A meta-analysis of selective versus routine nasogastric decompression after elective laparotomy

Supradiaphragmatic Jejunal Perforation Following Total Gastrectomy With Esophagojejunostomy Reconstruction for Gastric Adenocarcinoma

Nasogastric tube decompression is a common technique used after abdominal surgery as it is widely accepted to play a role in the management of postoperative ileus and possibly reduce anastomotic leaks after gastrointestinal surgery. However, the routine practice of nasogastric/nasoenteric tube decompression in elective abdominal surgeries has been challenged due to the increased incidence of pulmonary complications and the argued lack of expected benefit. Here, we present a rare complication of nasogastric tube drainage following a routine total gastrectomy for signet-ring cell adenocarcinoma of the cardia in a 43-year-old female. Her postoperative course was complicated with a supradiaphragmatic jejunal perforation presumably from nasogastric tube decompression resulting in a left pleural effusion. The workup included an endoscopy showing the perforation, after which the nasojejunal tube was removed and the patient was managed conservatively. She was eventually discharged on postoperative day 28.

Modified Enhanced Recovery After Surgery (ERAS) Protocol Versus Non-ERAS Protocol in Patients Undergoing Emergency Laparotomy for Acute Intestinal Obstruction: A Randomized Controlled Trial

BACKGROUND

Enhanced Recovery After Surgery (ERAS) is a multimodal approach with promising results in improving patient outcome. Only recently, is evidence emerging highlighting how similar principles of care can be applied to patients undergoing emergency abdominal surgery.

METHODS

A randomized controlled trial was conducted from November 2021 to April 2022 at PGIMER Chandigarh, which is a leading tertiary care hospital in northern India. 60 patients with acute intestinal obstruction requiring emergency laparotomy were randomized and assigned to ERAS or Non-ERAS group. ERAS protocol with some modifications was applied. Primary endpoints were post-operative hospital stay. Secondary end points were morbidity, 30-day readmission and mortality rate. Data analysis was done using SPSS 22.0. Independent t test or Mann-Whitney test and Chi-square or Fisher-exact test were used for analysis.

RESULTS

A significant 3-day reduction in hospital stay was observed in ERAS compared to non-ERAS group (median (interquartile range) 5.50 (4.75-8.25) vs 8.0 (6.0-11.0) p = 0.003) with no difference in 30-day readmission rate, mortality rate and complication rate (according to Clavien-Dindo classification). ERAS group was associated with early recovery of gastrointestinal functions including time to first passage of flatus (p < 0.001), stools (p = 0.014), early ambulation (p < 0.001), time to first fluid diet (p < 0.001), solid diet (p = 0.001) and reduced nasogastric tube reinsertion rates (p = 0.01) despite its early removal.

CONCLUSION

ERAS with some modifications can be applied in patients with intestinal obstruction. Thus, we can expedite post-operative recovery and early regain of gastrointestinal function with decreased hospital stay, comparable morbidity and mortality. Further studies are needed to assess ERAS role in emergency gastrointestinal surgeries. Trial registration Ctri.gov Identifier: CTRI/2022/04/042156.

Impact of Tailored-Enhanced Recovery After Surgery Versus Conventional Care in Patients of Gastro-Duodenal Perforation: A Pilot Randomized Control Trial

BACKGROUND

The enhanced recovery after surgery (ERAS) program established improved clinical outcomes in elective surgery; however, its role in emergencies is uncertain. This study was designed to assess the feasibility, safety, and efficacy of a tailored-ERAS (t-ERAS) protocol in patients undergoing modified Graham's patch closure for gastro-duodenal perforation.

METHODS

A single-centre, prospective, parallel-arm, open-label, randomized controlled trial was conducted from February 2021 to December 2021. Patients with gastroduodenal perforation undergoing modified Graham's patch were randomly assigned to either conventional care or the t-ERAS pathway. Patients with refractory septic shock, psychiatric or neurological disorders, pregnancy, multiple perforations, sealed-off perforations, and perforation sizes greater than 1.5 cm were excluded. The primary outcome was to compare the length of hospitalization (LOH). Functional recovery parameters and morbidity were compared in secondary outcomes.

RESULTS

Twenty-five patients each were included in conventional care and the t-ERAS group. In the t-ERAS group, LOH was significantly shorter (6.3 SD2.15 days versus 9.56 SD4.33 days, p = 0.001). Patients in the t-ERAS group had significantly early functional recovery (days) with time to first bowel sound (1.8 SD0.41; p 0.002), first flatus (2.52 SD0.65; p = 0.026), first stool (3.04 SD0.68; p < 0.001), first liquid diet (2.24 SD0.60; p = 0.002), and duration of ileus (2.64 SD0.86; p = 0.038). There was no significant difference in morbidity such as post-operative nausea and vomiting, SSI, or pulmonary complications between the two groups.

CONCLUSION

Tailored ERAS pathways are safe and effective in reducing the LOH and promoting early functional recovery in patients undergoing emergency closure of gastro-duodenal perforation.

Routine nasogastric tube placement after gastric endoscopic full-thickness resection of tumor size ≤ 2 cm may be unnecessary: a propensity score-matching analysis

BACKGROUND

Endoscopic full-thickness resection is a common endoscopic procedure for treating gastrointestinal submucosal tumors. Nasogastric tube placement is frequently performed after abdominal surgery, but the routine use of this approach remains controversial. The aim of this research was to explore whether nasogastric tube placement after gastric endoscopic full-thickness resection is necessary.

METHODS

A retrospective study enrolled patients who underwent gastric endoscopic full-thickness resection in our hospital between January 2014 and January 2019, and all the patients had a tumor size ≤ 2 cm. The patients were divided into two groups according to whether a nasogastric tube was placed. Postprocedural adverse events and hospital stay duration were compared between the two groups using 1:1 propensity score matching.

RESULTS

A total of 461 patients were enrolled in this study, including 385 patients in the nasogastric tube group (NGT group) and 76 patients in the non-nasogastric tube group (non-NGT group). After matching, the baseline characteristics of 73 patients in the NGT group and 73 patients in the non-NGT group were balanced (p > 0.05). The postprocedural fever rate in the NGT group was significantly higher than that in the non-NGT group (23.3% vs. 9.6%, p = 0.044). 6.9% (5/73) of patients experienced severe nasogastric tube-related throat discomfort. However, the duration of hospitalization stay was not different between the two groups.

CONCLUSIONS

For patients with tumor size ≤ 2 cm, routine nasogastric tube placement after gastric endoscopic full-thickness resection may be unnecessary.

Should nasogastric tube be used routinely in patients undergoing cardiac surgery? A narrative review

BACKGROUND AND AIM

Nasogastric tube (NGT) use has been common in the immediate postoperative period in surgical patients for decades. Potential advantages include the decompression of gastric contents and the early administration of time-sensitive medications. However, its routine use after cardiac surgery has not been established as a gold standard yet. The NGT use for prevention of postoperative nausea and vomiting has been a matter of debate in literature. Also, NGT use has also been associated with the incidence of some respiratory and gastrointestinal complications and it may be a source of significant pain and discomfort to patients. In this article, we review the current available literature regarding the use of NGT during and immediately after cardiac surgery, with particular emphasis on its potential role in enhanced postoperative recovery.

METHODS

We performed a database search in October 2021 using Embase, Cochrane Library, and Medline to identify studies that examined the use of NGT in patients that underwent cardiac surgery. Data and literature about NGT's impact on post-operative nausea and vomiting, early administration of medications, interference with imaging, post-operative complications, respiratory complications, gastrointestinal complications, pain and discomfort, and enhanced recovery after surgery were examined.

RESULTS

Three reports investigating the use of NGT to reduce post-operative nausea and vomiting were examined with sample sizes of 114, 104, and 202. The use of NGT did not significantly reduce the incidence of post-operative nausea and vomiting in 2/3 of the studies: a 2% nausea reduction with NGT (p < 0.05), a 7.7% nausea reduction with NGT (p = 0.6), and a 14% vomiting reduction with NGT (p = 0.007). The prevalence of pneumonia following NGT use has been shown to vary ranging from 4 to 95% with associated mortality rates of 17 to 62%.

CONCLUSION

Based on our findings, there is currently not sufficient evidence to support the routine use of NGT during cardiac surgery. Further research is needed to establish the role of NGT in this patient population.

Identification of risk factors and clinical model construction of abdominal distension after radical cystectomy

Background

The occurrence of abdominal distention after radical cystectomy (RC) is common. We sought to determine risk factors of abdominal distention after RC, and to establish a simple and reliable nomogram for clinical risk assessment.

Methods

Clinical information on 139 patients who underwent RC from January 2020 to August 2021 was collected. The chi-square test, hypergeometric test, and univariate/multivariate logistic regression were utilized to explore the relationship between variables and abdominal distention after RC. A nomogram was then used to predict the probability of abdominal distension for the patients who underwent RC. Calibration and receiver operating characteristic (ROC) curves were used to evaluate the accuracy of the model.

Results

We found that 35 patients (25%) occurred in abdominal distention after RC. Among the patients, 7 of them developed intestinal obstruction. Postoperative water fasting time and abdominal surgery history were independent risk factors for abdominal distension after surgery. Finally, we constructed a risk model to predict the probability of abdominal distension after surgery. This model showed good fitting and calibration and excellent diagnostic performance with an area under the curve (AUC) of 0.804.

Conclusions

Postoperative water fasting time and abdominal surgery history were independent risk factors for abdominal distension after surgery. There was no significant difference in the incidence of postoperative abdominal distention between robot-assisted cystectomy and laparoscopic cystectomy.

Effect of Coffee Consumption on Postoperative Ileus after Colorectal Surgery: A Meta-Analysis of Randomized Controlled Trials

Background

Postoperative ileus (POI) is an important complication after elective colorectal surgery, which prolongs hospital stay and increases hospital costs. Coffee has been reported to be beneficial for the recovery of gastrointestinal function. We aimed to investigate the effectiveness of coffee consumption in the treatment of POI, following elective colorectal surgery.

Methods

A comprehensive literature search for medical subject heading (MeSH) terms, including coffee, caffeine, colon, rectum, and colorectal surgery was conducted in PubMed, Embase, and Cochrane Library until November 2021. A meta-analysis of postoperative outcomes was conducted to assess the effectiveness of coffee consumption on POI after colorectal surgery.

Results

726 articles were identified and six RCTs that captured 416 patients were included. The time to first defecation was reduced with postoperative coffee consumption compared to the control group (mean difference = −15.03 h; 95% confidence interval: -17.79, -12.26; P < 0.00001). There was no difference in time to first flatus, time to tolerance for solid food, length of hospital stay, use of laxatives, reinsertion of nasogastric tube, need for reoperation, postoperative complications, and anastomotic leak between the groups. Coffee did not have any adverse effects.

Conclusion

The current literature revealed that postoperative coffee consumption shortened the time to first defecation following elective colorectal surgery. Large sample and tightly controlled multicenter randomized clinical trials are needed to offer a more accurate evaluation of the efficacy of coffee.

de Hingh I, Houwink AP, Stoevelaar HJ, Sonke GS, van Driel WJ. Standardizing HIPEC and perioperative care for patients with ovarian cancer in the Netherlands using a Delphi-based consensus

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Implementation of HIPEC for ovarian cancer is ongoing, aiming to offer this treatment to all eligible patients in the Netherlands.

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Standardization reduces unwanted variation in clinical treatment.

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We intend to standardize patient selection, technical aspects, and perioperative care of CRS and HIPEC.

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This consensus study comprised a two-phase modified Delphi approach.

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Consensus was reached on 82% of items.

Objective

Hyperthermic Intraperitoneal Chemotherapy (HIPEC) is standard of care in the Netherlands in patients with stage III epithelial ovarian cancer following interval cytoreductive surgery (CRS). Differences in patient selection, technical aspects, and perioperative management exist between centers performing HIPEC. Standardization aims to reduce unwanted variation in clinical practice. As part of an implementation process, we aimed to standardize perioperative care for patients treated with CRS and HIPEC using a Delphi-based consensus approach.

Methods

We performed a two-phase modified Delphi method involving a multidisciplinary panel of 40 experts who completed a survey on CRS and HIPEC. During a consensus meeting, survey outcomes and available scientific evidence was discussed. Items without consensus (<75% agreement) were adjusted and evaluated in a second survey.

Results

Consensus was reached in the first round on 51% of items. After two rounds, consensus was reached on the majority of items (82%) including patient selection, preoperative workup, technical aspects of CRS and HIPEC, and postoperative care. No consensus was reached on the role of HIPEC in rare ovarian cancer types, preoperative bowel preparation, timing to create bowel anastomoses, and manipulation of the perfusate.

Conclusions

Dutch experts reached consensus on most items regarding interval CRS and HIPEC for ovarian cancer. This consensus study may help to align treatment protocols and to minimize practice variation. Topics without consensus may be put on the research agenda of HIPEC for ovarian cancer.

Perioperative Pulmonary Atelectasis: Part II. Clinical Implications

The development of pulmonary atelectasis is common in the surgical patient. Pulmonary atelectasis can cause various degrees of gas exchange and respiratory mechanics impairment during and after surgery. In its most serious presentations, lung collapse could contribute to postoperative respiratory insufficiency, pneumonia, and worse overall clinical outcomes. A specific risk assessment is critical to allow clinicians to optimally choose the anesthetic technique, prepare appropriate monitoring, adapt the perioperative plan, and ensure the patient's safety. Bedside diagnosis and management have benefited from recent imaging advancements such as lung ultrasound and electrical impedance tomography, and monitoring such as esophageal manometry. Therapeutic management includes a broad range of interventions aimed at promoting lung recruitment. During general anesthesia, these strategies have consistently demonstrated their effectiveness in improving intraoperative oxygenation and respiratory compliance. Yet these same intraoperative strategies may fail to affect additional postoperative pulmonary outcomes. Specific attention to the postoperative period may be key for such outcome impact of lung expansion. Interventions such as noninvasive positive pressure ventilatory support may be beneficial in specific patients at high risk for pulmonary atelectasis (e.g., obese) or those with clinical presentations consistent with lung collapse (e.g., postoperative hypoxemia after abdominal and cardiothoracic surgeries). Preoperative interventions may open new opportunities to minimize perioperative lung collapse and prevent pulmonary complications. Knowledge of pathophysiologic mechanisms of atelectasis and their consequences in the healthy and diseased lung should provide the basis for current practice and help to stratify and match the intensity of selected interventions to clinical conditions.

Routine Gastric Decompression after Pancreatoduodenectomy: Treating the Surgeon?

BACKGROUND

The decision to routinely leave a nasogastric tube after pancreatoduodenectomy remains controversial. We sought to determine the impact of immediate nasogastric tube removal versus early nasogastric tube removal (<24 h) on postoperative outcomes.

METHODS

A retrospective review of our institution's prospective ACS-NSQIP database identified patients that underwent pancreatoduodenectomy from 2015 to 2018. Outcomes were compared among patients with immediate nasogastric tube removal versus early nasogastric tube removal.

RESULTS

A total of 365 patients were included in primary analysis (no nasogastric tube, n = 99; nasogastric tube removed <24 h, n = 266). Thirty-day mortality and infectious, renal, cardiovascular, and pulmonary morbidity were similar in comparing those with no nasogastric tube versus early nasogastric tube removal on univariable and multivariable analyses (P > 0.05). Incidence of delayed gastric emptying (11.1 versus 13.2%) was similar between groups. Patients with no nasogastric tube less frequently required nasogastric tube reinsertion (n = 4, 4%) compared to patients with NGT <24 h (n = 39, 15%) (OR = 3.83, 95% CI [1.39-10.58]; P = 0.009).

CONCLUSION

Routine gastric decompression can be safely avoided after uneventful pancreaticoduodenectomy.

Nasogastric- vs. percutaneous gastrostomy tube for prophylactic gastric decompression after cytoreductive surgery with hyperthermic intraperitoneal chemotherapy

Objectives

Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is associated with postoperative gastroparesis and ileus. In 2015, our practice shifted from using percutaneous gastrostomy tubes (PGT), to nasogastric tubes (NGT) for prophylactic gastric decompression after CRS-HIPEC. This study aimed to compare these methods for length of stay (LOS) and associated complications.

Methods

Patients that underwent CRS-HIPEC for peritoneal metastases from colorectal cancer between 2014 and 2019 were included. Cases were grouped based on receiving NGT or PGT postoperatively. Multivariable linear regression determined the independent effect of decompression method on LOS, thereby adjusting for confounders.

Results

In total, 179 patients were included in the analyses. Median age was 64 years [IQR:54–71]. Altogether, 135 (75.4%) received a NGT and 44 (24.6%) received a PGT. Gastroparesis occurred significantly more often in the PGT group (18.2 vs. 7.4%, p=0.039). Median LOS was significantly shorter for patients with a NGT (15 [IQR:12–19] vs. 18.5 [IQR:17–25.5], p<0.001). PGT was independently associated with longer LOS in multivariable analysis (Beta=4.224 [95%CI 1.243–7.204]). There was no difference regarding aspiration, pneumonia and postoperative mortality between groups.

Conclusions

NGT should be preferred over PGT for gastric decompression after CRS-HIPEC as it is associated with fewer gastroparesis and shorter LOS.

Pancreas transplantation would be easy if the recipients were not diabetic: A practical guide to post-operative management of diabetic complications in pancreas transplant recipients

Diabetes mellitus remains a major public health problem throughout the United States with over $300 billion spent in total cost of care annually. In addition to being a leading cost of kidney failure, diabetes causes a host of secondary hyperglycemic-related complications including gastroparesis and orthostatic hypotension. While pancreas transplantation has been established as an effective treatment for diabetes, providing long-term normoglycemia in recipients, the secondary complications of diabetes mellitus persist complicating the post-operative course of an otherwise successful pancreas transplantation. This review describes the mechanism and impact of diabetic gastroparesis and orthostatic hypotension in the post-operative course of pancreas transplant patients and analyzes the various treatment modalities, based on current data and extensive experience at our institution, to treat these respective complications. While gastroparesis and orthostatic hypotension remain challenging post-operative conditions, the establishment of institutional protocols and step-up treatment algorithms can help define more effective therapies.

The implementation of enhanced recovery after surgery protocols in ovarian malignancy surgery

The enhanced recovery after surgery (ERAS) refers to multimodal interventions to reduce the length of hospital stay and complications at various steps of perioperative care. It was first developed in colorectal surgery and later embraced by other surgical disciplines including gynecologic oncology. The ERAS Society recently published guidelines for gynecologic cancer surgeries to enhance patient recovery. However, limitations exist in the implementation of the guidelines in ovarian cancer patients due to the distinct characteristics of the disease. In the present review, we discuss the results that have been published in the literature to date regarding the ERAS protocols in ovarian cancer patients, and explain why more evidence needs to be specifically assessed in this type of malignancy among other gynecologic cancers.

The predictors of Enhanced Recovery After Surgery utilization and practice variations in elective colorectal surgery: a provincial survey

BACKGROUND

Enhanced Recovery After Surgery (ERAS) protocols use evidence-based perioperative practices that reduce morbidity and length of stay and improve patient satisfaction. ERAS is considered standard of care; however, utilization remains low and substantial practice variation exists. The aim of this study was to pragmatically characterize variation in colorectal surgery practice and identify predictors of ERAS utilization.

METHODS

A survey of general surgeons identified using the Ontario College of Physicians and Surgeons database was conducted. Information on basic demographic characteristics, utilization of ERAS and predictors of ERAS implementation was collected. Nine ERAS behaviours were analyzed. Multivariable analysis was used to determine effects of demographic, hospital and surgeon covariates on ERAS utilization.

RESULTS

Seven hundred and ninety-seven general surgeons were invited to participate in the survey, and 235 general surgeons representing 84 Ontario hospitals responded (30% response rate). Surgeons practising in academic settings and in large community hospitals represented 30% and 47% of the respondents, respectively. A total of 20% of the respondents used all 9 ERAS behaviours consistently. Rates of diet advancement on postoperative day 0, intravenous fluid restriction and having catheter and line procedures were significantly higher among respondents who adhered to ERAS protocols than among those who did not (74% v. 54%, p = 0.004; 92% v. 80%, p = 0.01; and 91% v. 41%, p < 0.001, respectively). Respondents from academic settings reported practising nearly 1 more ERAS behaviour than those from small community hospitals (odds ratio [OR] 0.86, 95% confidence interval [CI] 0.42 to 1.31, p < 0.001). Multivariable analysis demonstrated that colorectal fellowship training or exposure to ERAS during training did not significantly affect ERAS behaviour utilization (OR 0.32, 95% CI -0.31 to 0.94, p = 0.16; OR 0.28, 95% CI -0.26 to 0.82, p = 0.16, respectively).

CONCLUSION

Substantial practice variation in colorectal surgery still exists. Individual ERAS principles are commonly followed; however, ERAS behaviours are not widely formalized into hospital protocols.

Guidelines for Perioperative Care in Cytoreductive Surgery (CRS) with or without hyperthermic IntraPEritoneal chemotherapy (HIPEC): Enhanced Recovery After Surgery (ERAS®) Society Recommendations - Part II: Postoperative management and special considerations

BACKGROUND

Enhanced recovery after surgery (ERAS) pathways have been shown to considerably reduce complications, length of stay and costs after most of surgical procedures by standardised application of best evidence-based perioperative care. The aim was to elaborate dedicated recommendations for cytoreductive surgery (CRS) ± hyperthermic intraperitoneal chemotherapy (HIPEC) in a two-part series of guidelines based on expert consensus. The present part II of the guidelines highlights postoperative management and special considerations.

METHODS

The core group assembled a multidisciplinary panel of 24 experts involved in peritoneal surface malignancy surgery representing the fields of general surgery (n = 12), gynaecological surgery (n = 6), and anaesthesia (n = 6). Experts systematically reviewed and summarized the available evidence on 72 identified perioperative care items, following the GRADE (grading of recommendations, assessment, development, evaluation) system. Final consensus (defined as ≥50%, or ≥70% of weak/strong recommendations combined) was reached by a standardised 2-round Delphi process, regarding the strength of recommendations.

RESULTS

Response rates were 100% for both Delphi rounds. Quality of evidence was evaluated high, moderate low and very low, for 15 (21%), 26 (36%), 29 (40%) and 2 items, respectively. Consensus was reached for 71/72(98.6%) items. Strong recommendations were defined for 37 items. No consensus could be reached regarding the preemptive use of fresh frozen plasma.

CONCLUSION

The present ERAS recommendations for CRS ± HIPEC are based on a standardised expert consensus process providing clinicians with valuable guidance. There is an urgent need to produce high quality studies for CRS ± HIPEC and to prospectively evaluate recommendations in clinical practice.

Advancing the Time to the Initiation of Adjuvant Chemotherapy and Improving Postoperative Outcome: Enhanced Recovery after Surgery in Pancreaticoduodenectomy

Early initiation of chemotherapy could improve overall survival after pancreaticoduodenectomy (PD). The concept of enhanced recovery after surgery (ERAS), which aims to reduce the stress response to surgery and accelerate recovery, is relatively limited in PD. The aim of the study was to retrospectively analyze the relationships of ERAS with the time of initiation of postoperative chemotherapy and recovery in PD patients. Between January 1, 2008 and December 31, 2017, all patients who underwent open PD for malignant tumor at our unit were studied retrospectively. Patients were divided into ERAS and conventional groups. The time to initiation of adjuvant chemotherapy and postoperative outcomes were analyzed. There were 344 consecutive patients in this study, with 203 patients in the ERAS group. There were no significant differences between the ERAS and conventional groups in morbidity, mortality, and readmission. The median time of initiation of adjuvant chemotherapy in the ERAS group (54.1 days) was significantly shorter than that of initiation of adjuvant chemotherapy in the conventional group (67.8 days). The ERAS group had a shorter postoperative length of stay than the conventional group (14.9 vs 19.3 days). The ERAS program is safe and feasible in PD. These protocols improve postoperative recovery and advance the time of initiation of adjuvant chemotherapy.

Early feeding in colorectal surgery patients: safe and cost effective

PURPOSE

Enhanced recovery after surgery (ERAS) pathways has demonstrated improved outcomes in colorectal surgery. An important component of ERAS is early oral intake. The aim of this study is to determine the impact of early oral intake in patients following colorectal surgery.

METHODS

A retrospective analysis of patients who underwent colectomy and proctectomy at an academic institution from January 2015 to November 2018 was performed. Postoperative outcomes were compared between patients who had postoperative day 0 (POD 0) oral intake and those who did not.

RESULTS

A total of 436 ERAS patients had oral intake timing documented. The majority of patients were women (241, 55.3%) and white (313, 71.8%). The mean age was 57 ± 15.09. Patients who had early intake were found to have lower 30-day overall morbidity and length of stay (p < 0.05), and no difference in serious adverse events. Additionally, hospital costs were lower in the POD 0 feeding group for all patients (p < 0.05).

CONCLUSION

We have demonstrated that early oral feeding in an established ERAS pathway is associated with improved clinical outcomes as well as decreased total hospital costs. Early postoperative feeding is safe in colorectal patients and should be prioritized to decrease complications and healthcare costs.

Evidence according to Cochrane Systematic Reviews on Alterable Risk Factors for Anastomotic Leakage in Colorectal Surgery

Anastomotic leakage reflects a major problem in visceral surgery, leading to increased morbidity, mortality, and costs. This review is aimed at evaluating and summarizing risk factors for colorectal anastomotic leakage. A generalized discussion first introduces risk factors beginning with nonalterable factors. Focus is then brought to alterable impact factors on colorectal anastomoses, utilizing Cochrane systematic reviews assessed via systemic literature search of the Cochrane Central Register of Controlled Trials and Medline until May 2019. Seventeen meta-anaylses covering 20 factors were identified. Thereof, 7 factors were preoperative, 10 intraoperative, and 3 postoperative. Three factors significantly reduced the incidence of anastomotic leaks: high (versus low) surgeon's operative volume (RR = 0.68), stapled (versus handsewn) ileocolic anastomosis (RR = 0.41), and a diverting ostomy in anterior resection for rectal carcinoma (RR = 0.32). Discussion of all alterable factors is made in the setting of the pre-, intra-, and postoperative influencers, with the only significant preoperative risk modifier being a high colorectal volume surgeon and the only significant intraoperative factors being utilizing staples in ileocolic anastomoses and a diverting ostomy in rectal anastomoses. There were no measured postoperative alterable factors affecting anastomotic integrity.

The Use of Coffee to Decrease the Incidence of Postoperative Ileus: A Systematic Review and Meta-Analysis

PURPOSE

To investigate the efficacy of providing coffee to elective abdominal surgery patients, immediately postoperatively, to lessen postoperative ileus.

DESIGN

A systematic review with meta-analysis of six randomized controlled trials published since 2012.

METHODS

Methodological quality was evaluated using the Cochrane guidelines. The Grading of Recommendations, Assessment, Development, and Evaluations assessment tool evaluated the quality of the evidence. Subgroup analyses were completed if the I² statistic demonstrated heterogeneity (greater than 50%).

FINDINGS

Coffee was statistically significant in shortening the time between surgery and the first passage of stool (mean difference, -9.38; 95% confidence interval, -17.60 to -1.16; P = .03). Although not statistically significant (P = .20), the overall effect favored shorter hospital stays for those patients receiving coffee.

CONCLUSIONS

The current systematic review and meta-analysis suggests that coffee given as early as 2 hours postoperatively decreases time to first bowel movement. In addition, patients tolerated solid food faster and were discharged sooner when given coffee immediately postoperatively.

Nasogastric tube decompression is unnecessary in patients undergoing laparoscopic nephroureterectomy for localized upper tract urothelial carcinoma

BACKGROUND/PURPOSE

This study investigates the safety and feasibility to perform laparoscopic nephroureterectomy (LNU) for upper tract urothelial carcinoma (UTUC) without routine nasogastric tube (NGT) decompression.

METHODS

The hospital-based samples comprised of 100 consecutive UTUC patients receiving elective LNU performed by two experienced surgeons. The nationwide data was based on LHID2005 composed of one million beneficiaries randomly selected from the Taiwan National Health Insurance Research Database to identify patients with the diagnoses of UTUCs receiving LNUs. We then compared baseline characteristics, peri-operative data, convalescence parameters and complications between two groups stratified by use of NGT tube.

RESULTS

The hospital-based samples composed of 50 subjects with NGT and 50 without. There were no significant differences in baseline characteristics between two groups. Peri-operative and convalescence parameters were similar when comparing no NGT versus NGT: blood loss of 206 vs. 165 mL; operative time of 180.5 vs.181.1 min; days to intake was 2.1 vs.1.7 days; and hospital stay of 7.8 vs. 7.5 days (all p > 0.05). The nationwide study samples comprised 140 subjects, of which 72 were with NGT and 68 were with no NGT. The baseline data, complications and length of hospital stay were similar between two groups.

CONCLUSION

Surgery-naïve patients with localized UTUC received LNU without peri-operative NGT is safe and feasible.

Guidelines for perioperative care in gynecologic/oncology: Enhanced Recovery After Surgery (ERAS) Society recommendations-2019 update

BACKGROUND

This is the first updated Enhanced Recovery After Surgery (ERAS) Society guideline presenting a consensus for optimal perioperative care in gynecologic/oncology surgery.

METHODS

A database search of publications using Embase and PubMed was performed. Studies on each item within the ERAS gynecologic/oncology protocol were selected with emphasis on meta-analyses, randomized controlled trials, and large prospective cohort studies. These studies were then reviewed and graded according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system.

RESULTS

All recommendations on ERAS protocol items are based on best available evidence. The level of evidence for each item is presented accordingly.

CONCLUSIONS

The updated evidence base and recommendation for items within the ERAS gynecologic/oncology perioperative care pathway are presented by the ERAS® Society in this consensus review.

Early postoperative oral feeding shortens first time of bowel evacuation and prevents long term hospital stay in patients undergoing elective small intestine anastomosis

AIM

This study was conducted to compare outcome of early oral feeding (EOF) versus traditional oral feeding (TOF) in patients undergoing elective small intestine anastomosis.

BACKGROUND

Appropriate nutritional support after major surgeries is a real medical concern. As traditional surgical techniques have been replaced by novel methods, postoperative care should be revised as well. Early postoperative oral feeding was studied in trauma and burn. However, there are few trials among patients after major surgeries.

METHODS

This randomized single-blinded controlled trial was performed on 108 patients who had small intestine anastomosis at Imam Hossein Medical Centre in 2012. The patients were randomly assigned to schedule EOF (with starting oral feeding on the first day after surgery and complete return of the Gag reflex) or TOF (with delaying oral feeding till first passage of flatus and bowel movement). We compared overall prevalence of postoperative complication, length of hospital stay and outcome of surgery in two groups.

RESULTS

The time of the first passage of stool was shorter in EOF group than in TOF group (3.2 ± 0.59 days versus 3.6 ± 0.66 days (p= 0.006). The mean length of hospital stay in EOF group was also shorter than in TOF group (3.8 ± 1.06 days versus 6.3 ± 1.0 days, p= 0.001). The length of hospital stay shorter than 4 days was found in 75.9% of patients in EOF group and 11.1% of those patients in TOF group (p < 0.001).

CONCLUSION

The use of EOF in patients undergoing small intestine anastomosis can shorten time of the first passage of stool as well as reduce length of hospital stay.

Patient-Controlled Nutrition After Abdominal Surgery: Novel Concept Contrary to Surgical Dogma

Purpose

According to surgical dogma, patients who are recovering from general anesthesia after abdominal surgery should begin with a clear liquid diet, progress to a full liquid diet and then to a soft diet before taking regular meals. We propose patient-controlled nutrition (PCN), which is a novel concept in postoperative nutrition after abdominal surgery.

Methods

A retrospective pilot study was conducted to evaluate the feasibility and effects of PCN. This study was carried out with a total of 179 consecutive patients who underwent a laparoscopic appendectomy between August 2014 and July 2016. In the PCN group, diet was advanced depending on the choice of the patients themselves; in the traditional group, diet was progressively advanced to a full liquid or soft diet and then a regular diet as tolerated. The primary endpoints were time to tolerance of regular diet and postoperative hospital stay.

Results

Time to tolerance of a regular diet (P < 0.001) and postoperative hospital stay (P < 0.001) showed statistically significant differences between the groups. Multivariate analysis using linear regression showed that the traditional nutrition pattern was the only factor associated with postoperative hospital stay (P < 0.001). Multivariate analysis using logistic regression showed that traditional nutrition was the only risk factor associated with prolonged postoperative hospital stay (≥3 days).

Conclusion

After abdominal surgery, PCN may be a feasible and effective concept in postoperative nutrition. In our Early Recovery after Surgery program, our PCN concept may reduce the time to tolerance of a regular diet and shorten the postoperative hospital stay.

Is prophylactic nasogastric tube decompression necessary in patients undergoing laparoscopic adrenalectomy for unilateral benign adrenal tumor

BACKGROUND/PURPOSE

This study aims to investigate the safety and feasibility of laparoscopic adrenalectomy for benign adrenal tumor without peri-operative NGT decompression.

METHODS

From July 2010 to March 2014, 82 consecutive patients with benign unilateral adrenal tumor underwent elective laparoscopic adrenalectomy by a single surgeon were recruited for this study. We compared the clinico-demographic profile, estimated blood loss, operative time, time to full diet, time to ambulate, the length of hospital staying, analgesics use and complications between two groups stratified by the use of NGT.

RESULTS

There were no significant differences in the clinico-demographic profile of the two groups, including age, laterality, body mass index, gender, ASA classification, tumor diameter and histologic types between two groups. Peri-operative parameters were similar between NGT and Non-NGT groups (estimated blood loss, 55.85 vs. 54.4 ml; operative time, 110.3 vs. 112.3 min; p > 0.05) The post-operative outcome of interests, including days to full oral intake (3.32 vs. 3.34 days), days to ambulate (2.07 vs. 2.10 days), hospital stay (4.32 vs. 4.34 days), and analgesics use (6.00 vs. 5.83 mg; all p > 0.05) showed no significant difference between NGT and non-NGT group.

CONCLUSION

Laparoscopic adrenalectomy in patients with benign unilateral adrenal tumor without the use of peri-operative nasogastric tube decompression is safe and feasible.

Factors Influencing Length of Stay after Elective Bowel Resection within an Enhanced Recovery Protocol

A multimodality approach to enhance recovery after bowel surgery is demonstrated to reduce complications and decrease patient length of stay (LOS). This study evaluates the factors that influence patient LOS within a formal enhanced recovery protocol. From January 2014 to December 2016, all consecutive patients admitted to one ward, who had undergone bowel resection and were enrolled in an enhanced recovery protocol, were evaluated prospectively. We entered every patient's data into the American College of Surgeons Risk Calculator (ACSRC) to compare predicted versus actual outcomes. Statistical analysis of clinical factors, patient participation, and outcomes compared with the overall LOS was performed. Of 670 bowel resections performed during the study period, a total of 127 (19%) patients met the criteria and were analyzed for comorbidities, type of surgery, complications, and participation in recovery protocols. The median length of stay (mLOS) for all patients was 4.0 days (1.8–24.6 days). Factors influencing mLOS included laparoscopic versus open surgery (P = 0.006), COPD (P = 0.003), missing 24 hours of ambulation (P < 0.001), use of patient-controlled analgesia (P = 0.011), and diagnosis of insulin-dependent diabetes mellitus (P = 0.041). Increasing the use of morphine equivalents (MEs) increased mLOS beyond the ACSRC estimate (P = 0.003). Developing a major complication increased mLOS by 8.5 times the ACSRC estimate. Conclusion: A multimodality approach to enhance surgical recovery after bowel surgery decreases the LOS. The surgical approach, participation in ambulation, insulin-dependent diabetes mellitus, and COPD influenced the overall LOS. Increasing use of morphine equivalents and developing a complication increased mLOS beyond the ACSRC preoperative risk estimates.

Identification of core items in the enhanced recovery pathway

BACKGROUND & AIMS

The Enhanced Recovery After Surgery (ERAS) pathway represents an optimal approach in patients undergoing colorectal surgery but complexity in implementing its items could limit its application. The aim of this study is to identify possible core items within an ERAS pathway following elective colorectal resection.

METHODS

This is a retrospective review of data prospectively collected between January 2014 and September 2015 by 14 Italian Hospitals in an electronic registry dedicated to an ERAS protocol. 722 patients undergoing elective colorectal surgery within an ERAS protocol have been included in the study. Adherence to ERAS items was assessed in all patients. A secondary analysis was restricted to pre- and intraoperative ERAS items. Time to readiness for discharge (TRD) was the primary endpoint of the study. Postoperative overall morbidity was the secondary endpoint.

RESULTS

Multivariate analyses showed that active intraoperative warming (p = 0.008), early stop of intravenous fluids (p = 0.0001), and early removal of urinary catheter (p = 0.0001) were associated to a shorter TRD, while early stop of intravenous fluids (p < 0.001) also reduced morbidity. When the analysis was restricted to pre- and intraoperative items, removal of NGT at the end of surgery had an independent role to shorten TRD (p < 0.001) and to reduce overall morbidity (p = 0.019), while the absence of oral bowel preparation reduced postoperative overall morbidity (p = 0.021).

CONCLUSIONS

In implementing an ERAS pathway, hospitals could initially focus on active intraoperative warming, early stop of intravenous fluids, early removal of urinary catheter, removal of NGT at the end of surgery, and absence of oral bowel preparation, keeping on continuous effort to apply the complete ERAS protocol.

Adapted ERAS Pathway vs. Standard Care in Patients with Perforated Duodenal Ulcer-a Randomized Controlled Trial

OBJECTIVES

The objective of this study was to evaluate the feasibility and efficacy of ERAS pathways in patients undergoing emergency simple closure of perforated duodenal ulcer (PDU).

METHODS

This single-center, prospective, open-labeled, superiority, RCT was carried out from August 2014 to July 2016. Patients of PDU undergoing open simple closure were randomized preoperatively in 1:1 ratio into standard care and adapted ERAS group. Patients with refractory shock, ASA class ≥3, and perforation size ≥1 cm were excluded. Primary outcome was the length of hospitalization (LOH). Secondary outcomes were functional recovery parameters and morbidity.

RESULTS

Forty-nine and 50 patients were included in standard care and ERAS group, respectively. Patients in ERAS group had a significantly early functional recovery (days) for the time to first flatus (1.47 ± 0.18; p < 0.001), first stool (2.25 ± 0.20; p < 0.001), first fluid diet (2.72 ± 0.38; p < 0.001), and solid diet (3.70 ± 0.44; p < 0.001). LOH in ERAS group was significantly shorter (mean difference of 4.41 ± 0.64 days; p < 0.001). There was a significant reduction in postoperative morbidity such as superficial SSI (RR 0.35, p = 0.02), postoperative nausea and vomiting (RR 0.28, p < 0.0001), and pulmonary complications (RR 0.24, p = 0.04) in the ERAS vs. standard care group with similar leak rates (1/50 vs.2/49).

CONCLUSION

ERAS pathways are safe and feasible in select patients undergoing emergency simple closure of PDU.

Safety of total gastrectomy without nasogastric and nutritional intubation

The aim of the present study was to evaluate the safety of gastrectomy without nasogastric and nutritional intubations. Between January 2010 and August 2015, 74 patients with gastric cancer received total gastric resection and esophagogastric anastomosis without nasogastric and nutritional intubations at the First Department of Digestive Surgery of the XiJing Hospital of Digestive Diseases (Xi'an, China), of whom 42 were also received earlier oral feeding within 48 h. The data were retrospectively analyzed. An additional 301 cases who underwent traditional postoperative intubation were used for comparison. In patients without intubation compared with those managed traditionally with intubation, the mean operative time was decreased (190.97±38.18 vs. 216.12±59.52 min, respectively; P=0.026). In addition, the postoperative activity was resumed earlier (1.16±0.47 vs. 1.36±0.84 days, respectively; P=0.009), oral food intake was started earlier (4.28±1.79 vs. 5.71±2.66 days, respectively; P=0.009), the incidence of fever was lower (12.16 vs. 29.23%, respectively; P=0.003), and the incidence of total complications was not statistically significantly different between the two groups (9.41 vs. 6.31%, respectively; P=0.317). There were no significant differences regarding complications of the anastomotic port (1.37 vs. 1.69%, respectively; P=0.849). Compared with traditional postoperative management, earlier oral feeding did not increase the incidence of complications (7.21 vs. 4.76%, respectively; P=0.557). Our results suggest that total gastric resection without nasogastric and nutritional intubation is a safe and feasible option for patients undergoing total gastrectomy.

One-day nasogastric tube decompression after distal gastrectomy: a prospective randomized study

PURPOSE

Many surgeons in Japan use 1-day nasogastric tube (NGT) decompression after gastrectomy as a standard procedure. This prospective randomized study aimed to define whether 1-day NGT decompression is necessary after distal gastrectomy.

METHODS

The subjects were 233 patients with gastric cancer, randomized into two groups immediately after distal gastrectomy: one group received 1-day NGT decompression (NGT group, n = 119) and the other did not (no-NGT group, n = 114). The primary outcome measure was postoperative surgery-related and respiratory complications, whereas secondary measures were the postoperative course to recovery and patient complaints.

RESULTS

The incidence of surgery-related complications did not differ significantly between the NGT and no-NGT groups (21.0 and 19.2%, respectively; p = 0.87). The rate of respiratory complications was 6.7% in the NGT group and 7.0% in the no-NGT group (p > 0.99). The time to passage of first flatus and the postoperative hospital stay did not differ between the groups. Twenty-five patients in the NGT group and none in the no-NGT group complained of nasopharyngeal discomfort (p < 0.0001).

CONCLUSION

Considering the physical discomfort caused by the NGT, we believe that routine 1-day NGT decompression is unnecessary after distal gastrectomy.

Enhanced recovery after surgery in gastric resections

INTRODUCTION

Enhanced recovery after surgery is a modality of perioperative management with the purpose of improving results and providing a faster recovery of patients. This kind of protocol has been applied frequently in colorectal surgery, presenting less available experience and evidence in gastric surgery.

METHODS

According to the RICA guidelines published in 2015, a review of the bibliography and the consensus established in a multidisciplinary meeting in Zaragoza on the 9th of October 2015, we present a protocol that contains the basic procedures of fast-track for resective gastric surgery.

RESULTS

The measures to be applied are divided in a preoperative, perioperative and postoperative stage. This document provides recommendations concerning the appropriate information, limited fasting and administration of carbohydrate drinks 2hours before surgery, specialized anesthetic strategies, minimal invasive surgery, no routine use of drainages and tubes, mobilization and early oral tolerance during the immediate postoperative period, as well as criteria for discharge.

CONCLUSIONS

The application of a protocol of enhanced recovery after surgery in resective gastric surgery can improve and accelerate the functional recovery of our patients, requiring an appropriate multidisciplinary coordination, the evaluation of obtained results with the application of these measures and the investigation of controversial topics about which we currently have limited evidence.

Role of nasogastric tube in children undergoing elective distal bowel surgery

BACKGROUND

Nasogastric tubes are being routinely used in children and adults undergoing elective abdominal surgery without much scientific evidence supporting their true usefulness. The aim of our study was to assess the role of nasogastric tube in children undergoing elective distal bowel surgery.

MATERIALS AND METHODS

All pediatric patients undergoing elective distal bowel surgery were enrolled and randomized into two groups: those with nasogastric tube (NG group) or without nasogastric tube (NNG group). Outcome parameters such as resumption of bowel function, enteral feed tolerance, postoperative complications, hospital stay and patient with their parent satisfaction were compared between the groups.

RESULTS

A total of 60 patients were included with equal distribution in the NG and NNG groups. Patient variables were comparable in both the groups. Patients in NNG group progressed to full oral feeds significantly earlier (57 ± 18 vs. 106.07 ± 18.35 h, p < 0.001) and had shorter duration of hospital stay (91.93 ± 26.03 vs. 114.67 ± 18.83 h, p < 0.001) as compared to the NG group. Significant number of patients with nasogastric tube reported sore throat (9 vs. 1 p = 0.03) and nausea (5 vs. 0 p = 0.010). There was no significant difference in return of bowel function (39.43 h ± 15.92 vs. 43.60 h ± 17.77, p = 0.171), hiccups, sleep disturbance, complications and nasogastric tube reinsertion rate between the two groups.

CONCLUSION

Routine use of nasogastric tube after elective distal bowel surgery in children is not necessary.

Enhanced recovery after gastro-intestinal surgery: The scientific background

Enhanced recovery programs (ERP) are without any doubt a major innovation in the care of surgical patients. This multimodal approach encompasses elements of both medical and surgical care. The goal of this in-depth review is to analyze the surgical aspects of ERP, underlining the scientific rationale behind each element of ERP after surgery and in particular, the role of mechanical bowel preparation before colorectal surgery, the place of minimal access surgery, the utility of nasogastric tube, abdominal drainage, bladder catheters and early re-feeding. Publication of factual data has allowed many dogmas to be discarded.

Enhanced Recovery Pathways in Pancreatic Surgery

Enhanced recovery after surgery (ERAS) protocols were first introduced to help recovery after colorectal surgery. They have now been applied to multiple surgical specialties, including pancreatic surgery. ERAS protocols in pancreatic surgery have been shown to decrease length of stay and possibly postoperative morbidity.

Impact of centralization of pancreaticoduodenectomy coupled with fast track recovery protocol: a comparative study from India

BACKGROUND

Fast track strategy in the management of patients undergoing intra-abdominal surgery of various types has emerged as a landmark approach to reduce surgical stress and accelerate recovery. This study was to evaluate the effect of fast track strategy on patients subjected to pancreaticoduodenectomy (PD) from an individual unit during transit from low to a high volume center.

METHODS

A total of 142 PD patients who had been subjected to fast track strategy between June 2008 and September 2012 were compared with 46 patients who had received conventional surgery between January 2006 and May 2008. Comparative analysis was made of postoperative complications, postoperative recovery, length of hospital stay and patient readmission requirement.

RESULTS

The patients subjected to fast track strategy had a faster recovery and a shorter hospital stay than those who were treated conventionally (7.8 vs 12.1 days). The intraoperative events like operative blood loss (417.9+/-83.8 vs 997.4+/-151.8 mL, P<0.001), blood transfused (a median of 0 vs 1 unit, P<0.001) and operative time taken (125 vs 245 minutes, P<0.001) were significantly lower in the fast track group. The frequency of pancreatic fistula (4.9% vs 13.0%) and delayed gastric emptying (7.0% vs 17.4%) was also significantly reduced with fast track treatment. Nevertheless, the readmission rate (11.3% vs 6.5%) was found relatively higher within the fast track group. However, increased readmission rates in this study seem to be independent of fast track protocol.

CONCLUSIONS

This preliminary analysis suggests that the fast track approach might be beneficial to the well-being of the patients after PD, for it accelerates the immediate clinical recovery of patients and significantly shortens their length of hospital stay.

Elective Bowel Surgery with or without Prophylactic Nasogastric Decompression: A Prospective, Randomized Trial

Introduction:

Routinely postoperative nasogastric decompression was done until the nasogastric drainage is minimal, reoccurrence of bowel sounds and passing flatus. But prolonged nasogastric intubation is associated with complications like basal atelectasis due to poor cough reflux, loss of electrolytes and increased patient morbidity.

Aims and Objectives:

To study the need for routine use of nasogastric tube post operatively in bowel surgeries with reference to (1) Return of bowel movements (2) Compare the incidence of complications (3) Duration of hospital stay.

Methodology:

100 patients who underwent elective bowel surgery were randomized into two groups: Study group (50): Nasogastric tube was removed immediately after operation or in the recovery room. Control group (50): Underwent nasogastric tube removal postoperatively after the patient passed flatus and audible bowel sounds on auscultation.

Results:

Incidence of complications were less in the study group i.e., only three patients had vomiting, and two patients had abdominal distension which lead to postponement of oral feeds. Most of our control group patients complained of discomfort and difficulty in coughing and in bringing out sputum, which was the probable cause for high incidence of pulmonary complications.

Conclusion:

Routine use of the nasogastric tube adjunct to patient care following bowel surgery may be safely eliminated.

Redefining the implications of nasogastric tube placement following radical cystectomy in the alvimopan era

PURPOSE

Alvimopan has decreased ileus and need for nasogastric tube (NGT) after radical cystectomy (RC). However, the natural history of ileus versus intestinal obstruction in patients receiving alvimopan is not well defined. We sought to examine the implications of NGT placement before and after the introduction of alvimopan for RC patients.

METHODS

Retrospective review identified 278 and 293 consecutive patients who underwent RC before and after instituting alvimopan between June 2009 and May 2014. Baseline characteristics and postoperative outcomes were compared by alvimopan status. Multivariate logistic regression was performed to assess the impact of alvimopan on rates of NGT placement and reoperation for bowel complications.

RESULTS

The cohorts had similar age, stage, approach, and BMI. Patients receiving alvimopan had decreased ileus (16 vs 32 %, p < 0.01) but similar rates of reoperation for bowel complications (2.8 vs 2.7 %). On multivariate analysis, alvimopan was associated with lower risk of NGT placement (OR 0.30, p < 0.01). For patients requiring NGT placement, there was an increased rate of reoperation among patients receiving alvimopan compared with those who did not (28 vs 11 %, p = 0.03). Patients receiving alvimopan who needed NGT had significantly increased median length of stay (22 vs 7 days), need for TPN (66 vs 5.3 %), and readmission for ileus (10.3 vs 2.3 %) compared with those who did not require NGT.

CONCLUSIONS

Alvimopan significantly reduced the incidence of ileus and NGT placement following RC. NGT placement was associated with an increased need for reoperation for bowel complications in the setting of alvimopan.

Randomized Controlled Trial for Evaluation of the Routine Use of Nasogastric Tube Decompression After Elective Liver Surgery

BACKGROUND

The value of routine nasogastric tube (NGT) decompression after elective hepatetctomy is not yet established. Previous studies in the setting of non-liver abdominal surgery suggested that the use of NGT decreased the incidence of nausea or vomiting, while increasing the frequency of pulmonary complications.

STUDY DESIGN

Out of a total of 284 consecutive patients undergoing hepatectomy, 210 patients were included in this study. The patients were randomized to a group that received NGT decompression (NGT group; n = 108), in which a NGT was left in place after surgery until the patient passed flatus or stool, or a group that did not receive NGT decompression (no-NGT group; n = 102), in which the NGT was removed at the end of surgery.

RESULTS

There were no differences between the NGT group and no-NGT group in terms of the overall morbidity (34.3 vs 35.3 %; P = 0.99), incidence of pulmonary complications (18.5 vs 19.5 %; P = 0.84), frequency of postoperative vomiting (6.5 vs 7.8 %; P = 0.70), time to start of oral intake (median (range) 3 (2-6) vs 3 (2-6) days; P = 0.69), or postoperative duration of hospital stay (19 (7-74) vs 18 (9-186) days; P = 0.37). In the no-NGT group, three patients required reinsertion of the tube 0 (0-3) days after surgery. In the NGT group, severe discomfort was recorded in five patients.

CONCLUSIONS

Routine NGT decompression after elective hepatectomy does not appear to have any advantages.