1. Efficacy and Necessity of Nasojejunal Tube after Gasrectomy Presented by Dr. Sadjad Noorshafiee Resident of General Surgery Supervised by Dr.A.tavassoli General surgeon Endoscopic and Minimally Invasive Surgery Research Center

2. Background History: more than 300 years History: more than 300 years Levine in 1921 Levine in 1921 What is Nasogastric or nasojejunal tube? What is Nasogastric or nasojejunal tube?

3. Benefits: treatment: abdominal Benefits: treatment: abdominal distention distention vomiting vomiting diagnosis: GI bleeding diagnosis: GI bleeding prophylaxis: Ileus in major prophylaxis: Ileus in major abdominal operations abdominal operations

4. Major concern is ileus after abdominal operations; this entity leads to abdominal distention, nausea and vomiting, so risk of aspiration and pneumonia, wound dehiscence and inscisional hernia would be increased Major concern is ileus after abdominal operations; this entity leads to abdominal distention, nausea and vomiting, so risk of aspiration and pneumonia, wound dehiscence and inscisional hernia would be increased

5. Finally ileus leads to over pressure on anastomosis especially in upper GI; this could leads to anastomosis disruption and leakage; a very devastating complication. Finally ileus leads to over pressure on anastomosis especially in upper GI; this could leads to anastomosis disruption and leakage; a very devastating complication. This complication is the major cause of morbidity and mortality in these groups of surgical patients. This complication is the major cause of morbidity and mortality in these groups of surgical patients.

6. On the other hand, it has been reported that NJ tubes makes more discomfort for patient and increase the rate of respiratory complications by abruption of lower esophageal function On the other hand, it has been reported that NJ tubes makes more discomfort for patient and increase the rate of respiratory complications by abruption of lower esophageal function Additionally its benefits are under question Additionally its benefits are under question

7. Few studies evaluate the efficacy and necessity of NJ tubes and to our knowledge there is no prospective study in this era in IRAN Few studies evaluate the efficacy and necessity of NJ tubes and to our knowledge there is no prospective study in this era in IRAN

8. How this idea came to us?

9. The aim of this study is to evaluate the efficacy and necessity of nasojejunal tube after total gastrectomy The aim of this study is to evaluate the efficacy and necessity of nasojejunal tube after total gastrectomy

10. Materials and Methods interventional interventional Total gasterectomy with D2 lynphadenectomy and roux-en-y esophagojejunostomy Total gasterectomy with D2 lynphadenectomy and roux-en-y esophagojejunostomy (56 patients totally)50 patients enrolled (56 patients totally)50 patients enrolled from 2001 to 2008 from 2001 to 2008 approved by the ethical committee approved by the ethical committee explained for the patients and informed written consent was taken explained for the patients and informed written consent was taken

11. Exclusion criteria history of abdominal irradiation history of abdominal irradiation emergency surgery emergency surgery operative technical difficulties operative technical difficulties additional resections (splenectomy, pancreatectomy) additional resections (splenectomy, pancreatectomy)

12. patients were randomly divided into two groups:25 with tube and 25 without patients were randomly divided into two groups:25 with tube and 25 without In the tube group, the tube was left in at least 36 h after operation for continuous drainage until passage of flatus or stool. In the tube group, the tube was left in at least 36 h after operation for continuous drainage until passage of flatus or stool. In the group of without a tube, the tube was removed when the patient was in the recovery room. In the group of without a tube, the tube was removed when the patient was in the recovery room.

13. Diet beginning Diet beginning Antibiotic and DVT prophylaxis Antibiotic and DVT prophylaxis

14. Evaluated factors The day of passage of flatus and oral food intake, the duration of nasogastric or nasojejunal decompression, postoperative perfusions, and length of hospital stay were recorded. The day of passage of flatus and oral food intake, the duration of nasogastric or nasojejunal decompression, postoperative perfusions, and length of hospital stay were recorded.

15. Mortality, abdominal complications (generalized peritonitis, deep abscesses, obvious fistulas, wound complications), pulmonary complications (pneumonia, atelectasis), postoperative fever, nausea, and vomiting, tube insertion or reinsertion, and discomfort from the tube (pain, nasal soreness, painful swallowing) were evaluated Mortality, abdominal complications (generalized peritonitis, deep abscesses, obvious fistulas, wound complications), pulmonary complications (pneumonia, atelectasis), postoperative fever, nausea, and vomiting, tube insertion or reinsertion, and discomfort from the tube (pain, nasal soreness, painful swallowing) were evaluated

16. results Data were analyzed with fisher exact test and Man –Whitney test and two groups were compared statistically Data were analyzed with fisher exact test and Man –Whitney test and two groups were compared statistically

17. Patients’ demographic and operative characteristics

18. Tumor location in the studied patients

20. Frequency of bloating in patients with NJT and without NJT

21. Pain score at 3rd and 6th day after operation in both groups

22. Morbidity and mortality rate in two groups

23. They were also asked for discomfort of having the tube and scored from 0 to 3 (0: without discomfort, 1: mild, 2: moderate, 3: severe). The score average was 2.42±1.57 that means all the patients moderately feel discomfort of having NJT They were also asked for discomfort of having the tube and scored from 0 to 3 (0: without discomfort, 1: mild, 2: moderate, 3: severe). The score average was 2.42±1.57 that means all the patients moderately feel discomfort of having NJT

25. Discussion Advocators of NJT believe that it leads to sooner GI motility, early feeding, less abdominal complain and protection of esophagogastric anastomosis; some other authors noted the complications and reported that its benefits are under question Advocators of NJT believe that it leads to sooner GI motility, early feeding, less abdominal complain and protection of esophagogastric anastomosis; some other authors noted the complications and reported that its benefits are under question

26. All abdominal operations Cheatham et al. : 3964 patients 1995 Cheatham et al. : 3964 patients 1995 Days of first oral intake were significantly fewer, and pulmonary complication and postoperative fever were significantly lower in without NJT group. they experienced an earlier return of bowel function, a marginal decrease in wound infection, and ventral hernia. Anastomosis leakage was similar in the two groups Days of first oral intake were significantly fewer, and pulmonary complication and postoperative fever were significantly lower in without NJT group. they experienced an earlier return of bowel function, a marginal decrease in wound infection, and ventral hernia. Anastomosis leakage was similar in the two groups Nelson et al :same findings in 2005 Nelson et al :same findings in 2005

27. After total gasterctomy Yoo et al. :136 cases 2002 Yoo et al. :136 cases 2002 time to passage of flatus, time to taking liquid diet, and postoperative hospitalization were significantly shorter in the no-decompression group time to passage of flatus, time to taking liquid diet, and postoperative hospitalization were significantly shorter in the no-decompression group They showed that postoperative insertion of NJT was with delay in beginning oral intake and longer hospital stay They showed that postoperative insertion of NJT was with delay in beginning oral intake and longer hospital stay

28. Akbaba et al. :66 patients 2004 Akbaba et al. :66 patients 2004 bloating and vomiting were similar in both groups of with and without NJT, but fever and pulmonary complications were higher in NJT group bloating and vomiting were similar in both groups of with and without NJT, but fever and pulmonary complications were higher in NJT group

29. In our study, there was no significant different between two groups in named complications In our study, there was no significant different between two groups in named complications

30. Chang et al. 2003 Chang et al. 2003 There was statistically significant difference between two groups in the view of the rate of patients’ discomfort. The main complain was sore throat and sleep disorders There was statistically significant difference between two groups in the view of the rate of patients’ discomfort. The main complain was sore throat and sleep disorders

31. Carrire et al. 2007 complains about NJT were moderate to severe in 72% of cases after total gastrectomy Carrire et al. 2007 complains about NJT were moderate to severe in 72% of cases after total gastrectomy It was the same in our study It was the same in our study

32. On the other hand, Montgomery et al. in 1996 have described the nasogastric tubes as the standard of care after gastrectomy On the other hand, Montgomery et al. in 1996 have described the nasogastric tubes as the standard of care after gastrectomy

33. Conclusion insertion of NJT after gastrectomy didn’t have any effect in the prevention of anastomosis; moreover causes patients’ discomfort, so we didn’t recommend the use of NJT after gastrectomy. insertion of NJT after gastrectomy didn’t have any effect in the prevention of anastomosis; moreover causes patients’ discomfort, so we didn’t recommend the use of NJT after gastrectomy.