instituting a clinical care pathway in an attempt to reduce the time to an oral diet and hospital discharge for patients after radical cystectomy. Several preoperative, intraoperative, and postoperative modifications are advocated in the study, including a limited outpatient mechanical bowel preparation, reduced incision length, early nasogastric tube removal with prokinetic agent use, non-narcotic analgesics, and early institution of an oral diet. With a mean time to hospital discharge of 5.1 days, the authors demonstrate that a standardized care plan can potentially facilitate patient recovery in the early postoperative period.

Early nasogastric tube removal combined with metoclopramide after postchemotherapy retroperitoneal lymph node dissection for metastatic testicular nonseminomatous germ cell tumor

Objectives. To evaluate the efficacy of combining early nasogastric tube (NGT) removal and metoclopramide after postchemotherapy retroperitoneal lymph node dissection (RPLND) in decreasing complications, time to diet tolerance, and discharge. Methods. We performed a retrospective study of 31 patients who underwent postchemotherapy RPLND at the University of Texas M. D. Anderson Cancer Center between 1994 and 1996, who were treated with a clinical care pathway that included NGT removal on postoperative day 1 and immediate use of promotility agents such as metoclopramide. A comparison was made with 42 historic controls treated from 1988 to 1994 who were managed with an NGT until the return of flatus and minimal promotility agents. Results. Both groups had comparable age, chemotherapy, and surgical procedures. The study group had fewer complications, with an earlier tolerance of solid food (median 5 ± 2.5 days compared with 7 ± 5.1 days in controls, P = 0.000) and discharge (median 6 ± 2.6 days compared with 9 ± 6.9 days in controls, P = 0.000). NGT replacement was required in 3.2% of study patients versus 9% of controls. Multiple regression analyses demonstrated that the number of NGT days was an independent predictor of early return of bowel function and length of hospitalization ( P = 0.000), and metoclopramide was not. Conclusions. Early NGT removal combined with metoclopramide after postchemotherapy RPLND allowed earlier diet tolerance and shortened hospital stays without increased complications. The role that promotility agents play as a necessary component of safe, early NGT removal is unclear.

EARLY NASOGASTRIC TUBE REMOVAL COMBINED WITH METOCLOPRAMIDE AFTER RADICAL CYSTECTOMY AND URINARY DIVERSION

Prolonged nasogastric decompression increases pulmonary complications by inhibiting clearance of respiratory secretions. The literature supports early nasogastric tube removal following bowel resection. Metoclopramide stimulates bowel activity, promoting return of function. We examined combining early nasogastric tube removal with metoclopramide after radical cystectomy. From 1994 to 1996, 27 prospective cystectomy patients received intravenous metoclopramide (metoclopramide group) combined with early nasogastric tube removal (less than 24 hours). A total of 54 concurrent cystectomy controls received no metoclopramide and nasogastric tubes remained until return of normal bowel function. Preoperative and perioperative factors were comparable between the 2 groups. Nasogastric tubes were removed from 78% of the metoclopramide group in less than 24 hours, 11% on day 2 and 11% on day 3 compared to none on day 1, 50% on day 2 and 50% on day 3 or greater in controls. The metoclopramide group had a more rapid return of normal bowel sounds (2.9 versus 4.0 days, p = 0.0002) and earlier tolerance of solid food (6.7 versus 7.9 days, p = 0.04). Nasogastric tube replacement was required in 3 of 27 metoclopramide cases versus 5 of 54 controls. Atelectasis occurred more often in the control group (33 versus 15%). There were no bowel related complications in the metoclopramide group but partial small bowel obstruction in 2 controls was treated conservatively. This preliminary study suggests that combining intravenous metoclopramide with early nasogastric tube removal after cystectomy and urinary diversion may reduce postoperative atelectasis and speed return of bowel function while posing no danger to the small bowel anastomosis. This regimen may result in fewer complications and shorter hospitalizations, translating into lower costs without compromising quality of care.