1. The prophylactic use of nasogastric tube as a routine procedure after abdominal operations Seattle Children’s Hospital – Pediatric Surgery Panos Vardas, MD

2. C.S. 16 yo M transferred from Yakima Valley Hospital to SCH on 1/29: 10 days Hx of abdominal pain and diarrhea and 1 day Hx of vomiting. CT abd and pelvis (1/23): possible dilation of the appendix to 1.4 cm and 2 possible fluid collections. Dilated loops of bowel and air fluid levels At Yakima: GS consult  did not feel there was “indicated a surgical management “ C. diff (-) and stool Cx (-) Was treated for gastrenteritis, and prerenal azotemia

3. At SCH Emergency Department: VS: 39.5/109/154-81/26/96% on RA. Suprapubic pain and tenderness. Non peritoneal. WBC- 21.4 (Polys-73%), CRP-33.3 U/S  Appendiceal enlargement and loss of normal architecture distally, consistent with perforated appendicitis and a fluid collection 4.7 x 5.9 x 4.5 cm, superior to the bladder. Surgery consult: Admitted, NPO, IVF, Zosyn, IR drainage on 1/30

4. On 2/2- Surgical Floor: Patient distended. Abdominal x-Ray: distal SBO OR: ex-lap, LOA and ileocecectomy w/ 50cm resection of terminal ileum: “minimal purulence, but very dense inflammatory adhesions and a high-grade small-bowel obstruction” Post-op: Epidural, NGT to LIS (high bilious output), NPO POD 3: Epidural pulled, started ketorolac.

5. On 2/8- Surgical Floor: POD 6: Hematemesis, NGT w/bloody output. Tachy to 130s, more lethargic. RRT called. Hct: 26.8  24.9  17 w/ ongoing bloody emesis Toradol d/c, started PPI, 2 U PRBCs, IVF and g. lavage GI consulted and performed EGD: “Linear ulceration in the cardia fundus of the stomach, LIKELY CAUSED by the nasogastric tube.” “Also, nodularity in the pyloric antrum and duodenum consisting w/ H.Pylori gastritis. No active bleeding ulcers.” PICU for monitoring. No more bleeding, no NGT.  Surgical floor: tolerated diet, normal post-op course and discharged home on PO antibiotics and PPI on 2/14.

7. Indications:  Bowel obstruction management (monitors progress, prevents recurrent vomiting)  Administration of medications (oral contrast in pts unable to swallow)  Enteral nutrition  Stomach lavage Contraindications:  Esophageal stricture or varices  Facial or basilar sculp fracture Nasogastric tube use

8.  Traditionally used by most surgeons  Standard of care  Common practice, unquestioned and routine for almost a century. The prophylactic use of nasogastric tube after abdominal operations

9. Intent of use:  Gastric decompression and decreased distention  Decreased likelihood of nausea and vomiting  Less risk of wound separation and infection  Less chance of pulmonary aspiration and pneumonia  Earlier return of bowel function and earlier discharge from hospital The prophylactic use of nasogastric tubes after abdominal operations

10. -Does the routine/prophylactic NGT placement after an abdominal operation make any difference?

11. British Journal of Surgery 2005; 92: 673-680 28 Randomized clinical trials (4194 patients) 2108 patients were randomized to routine NG decompression 2087 patients were randomized to selective NG decompression o Patients were adults o All types of operation: elective + emergency (including penetrating trauma, but NOT laparoscopic procedures) o Control group: no NGT or NGT only in the OR

12. British Journal of Surgery 2005; 92: 673-680 Outcome measures: First flatus as evidence of return of bowel function Pulmonary complications (atelectasis and pneumonia) Fever Wound infection Length of post-operative stay Wound dehiscence Anastomotic leak Ventral hernia Nausea and/or vomiting Need for tube insertion/ reinsertion Death Pain or discomfort tube related Adverse events related to the tube

13. - Routine nasogastric decompression does not accomplish any of its intended goals and so should be abandoned in favor of selective use of the nasogastric tube. Conclusion: British Journal of Surgery 2005; 92: 673-680 Earlier return of bowel function (p < 0.001) Marginal decrease in pulmonary complications (p = 0.07) Marginal increase in wound infection (p = 0.08) and ventral hernia (p= 0.09) No difference for anastomotic leakage These are the 4 outcome measures that heterogeneity was not encountered in meta-analysis. Group without NGT routinely inserted

14. Children are thought to swallow a large amount of air when crying  the use of NG decompression following laparotomy is often routine. 94 children (age 3.8 ± 0.5) who underwent abdominal surgery by a single surgeon, compared with 94 retrospective match controls routinely managed with NGT Excluded patients with bowel obstruction or intra-abdominal infection The two groups had no difference in gender, age or postoperative complications

16. The group treated without the use of routine NG decompression: Significant decrease in time of first feed, of first stool, of discharge Higher incidence of post-operative vomiting (“For every patient requiring insertion of a NGT in the postoperative period, at least 20 patients will not require NGT decompression”- Annals of Surgery, 1995) Conclusion: - Routine nasogastric decompression is not justify by decreasing alone the post- operative vomiting, as it increases discomfort and the hospital stay. Instead, a selective use for specific indications in pediatric patients should be implied.

17.  In literature very few papers review the topic for the group of patients w/ contamination of the peritoneal cavity prior to surgery, which predisposes to ileus and delayed return of bowel function Retrospective chart review of all children operated for perforated appendicitis between 1999 - 2004 Patients with prolonged hospitalizations (>7days) /complications were excluded, to eliminate bias and data in favor of pts with NGT 105 pts with NGT after laparoscopic or open appendectomy (age 8.4 ±0.5 yo) 54 pts without NGT after laparoscopic or open appendectomy (age 7.6±0.4 yo)

19. Mean time to first oral intake was 3.8 days NGT Mean time to first oral intake was 2.2 days Without NGT (P < 0,001) Mean length of stay was 6 days NGT Mean length of stay was 5.6 days Without NGT (P < 0,002) Conclusion: The routine use of NG decompression after an operation for perforated appendicitis does not appear to improve the postoperative course. NG postoperative placement should be viewed as an adjunct to symptom control, like an anti-emetic, and not a maneuver that prevents complications or shortens hospital stay.

20. Patient C.S.:  What would you have done different? NG decompression?  YES There is no evidence against NG decompression in the setting of small bowel obstruction. “Selective use”  Use of tubes and radiographs in the management of small bowel obstruction. Ann Surg. 1987;206(2):126. Anything different?  YES An earlier administration of gastric antisecretory therapy (PPI), in the presence of prolonged fasting and NSAID- induced chemical gastropathy. For