Nasogastric Tube Decompression Research Articles

Specific oral medications decrease the need for surgery in adhesive partial small-bowel obstruction

Nothing by mouth (NPO) is the standard treatment for small-bowel obstruction. Whether oral medications should be prohibited during treatment of adhesive, partial small-bowel obstruction is unclear. The goal of this study was to determine whether a combination of specific oral medications in adhesive, partial small-bowel obstruction will decrease the need for operative intervention. Of 266 consecutive adult patients with partial small-bowel obstruction admitted at a tertiary medical center, 236 were randomized into 2 groups. Group I patients were treated with intravenous hydration, nasogastric tube decompression, and NPO. Group II patients were placed on intravenous hydration, nasogastric tube decompression, and oral fluids incorporating an oral laxative, a digestant, and a defoaming agent. We compared differences between the groups in (1) the number of patients having a successful nonoperative treatment, (2) complications, and (3) recurrence of symptoms. A total of 116 and 120 patients comprised groups I and II, respectively. The number of patients treated successfully by a nonoperative approach was less in group I than in group II (77% vs 90%, P < .01). The complications and recurrence rate for groups I and II did not differ (4% vs 5% and 5% vs 4%, respectively). The NPO status for patients with adhesive, partial small-bowel obstruction may not be necessary. This cocktail of oral medications can decrease the need for operative intervention in patients with presumed adhesive, partial small-bowel obstruction.

Bench-to-bedside review: Routine postoperative use of the nasogastric tube – utility or futility?

This article provides a summary of current information on rational postoperative use of the nasogastric tube, based on a review of literature related to postoperative gastrointestinal discomfort and management with the nasogastric tube. Routine gastric decompression after major surgery neither hastens the return of bowel function nor diminishes the incidence of postoperative nausea and vomiting. The multimodal postoperative rehabilitation programme is a modern and more efficient approach. Omission of nasogastric tube decompression does not increase the incidence of anastomotic leakage or wound dehiscence. Conversely, early enteral feeding is feasible and safe, favours local immunity and gut integrity, and improves nutritional status. With the objective to feeding, nasogastric tube could be used in selected patients. To conclude, use of the nasogastric tube to prevent or limit postoperative gastrointestinal discomfort must be challenged. In contrast to gastric decompression, early gastric feeding must be considered within the new concept of fast track surgery.

Acellular Dermal Matrix (AlloDerm): New Material in the Repair of Stoma Site Hernias

Parastomal hernias are a common complication after ileostomy or colostomy formation and can lead to complications, such as intestinal obstruction and strangulation. When a parastomal hernia presents, repair of the defect can pose a challenge to the surgeon to choose a repair that both reduces complications and recurrence rates. We present three cases of parastomal hernia repair using acellular dermal matrix (AlloDerm) as reinforcement to the primary hernia repair. We prospectively followed three patients who presented with parastomal hernia after ostomy formation in 2001-2002. The patients underwent repair of the parastomal hernia using primary fascial repair with reinforcement using AlloDerm as an on-lay patch. Two patients were followed for 6 months and 1 year, respectively, and remained hernia-free. One patient presented 8 months later with symptoms of intestinal obstruction that were relieved by nasogastric tube decompression and bowel rest. The patient subsequently returned 3 months later with intestinal obstruction and recurrent parastomal hernia that necessitated an operation for relocation of the stoma and repeat hernia repair. Repair of parastomal hernias using AlloDerm acellular dermal matrix as a substitute for a synthetic graft showed resilience to infection and, more importantly, tolerated exposure in an open wound without having to be removed. Larger studies with longer follow-up are needed to see if this material reduces the incidence of hernia recurrence.

Nonsurgical management of partial adhesive small-bowel obstruction with oral therapy: a randomized controlled trial

Patients with partial adhesive small-bowel obstruction are usually managed conservatively, receiving intravenous hydration and nothing by mouth. Previous studies have suggested that this approach is associated with longer hospital stays and an increased risk of delayed surgery. We conducted a randomized controlled trial to see if combining standard conservative treatment with oral administration of a laxative, a digestant and a defoaming agent would reduce the frequency of subsequent surgical intervention and reduce the length of hospital stay. We identified 144 consecutive patients admitted between February 2000 and July 2001 with adhesive partial small-bowel obstruction and randomly assigned 128 who met the inclusion criteria to either the control group (intravenous hydration, nasogastric-tube decompression and nothing by mouth) or the intervention group (intravenous hydration, nasogastric-tube decompression and oral therapy with magnesium oxide, Lactobacillus acidophilus and simethicone). The primary outcome measures were the number of patients whose obstruction was successfully treated without surgery and the length of hospital stay. We also monitored rates of complications and recurring obstructions. Of the 128 patients, 63 were in the control group and 65 in the intervention group; the mean ages were 54.4 (standard deviation [SD] 15.9) years and 53.9 (SD 16.3) years respectively. Most of the patients were male. More patients in the intervention group than in the control group had successful treatment without surgery (59 [91%] v. 48 [76%], p = 0.03; relative risk 1.19, 95% confidence interval 1.03-1.40). The mean hospital stay was significantly longer among patients in the control group than among those in the intervention group (4.2 [SD 2.7] v. 1.0 [SD 0.7] days, p < 0.001). The complication and recurrence rates did not differ significantly between the 2 groups. Oral therapy with magnesium oxide, L. acidophilus and simethicone was effective in hastening the resolution of conservatively treated partial adhesive small-bowel obstruction and shortening the hospital stay.

Atrial fibrillation after off-pump versus on-pump: Are we not missing a common pathophysiological pathway?

We read with interest Junemann-Ramirez and colleagues’ article [1] on esophagogastric anastomotic leaks and their analysis of predictive factors, management and survival. We agree with the authors that esophagogastric anastomotic leaks are the most devastating of complications after esophageal resection and that they carry high morbidity and mortality rates. The choice of surgical procedure has a lot to do with the ultimate outcome of the patient. We feel that the consequences of an anastomotic leak are far worse with an intrathoracic anastomosis compared with a neck anastomosis. The Ivor Lewis esophagectomy has neither the advantages of a transhiatal esophagectomy (in avoiding a thoracotomy) nor does it have the advantages of a transthoracic (three-hole) total esophagectomy (where a neck anastomosis avoids the morbidity of mediastinitis in case of a leak). A three-hole esophagectomy also enables radical supracarinal mediastinal lymphadenectomy. The authors’ conclusions that patients treated conservatively fared better than those who underwent surgical intervention could clearly be explained by a selection bias as it is likely that clinically stable patients would have been treated conservatively and sicker patients with mediastinitis would have been reoperated. We also fail to understand how a pyloric drainage procedure could reduce anastomotic leaks—decompression of the gastric tube could easily and effectively be achieved by nasogastric tube decompression. In our unit (we perform an average of 160 esophagectomies a year), we perform a three-hole total esophagectomy in all patients with a neck anastomosis, but do not perform a formal pyloric drainage procedure. None of the leaks we encountered could be explained by non-performance of a gastric drainage procedure. Most true anastomotic leaks in our unit are managed conservatively as the leak gets localized in the neck with no signs of mediastinitis. Gastric tube necrosis or ischemia, on the other hand, are managed aggressively by immediate surgical reoperation with disconnection of the anastomosis with reconstruction by a coloplasty as an interval surgery [2]. Needless to state, the latter group fare worse than the former.

Management of esophagogastric anastomotic leaks☆

We read with interest Junemann-Ramirez and colleagues’ article [1] on esophagogastric anastomotic leaks and their analysis of predictive factors, management and survival. We agree with the authors that esophagogastric anastomotic leaks are the most devastating of complications after esophageal resection and that they carry high morbidity and mortality rates. The choice of surgical procedure has a lot to do with the ultimate outcome of the patient. We feel that the consequences of an anastomotic leak are far worse with an intrathoracic anastomosis compared with a neck anastomosis. The Ivor Lewis esophagectomy has neither the advantages of a transhiatal esophagectomy (in avoiding a thoracotomy) nor does it have the advantages of a transthoracic (three-hole) total esophagectomy (where a neck anastomosis avoids the morbidity of mediastinitis in case of a leak). A three-hole esophagectomy also enables radical supracarinal mediastinal lymphadenectomy. The authors’ conclusions that patients treated conservatively fared better than those who underwent surgical intervention could clearly be explained by a selection bias as it is likely that clinically stable patients would have been treated conservatively and sicker patients with mediastinitis would have been reoperated. We also fail to understand how a pyloric drainage procedure could reduce anastomotic leaks—decompression of the gastric tube could easily and effectively be achieved by nasogastric tube decompression. In our unit (we perform an average of 160 esophagectomies a year), we perform a three-hole total esophagectomy in all patients with a neck anastomosis, but do not perform a formal pyloric drainage procedure. None of the leaks we encountered could be explained by non-performance of a gastric drainage procedure. Most true anastomotic leaks in our unit are managed conservatively as the leak gets localized in the neck with no signs of mediastinitis. Gastric tube necrosis or ischemia, on the other hand, are managed aggressively by immediate surgical reoperation with disconnection of the anastomosis with reconstruction by a coloplasty as an interval surgery [2]. Needless to state, the latter group fare worse than the former.

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.

Conservative management of pneumatosis intestinalis

Background. Pneumatosis intestinalis is a rare condition characterized by subserosal and submucosal gas-filled cysts in the gastrointestinal tract; it may be associated with bowel ischemia, perforation, and a high mortality rate. As a result, many authorities advocate an aggressive surgical approach in patients with pneumatosis intestinalis. Case. A 53-year-old female with recurrent, metastatic uterine leiomyosarcoma underwent resection of the pelvic recurrence, low anterior rectal resection with primary anastomosis, and partial hepatectomy for liver metastasis. Her postoperative course was notable for a small bowel obstruction and the finding of pneumatosis intestinalis on radiologic studies. The patient developed mild abdominal pain. She did not develop tenderness or fevers. She was managed with bowel rest, nasogastric tube decompression, total parenteral nutrition, and broad-spectrum antibiotics. The finding of pneumatosis intestinalis resolved over the ensuing 6 days. Her diet was slowly advanced, and she was discharged home in stable condition without further surgical intervention or recurrence of the obstruction or pneumatosis. Currently, her only evidence of disease is pulmonary metastases. Conclusions. In select patients, the outcome of a conservative approach to the management of pneumatosis intestinalis is not much different than surgical re-exploration for highly selected patients. The clinical condition of the patient, not solely the finding of pneumatosis intestinalis, should drive management in these cases.

Amitraz: an unusual aetiology of Ogilvie's syndrome

Amitraz is an insecticide/acaricide of formamidine pesticides used worldwide for ectoparasites in animals. Because of its widespread use, amitraz poisoning is frequently encountered in Turkey. A 36-year-old, comatose female was admitted to the hospital. Although it was stated that she had taken a glass of water containing amitraz, the exact volume of the substance was unknown. On admission, her Glasgow Coma Scale score was 10/15. Clinical findings were vomiting, miosis, bradycardia and hypotension. The patient's vital signs were body temperature 37.2 degrees C, pulse 54 bpm, blood pressure 80/50 mmHg and pulseoximetry 84%. Supportive treatment consisting of oxygen, fluid replacement and gastric lavage, activated charcoal and atropine was administered. On the second day, signs of Ogilvie's syndrome characterized by severe tenderness, distension and pain in the abdomen were seen. On the third day, the patient's condition improved except for abdominal distension and pain, inability to pass faeces or flatus through the anus. Although continuous nasogastric tube decompression was performed, her complaints were not resolved completely. Neostigmine was administered on the fourth day. On the fifth day, abdominal pain and distension were decreased, and stool passage began. She had a complete clinical and laboratory improvement, which warranted her discharge on the seventh day of admission.

The Use and Modification of Clinical Pathways to Achieve Specific Outcomes in Bariatric Surgery

Clinical pathways are promoted for standardizing patient care and decreasing resource use without compromising outcome. Once established, we hypothesized that clinical pathways can then be used to modify patient care to achieve specific goals. Our aim was to evaluate a clinical pathway for the bariatric surgical patient that was initially designed to standardize care and later altered to modify the postoperative course. We retrospectively reviewed 150 consecutive patients undergoing open gastric bypass by a single surgeon. The first 50 patients were managed without a formal pathway, (group I). The next 50 were managed with a pathway that standardized care in order to reduce length of stay (LOS), (group II). For the final 50 patients, the pathway was modified to shorten nasogastric decompression time (group III). Patient information, blood loss (EBL), operative time, length of stay (LOS), nasogastric decompression, 30-day complication rates, and early readmissions were reviewed. The groups were similar with respect to gender, age, body mass index, American Society of Anesthesiologists (ASA) classification, and EBL. Operative time was significantly less in groups II and III compared to group I (82% and 68% vs. 38% <180 minutes, P < 0.05). LOS was shorter in groups II and III compared to group I (62% and 42% vs. 20% with a 4-day LOS, P < 0.05). Duration of nasogastric tube decompression was successfully decreased in group III when compared to groups I and II (76% vs. 14% and 6% 1 day or less, P < 0.05). Complication rates were significantly lower in group III as well (14% vs. 36% and 28%, P < 0.05). Standardizing patient care with a clinical pathway decreases LOS after bariatric surgery. An established clinical pathway can then be used to further modify patient care in order to achieve specific goals, such as shortened time of nasogastric decompression. This goal was accomplished without compromising patient outcome.

Percutaneous Needle Decompression during Laparoscopic Gastric Surgery: A Simple Alternative to Nasogastric Decompression

Laparoscopic gastric surgeries are routinely performed with use of a nasogastric tube to decompress the upper gastrointestinal tract. A distended upper gastrointestinal tract can complicate successful laparoscopic gastric surgery as the distention compromises not only the visual field but also the laparoscopic manipulation of the stomach. Since nasogastric intubation is not without risks, we have attempted laparoscopic-assisted gastric cancer surgeries without nasogastric tubes. In this article we describe a simple method of aspirating gastric contents using a 9 cm long 19-gauge needle inserted percutaneously during laparoscopic-assisted gastrectomy. First, a 9 cm long 19-gauge disposable needle was introduced through the abdominal wall. This needle was then introduced to the stomach through the anterior wall and the stomach gases and fluids were aspirated by connecting the needle to suction. Thus, a collapsed upper gastrointestinal tract was easily obtained. We performed this procedure instead of nasogastric decompression on twenty-two patients with gastric cancer who underwent laparoscopic-assisted distal subtotal gastrectomy with lymph node dissection. The results were good with only one patient experiencing wound infection (4.5%) and one patient with postoperative acalculus cholecystitis (4.5%). There were no patients with either intraabdominal infection or anastomotic leakage and none of the patients needed postoperative nasogastric decompression, except the patient who experienced acaculus cholecystitis. Percutaneous needle aspiration is a very simple and efficient technique with little risk of postoperative complications. It can be used as an alternative to nasogastric tube decompression of the gastrointestinal tract for laparoscopic-assisted gastrectomy.

Fifteen years of typhoid perforation in children in Ibadan: still a millstone around the surgeon's neck

Objective: To study the disease of typhoid in children over a significant period of time, in this case, 15 years to see whether there have been any changes in presentation, mode of treatment, morbidity and mortality rates. Method: A retrospective study of 183 children operated on for typhoid ileal perforation in 15 years. Results: All the patients were resuscitated with intravenous infusion of normal saline, nasogastric tube decompression, correction of deranged electrolytes. Antibiotic treatment with intravenous chloramphenicol and metronidazole with or without gentamycin prior to 1996 and intravenous ofloxacin (ciprofloxacin or perfloxacin) with metronidazole from 1996 till date. All patients had exploratory laparotomy under general anaesthesia and endotracheal intubation with closure of the perforation in 2 layers for most of the patients and ileal resection with end –to- end anastomosis or right hemicolectomy in a few patients. Conclusion: Incidence rates at 5-yearly intervals seem to be decreasing and mortality rates seem to be increasing. Complications seem to remain unchanged inspite of different surgical techniques and newer anti-salmonella drugs. Key Words: Typhoid perforation, children, morbidity, mortality Nigerian Journal of Surgical Research Vol.5(1&2) 2003: 92-99

Assessment of routine elimination of postoperative nasogastric decompression after Roux-en-Y gastric bypass

Background. Anastomotic disruption after surgical intervention is an infrequent complication, but may lead to severe morbidity and mortality when it occurs. Of the various gastric procedures, the Roux-en-Y gastric bypass (RYGB) has one of the highest risks for anastomotic leakage. Consequently, a nasogastric tube (NGT) is frequently placed when these operations are performed. Most studies examining the outcomes for patients without postoperative NGTs have been relatively small with groups of patients undergoing a variety of operations. Assessing the incidence of anastomotic leaks by routine elimination of postoperative NGTs requires a large number of patients. In this study, we assessed the safety and efficacy of routine elimination of NGTs in a large cohort of patients undergoing a single operation. Methods. We reviewed our experience with 1067 patients who underwent RYGB at the UCLA medical center. Fifty-six patients had NGTs routinely placed before the implementation of a standard protocol, which eliminated postoperative NGT decompression. The complication rate for the RYGB patient cohort with and without postoperative NGT was compared. Results. We found no difference in the complication rates between the 2 groups (Fisher exact test; P =.21). Conclusions. Our findings suggest that routine placement of an NGT after RYGB is unnecessary. (Surgery 2002;132:844-8.)

Update on acute colonic pseudo-obstruction

Acute colonic pseudo-obstruction is characterized by distention of the colon in the absence of mechanical obstruction. This presentation is typically related to recent surgery, severe illness, or medication. Nasogastric and rectal tube decompression and correction of electrolyte abnormalities are the standard of care. Colonoscopic decompression, performed in a number of these cases, was felt to be unwarranted in many situations and is associated with a high recurrence rate. Medical management beyond conservative measures has been limited. Medical therapy with pharmacologic agents such as erythromycin, metoclopromide, and cisapride was of limited use. Recent findings confirm that an older agent, neostigmine, provides excellent results, including colonic decompression and clinical improvement after administration. This suggests a new standard of care.

Small volume hyperosmolar abdominal CT in acute small bowel obstruction

Purpose: Identification of the degree of small bowel obstruction (SBO) is helpful in patient management decisions since the treatment of partial SBO is nonoperative, whereas the treatment of complete SBO requires surgical intervention. We describe a technique providing the benefits of CT and enteroclysis together, which allows the radiologist to determine the degree of the SBO and thereby to distinguish partial from complete SBO. Methods and materials: Abdominal CT scans were performed on 21 patients. Patients were given 200 ml concentrated oral contrast medium. Serial radiographs followed the progression of contrast at 1, 3, and 5 h in order to optimize the timing of the abdominal CT. A partial SBO was diagnosed if the oral contrast reached the colon at or before the 5-h film, and a complete SBO if the oral contrast did not reach the colon by the 5-h abdominal radiograph. The CT was performed when the contrast reached the colon or after the 5-h film. Results: CT findings demonstrated complete obstruction in eight patients, all of whom required surgical treatment. Partial SBO was demonstrated in 13 patients. Ten of the 13 patients with partial SBO had an uncomplicated transition zone, probably due to adhesions, and were treated medically. Nine of these patients were managed with nasogastric tube decompression and were discharged without surgical intervention. One patient failed to respond to a 12-h course of nasogastric tube decompression and underwent lysis of adhesions. Three of the 13 patients had a complicated transition zone, due to an intussusception and two hernias, which were responsible for the SBO. Two were treated surgically and one medically. Conclusion: The use of small-volume hyperosmolar abdominal CT allows the radiologist to determine the degree of the SBO. This additional information is very useful in patient management because uncomplicated partial SBO is often treated successfully via tube decompression, whereas complete SBO requires surgical intervention.

Minimal incision abdominal aortic aneurysm repair

Purpose: The use of a limited incision for abdominal aortic aneurysm (AAA) repair was evaluated, and its outcome was analyzed in comparison to laparoscopic-assisted and standard open repair. Methods: Eleven patients who had an AAA that required a tube graft underwent minimal incision (MINI) repair. The procedure consisted of a standard endoaneurysmorrhaphy performed through an 8- to 10-cm minilaparotomy. Clinical characteristics, in-hospital outcomes, and total in-hospital charges for this procedure were then compared with those of comparative groups of patients who had undergone repair of AAA by means of a laparoscopic-assisted (LAP) approach or a standard open (OPEN) technique. Results: MINI repair was successfully completed in all 11 patients. Patients in the three groups were comparable for age, sex, risk factors, and aortic dimensions. The mean values for operative time, blood loss, length of hospital stay, and total hospital charges for the three comparison groups were: 129.7 minutes (MINI) vs. 244.8 minutes (LAP)*, 209.9 minutes (OPEN)*; 522.7 mL (MINI) vs. 1214.7 mL (LAP), 1795.8 mL (OPEN)*; 5.18 days (MINI) vs. 18.7 days (LAP), 17.4 days (OPEN); $22,692 (MINI) vs. $59,922 (LAP)*, $62,324 (OPEN)* (* P < .05). Local complications occurred in 18.2% of patients who underwent MINI repair, 23.5% of patients who underwent LAP repair, and 29.7% of patients who underwent OPEN repair ( P = not significant). Patients undergoing minilaparotomy demonstrated decreased compromise of gastrointestinal function, with a decreased need for postoperative fluid resuscitation (6799.7 mL [MINI], 7781.8 mL [LAP] vs. 11061.1 mL [OPEN]*) and shortened nasogastric tube decompression (1.6 days [MINI], 1.5 days [LAP] vs. 4.1 days [OPEN]*; * P < .05). Conclusion: MINI repair is a technically feasible technique that combines the benefits of minimally invasive surgery with those of conventional open repair with few, if any disadvantages. Facility of the procedure, combined with the potential cost benefits, encourages further study for consideration of this technique as a viable alternative for the management of AAAs. (J Vasc Surg 1999;30:977-84.)

Relief of Chronic Refractory Hiccups with Glossopharyngeal Nerve Block

To the Editor: A 66-yr-old male patient planned to undergo right cochleosacculotomy for Meniere's disease complained of chronic refractory hiccups that lasted for 8 mo and did not respond to chlorpromazine, metoclopramide, omeprazole, or nifedipine. Because the patient had dilated cardiomyopathy, type II diabetes mellitus, and a permanent transvenous pacemaker, a cardiology consultation recommended that local rather general anesthesia be used. However, when the patient was taken to the operating room, he had hiccups that prevented the surgeons from performing the operation. Initially, nasogastric tube decompression was unsuccessful for the relief of hiccups. We then performed a glossopharyngeal nerve block by injecting 3 mL of 0.5% bupivacaine into each posterior tonsillar pillar. Within minutes, a complete relief of hiccups resulted, allowing surgery to proceed under local anesthesia. Approximately 3.5 h after glossopharyngeal nerve block, hiccups occurred again. We repeated the glossopharyngeal nerve block two times postoperatively, but the relief of hiccups lasted approximately 3 h after each block. Unfortunately, these blocks were not curative. Gallacher and Martin [1] not only were the first to perform and describe this block, but they also showed that this block was curative at the same time in a patient suffering from acute hiccups. In conclusion, we showed that despite the fact that this method was not curative in the patient suffering from chronic hiccups, it maintains a temporary relief of chronic hiccups. Avni Babacan, MD Ertan Ozturk, MD Kadir Kaya, MD The University of Gazi; Faculty of Medicine; Department of Anesthesiology and Reanimation; Ankara, Turkey

A Prospective Controlled Trial of Early Postoperative Oral Intake Following Major Abdominal Gynecologic Surgery

Objective.The objective was to determine whether, when compared with traditional dietary advancement, early oral intake following major gynecologic surgery leads to a reduction in the length of hospitalization. Methods.Patients undergoing major abdominal gynecologic surgery were invited to participate in this study. After informed consent was obtained, they were randomized to one of two groups. The control group (group 1) was treated traditionally. Oral intake was initiated only after documentation of bowel function, which was defined by two of the following three criteria: (1) bowel sounds; (2) flatus or bowel movement; and (3) subjective hunger. Those assigned to the study group (group 2) were given a clear liquid diet on postoperative day 1. Once 500 cc was tolerated, a regular diet was given. Patients were evaluated on a daily basis for bowel sounds, flatus, bowel movement, hunger, nausea, vomiting, and need for nasogastric tube decompression. The groups were compared with regard to length of hospital stay, length of postoperative ileus, and incidence of adverse effects including nausea, vomiting, and postoperative complications. Statistical analyses were performed with the Student tand χ 2tests. Results.The demographic characteristics of the control ( N= 47) and study groups ( N= 49) were similar, with no significant differences in underlying medical conditions, prior abdominal surgery, or diagnosis of a malignancy. The groups did not vary statistically in the number of subjects who required postoperative antiemetics or postoperative biscodyl suppository. There was a statistically significant reduction in the length of hospitalization for those patients on the early feeding regimen. The average length of stay for group 1 was 4.02 days ± 0.30 (SEM), while that for group 2 was 3.12 days ± 0.16 ( P= 0.008). While there was a significantly higher incidence of emesis in the study population, this was not associated with any untoward outcome, and this group actually tolerated a solid diet nearly one full day earlier (2.72 days ± 0.14 vs 1.88 days ± 0.14, P< 0.0001). Conclusions.Early postoperative oral intake results in a decreased length of hospitalization and is well tolerated when compared with traditional dietary management in patients undergoing abdominal surgery on a university gynecologic oncology service.

Malrotation: The postoperative period

Background/Purpose: There have been many reports of patients who have persistent gastrointestinal symptoms after undergoing Ladd's procedure. Postoperative return of bowel function in many of these patients seems to be delayed. Methods: Postoperative return of bowel function after performance of a Ladd's procedure was studied retrospectively in a series of 57 children treated between 1981 and 1994. Excluded were those patients who had a malrotation in combination with an abdominal wall defect, a congenital diaphragmatic hernia, or duodenal atresia. Patients were divided in two groups; one group consisted of patients less than 1 year of age and one group of those 1 year of age and older. Results: Nasogastric tube decompression was necessary for an average of 6.7 days in the first group and 4.3 days in the older children ( P = .03). A midgut volvulus delays resumption of bowel function postoperatively. Gastric tube decompression was necessary for 8.6 days (n = 15) compared with only 5.1 days (n = 45) for the group without a volvulus ( P = .003, analysis by t test). Conclusion: The authors recommend that a central venous line be inserted for feeding purposes when a volvulus is present at operation.

Is nasogastric tube decompression necessary after major abdominal surgery in children?

Nasogastric (NG) decompression has traditionally been used after major abdominal surgery in pediatric patients. This study was designed to determine if NG tubes could be routinely omitted in pediatric patients undergoing major abdominal procedures. Between January 1993 and December 1995, 83 patients had follow-up prospectively without NG decompression after a variety of major abdominal surgeries. NG tubes were inserted for persistent vomiting or abdominal distension. Exclusion criteria included bowel obstruction, intestinal atresia, and perforation of the stomach or duodenum. Ages ranged from 13 days to 22 years. Seventy-four patients (89%) were treated successfully without postoperative NG decompression. There were no cases of pneumonia, wound dehiscence, anastomotic leak, or delay in return of gastrointestinal function. Nine patients required NG tubes for persistent vomiting or abdominal distension. An anastomotic leak developed in one patient after endorectal pull-through. NG decompression is unnecessary after most major abdominal operations in pediatric patients. The endorectal pull-through may represent a group of patients that benefit from routine decompression.