Introduction
It is a common practice to have nasogastric or nasojejunal tubes(NG or NJ) decompression after gastrectomy. It is believed that it can help to rest the bowel, prevent abdominal distension, decrease nausea and vomiting, and possibly protect the anastomosis. However, evidence from many "Enhanced Recovery After Surgery" programs shows NG and NJ tubes are associated with discomfort, decreased coughing effect and impaired mobilization. Patients without these tubes may have less throat discomfort and less pulmonary complications.
Aims & Methods
The aim of our study is to investigate the need of the use of NG and NJ tubes after gastrectomy for cancer in a randomized controlled trial setting. If the non-necessity can be proved, the practice can be applied to "Enhanced Recovery After Surgery" programs. The patients may have less discomfort and earlier discharge without compromise in complication and mortality.
This is an open labelled randomized controlled trial conducted in Department of Surgery, Tuen Mun Hospital, Hong Kong. It is approved by the ethics and research committee. Inclusion criteria include patients undergoing elective operations for gastric cancer, patents with age>18, and patients mentally fit. Exclusion criteria include gastric outlet obstruction, intestinal obstruction, unresectability, ASA>2. Randomization is made at pre-anaesthetic clinic by generation of random number. In Group A, NG or NJ tubes are inserted in operation room and removed at the end of operation. In Group B, NG or NJ tubes are inserted in operation room and kept at the end of operation. Primary end points include pulmonary and overall complications rate, degree of throat discomfort(0 to 4), length of hospital stay. Secondary endpoints include anastomotic leakage rate, reoperation and mortality. Sample size is calculated assuming a difference of 5% in pulmonary complication rate, alpha=0.5, beta=0.8, thus requiring 70 patients in each arm. Analysis is based on intention-to-treat basis. Chi-square or Fisher exact tests are used to compare categorical variables. Student t-test or Mann-Whitney test are used to compare continuous variables. P values are 2-sided and values less than 0.05 will be considered significant.
Results
From 2013 to 2021, 160 patients were recruited. 80 patients were randomized to group A and 80 to group B. The overall crossover rate was 13.1%. In group A, the mean age was 64.1. In group B, the mean age was 64. Concerning throat discomfort score on postoperative day 1, the mean score for group A and group B were 0.45 and 1.01 respectively(p<0.005). The mean score on day 3 were 0.31 and 0.40. The mean score on day 7 were 0.03 and 0.23(P>0.05).The pulmonary complication rate for group A and Group B was 17.5% and 21.3%(no significant difference). The non-pulmonary complication rate for group A and B was 20% and 21.3%(no significant difference). The mean time for patients to pass flatus for group A and B was 3.5 and 3.9(no significant difference). The mean length of stay for group A and B was 15.11 and 15.7(no significant difference). There was no hospital mortality.
Conclusion
This randomized controlled trial showed similar postoperative recovery for patients with and without NG or NJ tubes after gastrectomy for cancer. The was a trend for less throat discomfort, postoperative complications, time to pass flatus and shorter length of stay for the group without tubes. However, it only reached statistical significance in early postoperative throat discomfort score.
Performing gastrectomy for cancer without NG and NJ tubes is safe. It also causes less throat discomfort for the patients. It should be part of the "Enhanced Recovery After Surgery" program.
References
1. The future of fast-track surgery--British Journal of Surgery 2012;99: 1025-1026
2. Efficacy and necessity of nasojejunal tubes after gastrectomy--Intenrational Journal of Surgery 2011;9: 233-236
3. Nasojejunal tube placement after total gastrectomy: a multicenter prospective randomized trial--Arch Surg 2004;139(12): 1309-13
4. Enhanced Recovery after Surgery for gastric cancer patients improves clinical outcomes at a US Cancer Centre--J Gastric Cancer 2018;18(3): 230-241
5. Omitting nasogastric tube placement after gastrectomy does not enhance postoperative recovery:a propensity score matched analysis--Langenbeck's Archives of Surgery 2022;407:113-122
6.The application of enhanced recovery after surgery in total gastrectomy: a propensity score-matched analysis--World Journal of Surgical Oncology 2023;21:148
Disclosure
Nothing to declare.
