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  IN THIS Article
 ::  Introduction
 ::  Material and methods
 ::  Results
 ::  Discussion
 ::  References

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Year : 1985  |  Volume : 31  |  Issue : 2  |  Page : 102-4

No tube regimen in gastric surgery (a study of 201 cases).







How to cite this article:
Dorairajan N N, Kannan K K, Venkataraman M S. No tube regimen in gastric surgery (a study of 201 cases). J Postgrad Med 1985;31:102


How to cite this URL:
Dorairajan N N, Kannan K K, Venkataraman M S. No tube regimen in gastric surgery (a study of 201 cases). J Postgrad Med [serial online] 1985 [cited 2019 Dec 11];31:102. Available from: http://www.jpgmonline.com/text.asp?1985/31/2/102/5414




  ::   Introduction Top

Nasograstric intubation has been in use for more than a decade now.[1] Various factors like lack of pre-operative bowel preparation, poorly developed anaesthetic technics, sepsis and various metabolic factors warranted its continued use in the earlier days. However, the present knowledge of effective pre-operative preparation, post-operative management and highly developed anaesthetic methods make the routine use of the nasogastric tube obsolete. We, herein, wish to present our experience in 201 cases undergoing gastric surgery but without the postoperative use of the nasogastric tube.

  ::   Material and methods Top

Vagotomy with drainage procedure or drainage procedure alone was performed in 201 cases admitted to our surgical unit of The Government General Hospital and Medical College, Madras over a period of 30 months. Various surgical procedures employed in these cases are shown in [Table - 1]. The ages of the patients varied from 13 to 75 years. Patients who had gastric surgery as an emergency or for haematemesis were not included in this study. Only liquid diet was allowed in these patients 24 hours prior to surgery. Pre-operative enema was given. A nasogastric tube was used for pre-operative and per operative aspirations only and was removed soon after the patient recovered from anaesthesia. No oral fluids were allowed for 48 hours or longer post-operatively and the patients were managed with intravenous fluids only. In a few cases selected at random, gastrograffin study of the motility of the stomach was done in the immediate post-operative period. The contrast was given two hours after surgery and the patients were screened for movement of the contrast into the anastomosis and/or the duodenum.

  ::   Results Top

Follow-up of patients was done on the following criteria: (a) abdominal girth, (b) passage of flatus, (c) onset of peristaltic sounds, (d) presence of any complications and (e) gastrograffin studies. Abdominal distension never exceeded 4 cm in any patient; the abdominal girth returned to the pre-operative levels within 60-96 hours in all except two cases [Table - 2]. Of these two cases, one had an anterior gastro-jejunostomy for carcinoma of the antrum of the stomach and the other had posterior gastro-jejunostomy for chronic duodenal ulcer. Abdominal distension was evident in these two cases on the second and third post-operative days respectively. Nasogastric tube was re-introduced and the patients were managed with intravenous fluids only. The aspiration of gastric contents was continued. The abdominal distension settled, aspirate lessened in quantity and the nasogastric tube was removed on the 5th and 4th post-operative days respectively. Vomiting necessitating re-introduction of the nasogastric tube was present only in one case. These three patients had mild to severe discomfort preceding the re-introduction of the nasogastric tube. Two patients developed respiratory infection on the 2nd post-operative day. They were treated with antibiotics, bronchodilators and steam inhalation. All the remaining patients were subjectively comfortable.
Intestinal peristalsis was heard and flatus was passed on the 2nd or the 3rd post-operative day. The patients were allowed oral fluids thereafter.
No other complications were evident in any of the patients of our series.
Gastrograffin introduced two hours after truncal vagotomy and posterior gastrojejunostomy [Fig. 1] was visualized in the anastomotic site and duodenum as early as 45 minutes [Fig. 2].

  ::   Discussion Top

Two methods of gastric decompression, are in vogue: (A) nasogastric and (b) transgastric. The advantages of nasogastric intubation are: (i) pre-operative preparation of a dilated stomach, (ii) pre-operative aspiration of secretions and (iii) postoperative gastric decompression to prevent abdominal distension and aspiration of secretions into the lungs. The disadvantages of this procedure are: (a) irritation leading to pressure necrosis, ulceration and aural complications in the nose,[4] (b) ulceration with subsequent fibrosis and laryngeal damage,[2],[4] (c) perforation of the recent gastric suture lines due to pressure from the nasogastric tube,[3] (d) incompetence of the sphincters leading to gastro-oesophageal reflux, oesophagitis, and even stricture at the cardia,[2],[5],[8] (e) interference with deglutition leading to aspiration of saliva or of regurgitated gastric contents,[3] (f) respiratory problems due to entry of air in the oesophagus and stomach,[5],[7] and (g) increased gastric secretions bleeding and knotting of the tube itself. (B) Transgastric decompression, on the other hand, is free from the above-mentioned disadvantages. The larger tube allows more efficient gastric decompression. It can be kept for prolonged periods without any inconvenience to the patient. This tube does not induce the patient to swallow air or to produce as much saliva as the nasogastric tube which may add to the abdominal distension. However, this mode of decompression has its own disadvantages such as local septic complications and fistula formation. More over, it is required to be kept for a minimum of 4-5 days to allow formation of a track to prevent any leak into the peritoneal cavity.
In view of the shortcomings of both the tubes, a no-tube regime has been tried in this series. Routine use of nasogastric decompression is dispensable in the postoperative management of many upper gastro-intestinal surgeries even though it has its own limited value in the management of emergency cases and following surgery for haematemesis.

  ::   References Top

1.Barnes, A. D. and Williams, J. A.: Post-operative gastric drainage tubes. In, "After Vagotomy." Editors: J. A. Williams and A. G. Coe, Butterworths, London, 1969, pp. 293-305.  Back to cited text no. 1    
2.Farris, J. M. and Smith, G. K.: An evaluation of temporary gastrostomy as a substitute for nasogastric suction. Ann. Surg., 144: 475-486, 1956.  Back to cited text no. 2    
3.Gillesby, W. J. and Puestow, C. B.: 'Tube gastrostomy in abdominal surgery. American Surgeon, 25: 927-930, 1959.  Back to cited text no. 3    
4.Hafner, C. D., Wylie, J. H. and Brush, B. E.: Complications of gastrointestinal intubation. Arch. Surg., 83: 147-160, 1961.  Back to cited text no. 4    
5.Maddock, W. G., Bell, J. L. and Tremaine, M. J.: Gastro-intestinal gas; observations on belching during anaesthesia, operations and pyelography and rapid passage of gas. Ann. Surg., 130: 512537, 1949.  Back to cited text no. 5    
6.McGredie, J. A. and McDowell, R. F. C.: Oesophageal stricture following intubation in a case of hiatus hernia. Brit. J. Surg., 46: 260-261, 1958.  Back to cited text no. 6    
7.Mehnert, J. A., Brown, M. J., Woodwarl, B., Paetkeu, E. and Donovan, P. B.: A clinical evaluation of postoperative naso-gastric suction. Surg. Gynaec. & Obstet., 109: 607-612, 1959.  Back to cited text no. 7    
8.Nagler, R. and Spiro, H. M.: Persistent gastro-oesophageal reflux induced during prolonged gastric intubation. New Engl. J. Med., 269: 495-500, 1963.  Back to cited text no. 8    

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Online since 12th February '04
2004 - Journal of Postgraduate Medicine
Official Publication of the Staff Society of the Seth GS Medical College and KEM Hospital, Mumbai, India
Published by Wolters Kluwer - Medknow