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Abdominal decompression: Increased efficiency by esophageal aspiration utilizing a new nasogastric tube
Abdominal Decompression: Increased Efficiency by Esophageal Aspiration Utilizing a New Nasogastric Tube Gerald Moss, PhD, MD, FACS, Troy, New York Robert C. Friedman, MD,* Troy, New York
Distention of the gastrointestinal tract by accumulated swallowed air is well recognized as a major factor in the development of adynamic ileus. Active prophylactic or therapeutic measures have been directed toward removal of the air after its arrival into the large capacity stomach. The most common regimens utilize a nasogastric (Levin-type) tube. Occasionally there is direct transabdominal placement of a gastrostomy tube. Neither approach is efficient. It was the purpose of this study to evaluate these regimens objectively and contrast results with a supplemental aspiration site, the esophagus, which improved efficiency on clinical testing by a factor of approximately 12:l. By a radiographic study upon a volunteer subject, the reason for inefficiency was clearly demonstrated, and the esophagus was validated as a logical site for aspiration. Material and Methods Clinical Study. The decision to utilize decompression was not influenced by the conduct of the study. Each regimen was chosen, initiated, and terminated by the patient’s surgeon based upon his usual indications. There were twenty-four patients with Levin-type tubes, five with gastrostomies, and thirty-one with esophagogastric aspiration [4]. All were given “cold” iodide to block thyroid uptake of radioiodide and insure stoichiometric urinary excretion of the unremoved residual “tag.” When the surgeon decided his patient no longer needed decompression, the tube was irrigated to insure patency, and the adequacy of suction was checked. The patient swallowed a 50 ml bolus of Hz0 containing 0.5 PC Na12”I, followed by 100 ml of “cold” HsO. Suction was continued for 1 minute after all visible aspiration had ceased. Each tube then was disconnected from the suction trap, and manually irrigated with 50 ml saline (X3). Each time a maximum effort was made to withdraw the gastric washings, which were pooled with the initial aspirate for
From Rensselaer Polytechnic Institute. Biomedical Engineering Laboratory. and Departments of Surgery and Radiology’, Memorial Hospital, Troy, New York. Repint requests shovkl be addressed to Geraki Moss, PhD, MD, Professor of Biomedical Engineering, Rensselaer Polytechnic Instttute,Troy, New York 12181.
Volume 133, February 1977
counting. The unremoved lz51 (inefficiency) was calculated and confirmed by assay of its excretion in the patient’s 24 hour urine collection. Radiographic Study. On separate occasions a healthy volunteer (GM) had either a Levin-type tube or the esophagogastric device inserted, with proper position verified by fluoroscopy. The supine subject swallowed 100 ml of barium sulfate suspension, while 100 mm Hg suction was applied on each occasion to the tube. The resultant patterns of contrast agent passage were recorded on videotape and tine photography. Results Clinical Study. vse of the Levin-type tube (24 patients) resulted in 35 f 17 per cent residual activity (inefficiency); the gastrostomy tube (5 patients) 42 f 28 per cent residual activity (inefficiency); and the esophagogastric aspiration tube (31 patients) 3 & 3 per cent residual activity (inefficiency). Radiographic Study. Despite the “properly” positioned Levin-type tube within the stomach (which removed some contrast agent), the swallowed bolus promptly traversed the length of the stomach to enter and visualize the duodenum and jejunum. (Figure 1.) (The senior author was reassured that he did not have a duodenal ulcer.) With esophagogastric aspiration, the swallowed bolus was intercepted within the esophagus and did not enter the stomach. (Figure 2.) (In a previous unrecorded study, a minimal quantity of barium sulfate did appear in the stomach to outline this organ. The agent adhered to the mucosa and during the time of study did not lead to visualization of the duodenum.) Comments
Gastrointestinal peristalsis begins its recovery immediately after surgery [I]. Visible activity is observed frequently while the abdominal incision is closed. This hypofunctioning gastrointestinal tract is vulnerable to complete decompensation by accumulation of swallowed gas delivered into the small and large intestine. Visceral distention will terminate peristaltic activity (enterogastric and enteroenteral reflexes).
Moss and Friedman
Figure 1. Left, suptne with volunteer Levin on tube suctkn. lhe is tube visible in stomach the because of its radiopaque marker. Note channels followed by barium &fate not in contact with the aspiration orifices. Right, in same subJect after 2 minutes, radiopaque meal has traversed stomach We enter to and outline the duodenum and small bowel. Levin The tube is obscured but functional.
Figure 2. Same volunteer separate on occasion with esophagogastric aspiration devke on suction. The swallowed radiopaque bolus (#7) does descend not beyond the distal esophagus, from which it is aspirated. The radioiucent air-filled balloon is at the esophagogastric Junction (#2). No barium suifate was visualized within the stomach.
226
Aspiration of the large volume, muscular stomach is inefficient. A swallowed bolus is propelled in multiple parallel channels (“magenstrasse”) toward the pylorus. These streams can be anterior, posterior, superior, or inferior to the gastric aspiration orifices of the Levin-type tube, which are bypassed. (Figure 1, left.) Only material in intimate contact with the gastric orifices can be aspirated. Nasopharyngeal and esophageal irritation by a nasogastric tube provokes aerophagia. With early return of gastric peristalsis and inefficient gastric aspiration, a greater net volume of air may enter the bowel than if the device had been omitted. Bowel sounds, indicative of peristalsis, are present in the recovery room (but are seldom listened for). Most usually these disappear by the next morning as recovery of gastrointestinal function is aborted and paralytic ileus supervenes. We reasoned that the esophagus of small circumference would not allow for channeling of air to bypass aspiration orifices within this tubular structure. Our original device [2] (circa 1963) was bulky (#28 French), relatively expensive, and poorly accepted, but it functioned well. An elemental diet was delivered distal to the aspiration site and was absorbed enterally. Positive protein and caloric balance were achieved within hours of major abdominal surgery [2,3]. This was confirmed independently by Lorrain and Page [4] in patients who underwent cholecystectomy and aortic aneurysmectomy. They noted passage of stool and flatus three days earlier than with conventional regimens. Their patients regained admission weight by the time of discharge, attributed to nutrition, not fluid. They concluded that hospital stay was shortened, but this remains a statistically unverified opinion.
The American Journal of Surgery
Abdominal Decompression
ATTACH TO SUCT/OIV
BALLOON /NFL AT/OA’ VALVE y
/
BALLOON /AFL A7701V TUBE MAIN LUME# ESOPHAGEAL OR/F/CE
GASTRK’ Off//=/CE \
/
/i’
Figue 3. Diagram of esophagogastrlc aspiration balloon device (National Catheter Corp, Argyle, NY).
Studies of an animal model in which elemental diet was fed immediately after bowel resection showed that the exogenous nutrients were incorporated into plasma and wound proteins, whose syntheses were stimulated [5]. Total glucose oxidation was approximately double that of the unfed controls [6]. This correlated with increased insulin levels and the availability of massive carbohydrate substrate. At 96 hours postoperatively, the bursting strength of the bowel wounds of the fed beagles was approximately triple that of the unfed controls [6]. DNA synthesis in the healing bowel wound was 6.2 times that of the unfed controls at 72 hours [ 71. A newer device has become available recently that utilizes esophagogastric aspiration but. is of more acceptable size (# 20 French), and is mass-produced by extrusion rather than made by hand. (Figures 3 and 4.) With twelvefold the efficiency of the Levintype tube, it is expected that this will supplant the latter device (circa 1921) [S].
Volume 133, February 1977
The nasogastric device bears a superficial resemblance to the familiar Foley catheter. It consists of two lumens, the smaller of which inflates a 30 ml balloon with air after passage into the stomach. The tube is withdrawn until the balloon is positioned at the esophagogastric junction and is secured without tension. The larger lumen has openings both above and below the balloon and, when placed on continuous suction, aspirates both the esophagus and the stomach. The patient may drink water or hot tea. This irrigates the tube and serves as a check on function as the swallowed bolus immediately returns from the esophagus. This efficient esophageal aspiration provides some potential problems. The patient with thick, profuse bronchial secretions must be instructed to expectorate into tissues. If such secretions are swallowed, this rapidly plugs the aspiration lumen, requiring prompt irrigation. Also, all nasogastric tubes cause small amounts of nasopharyngeal irritation and bleeding. A few specks
Moss and Friedman
Figure 4. Diagram of esophagogastric aspiration balloon device, with sewrate kimen in duodenum for feeding. (Reprinted with permission of publisher from [ 71.)
of “coffee grounds” returned by the Levin-type tubes (after acidification of the blood) cause no alarm. The same bright red return from the esophagus causes concern unless personnel are prewarned. This modern device also is available in a modified form (still #20 French) but with an additional fine-feeding lumen to be passed through the pylorus at the time of surgery. (Figure 4.) Elemental diet is delivered into the duodenum immediately after the procedure to take advantage of the returning of gastrointestinal function. Utilizing this regimen, we performed elective cholecystectomy in twenty-nine consecutive patients. Length of postoperative hospitalization was 48 hours in five patients, 72 hours in eleven patients, and 96 hours in the remaining thirteen patients, with no complications. This uncontrolled observation upon a small series does not yet permit conclusions regarding the effect upon length of hospital stay of efficient abdominal decompression and early provision of total nutrition after cholecystectomy. A controlled study in several institutions is being organized.
Summary
Gastric aspiration alone utilizing either a Levintype nasogastric tube or a gastrostomy tube is inefficient. The esophagus proved to be a more efficient supplemental site for aspiration of a swallowed bolus. For thirty-one patients, esophagogastric aspiration proved to be approximately twelve times as efficient as aspiration via a Levin-type tube for twenty-four
228
patients or a gastrostomy tube in five patients (residual activity, of 3,35, and 42 per cent, respectively). Radiographic studies of a volunteer swallowing barium with each type of nasogastric tube in place showed efficient removal of the contrast agent by esophageal aspiration. With the Levin-type tube, the bolus promptly traversed the stomach and entered the duodenum along parallel channels remote from the x-ray-visualized gastric tube. Efficient postoperative exclusion of swallowed air clinically and experimentally by esophageal aspiration permits more rapid return of gastrointestinal function and full nutrition and perhaps shortened hospitalization. References 1. Glucksman GL, Kaiser MH, Warren WD: Small intestinal absorption in the immediate postoperative period. Surgery 60: 1020, 1966. 2. Moss G: Nitrogen equilibrium in the early postoperative period. Surg Forum 14: 67, 1963. 3. Moss G: Postoperative decompression and feeding. Swg @necol Obstet 122: 550, 1966. 4. Lorrain J, Page A: Positive nitrogen balance and the prevention of ileus in the immediite postoperative period. Can MedAssoc J 93: 546, 1965. 5. Moss G, Koblenz G: Postoperative positive protein balance: effects upon wound and plasma protein synthesis. Surg Forum 21: 71, 1970. 6. Bierenbaum A, Bova F, Moss G: Postoperative positive protein balance: accelerated oxidative glucose consumption. Surg Forum 24: 81, 1973. 7. Moss G, Bierenbaum A, Bova F, Slavin JA: Postoperative metabolic patterns following immediate total nutritional support: hormonal levels, DNA synthesis, nitrogen balance, and accelerated wound healing. J Surg Res 21: 00, 1976. 8. Levin AL: A new gastroduodenal catheter. JAMA 76: 1007, 1921.
The American Journal of Surgery
Distention of the gastrointestinal tract by accumulated swallowed air is well recognized as a major factor in the development of adynamic ileus. Active prophylactic or therapeutic measures have been directed toward removal of the air after its arrival into the large capacity stomach. The most common regimens utilize a nasogastric (Levin-type) tube. Occasionally there is direct transabdominal placement of a gastrostomy tube. Neither approach is efficient. It was the purpose of this study to evaluate these regimens objectively and contrast results with a supplemental aspiration site, the esophagus, which improved efficiency on clinical testing by a factor of approximately 12:l. By a radiographic study upon a volunteer subject, the reason for inefficiency was clearly demonstrated, and the esophagus was validated as a logical site for aspiration. Material and Methods Clinical Study. The decision to utilize decompression was not influenced by the conduct of the study. Each regimen was chosen, initiated, and terminated by the patient’s surgeon based upon his usual indications. There were twenty-four patients with Levin-type tubes, five with gastrostomies, and thirty-one with esophagogastric aspiration [4]. All were given “cold” iodide to block thyroid uptake of radioiodide and insure stoichiometric urinary excretion of the unremoved residual “tag.” When the surgeon decided his patient no longer needed decompression, the tube was irrigated to insure patency, and the adequacy of suction was checked. The patient swallowed a 50 ml bolus of Hz0 containing 0.5 PC Na12”I, followed by 100 ml of “cold” HsO. Suction was continued for 1 minute after all visible aspiration had ceased. Each tube then was disconnected from the suction trap, and manually irrigated with 50 ml saline (X3). Each time a maximum effort was made to withdraw the gastric washings, which were pooled with the initial aspirate for
From Rensselaer Polytechnic Institute. Biomedical Engineering Laboratory. and Departments of Surgery and Radiology’, Memorial Hospital, Troy, New York. Repint requests shovkl be addressed to Geraki Moss, PhD, MD, Professor of Biomedical Engineering, Rensselaer Polytechnic Instttute,Troy, New York 12181.
Volume 133, February 1977
counting. The unremoved lz51 (inefficiency) was calculated and confirmed by assay of its excretion in the patient’s 24 hour urine collection. Radiographic Study. On separate occasions a healthy volunteer (GM) had either a Levin-type tube or the esophagogastric device inserted, with proper position verified by fluoroscopy. The supine subject swallowed 100 ml of barium sulfate suspension, while 100 mm Hg suction was applied on each occasion to the tube. The resultant patterns of contrast agent passage were recorded on videotape and tine photography. Results Clinical Study. vse of the Levin-type tube (24 patients) resulted in 35 f 17 per cent residual activity (inefficiency); the gastrostomy tube (5 patients) 42 f 28 per cent residual activity (inefficiency); and the esophagogastric aspiration tube (31 patients) 3 & 3 per cent residual activity (inefficiency). Radiographic Study. Despite the “properly” positioned Levin-type tube within the stomach (which removed some contrast agent), the swallowed bolus promptly traversed the length of the stomach to enter and visualize the duodenum and jejunum. (Figure 1.) (The senior author was reassured that he did not have a duodenal ulcer.) With esophagogastric aspiration, the swallowed bolus was intercepted within the esophagus and did not enter the stomach. (Figure 2.) (In a previous unrecorded study, a minimal quantity of barium sulfate did appear in the stomach to outline this organ. The agent adhered to the mucosa and during the time of study did not lead to visualization of the duodenum.) Comments
Gastrointestinal peristalsis begins its recovery immediately after surgery [I]. Visible activity is observed frequently while the abdominal incision is closed. This hypofunctioning gastrointestinal tract is vulnerable to complete decompensation by accumulation of swallowed gas delivered into the small and large intestine. Visceral distention will terminate peristaltic activity (enterogastric and enteroenteral reflexes).
Moss and Friedman
Figure 1. Left, suptne with volunteer Levin on tube suctkn. lhe is tube visible in stomach the because of its radiopaque marker. Note channels followed by barium &fate not in contact with the aspiration orifices. Right, in same subJect after 2 minutes, radiopaque meal has traversed stomach We enter to and outline the duodenum and small bowel. Levin The tube is obscured but functional.
Figure 2. Same volunteer separate on occasion with esophagogastric aspiration devke on suction. The swallowed radiopaque bolus (#7) does descend not beyond the distal esophagus, from which it is aspirated. The radioiucent air-filled balloon is at the esophagogastric Junction (#2). No barium suifate was visualized within the stomach.
226
Aspiration of the large volume, muscular stomach is inefficient. A swallowed bolus is propelled in multiple parallel channels (“magenstrasse”) toward the pylorus. These streams can be anterior, posterior, superior, or inferior to the gastric aspiration orifices of the Levin-type tube, which are bypassed. (Figure 1, left.) Only material in intimate contact with the gastric orifices can be aspirated. Nasopharyngeal and esophageal irritation by a nasogastric tube provokes aerophagia. With early return of gastric peristalsis and inefficient gastric aspiration, a greater net volume of air may enter the bowel than if the device had been omitted. Bowel sounds, indicative of peristalsis, are present in the recovery room (but are seldom listened for). Most usually these disappear by the next morning as recovery of gastrointestinal function is aborted and paralytic ileus supervenes. We reasoned that the esophagus of small circumference would not allow for channeling of air to bypass aspiration orifices within this tubular structure. Our original device [2] (circa 1963) was bulky (#28 French), relatively expensive, and poorly accepted, but it functioned well. An elemental diet was delivered distal to the aspiration site and was absorbed enterally. Positive protein and caloric balance were achieved within hours of major abdominal surgery [2,3]. This was confirmed independently by Lorrain and Page [4] in patients who underwent cholecystectomy and aortic aneurysmectomy. They noted passage of stool and flatus three days earlier than with conventional regimens. Their patients regained admission weight by the time of discharge, attributed to nutrition, not fluid. They concluded that hospital stay was shortened, but this remains a statistically unverified opinion.
The American Journal of Surgery
Abdominal Decompression
ATTACH TO SUCT/OIV
BALLOON /NFL AT/OA’ VALVE y
/
BALLOON /AFL A7701V TUBE MAIN LUME# ESOPHAGEAL OR/F/CE
GASTRK’ Off//=/CE \
/
/i’
Figue 3. Diagram of esophagogastrlc aspiration balloon device (National Catheter Corp, Argyle, NY).
Studies of an animal model in which elemental diet was fed immediately after bowel resection showed that the exogenous nutrients were incorporated into plasma and wound proteins, whose syntheses were stimulated [5]. Total glucose oxidation was approximately double that of the unfed controls [6]. This correlated with increased insulin levels and the availability of massive carbohydrate substrate. At 96 hours postoperatively, the bursting strength of the bowel wounds of the fed beagles was approximately triple that of the unfed controls [6]. DNA synthesis in the healing bowel wound was 6.2 times that of the unfed controls at 72 hours [ 71. A newer device has become available recently that utilizes esophagogastric aspiration but. is of more acceptable size (# 20 French), and is mass-produced by extrusion rather than made by hand. (Figures 3 and 4.) With twelvefold the efficiency of the Levintype tube, it is expected that this will supplant the latter device (circa 1921) [S].
Volume 133, February 1977
The nasogastric device bears a superficial resemblance to the familiar Foley catheter. It consists of two lumens, the smaller of which inflates a 30 ml balloon with air after passage into the stomach. The tube is withdrawn until the balloon is positioned at the esophagogastric junction and is secured without tension. The larger lumen has openings both above and below the balloon and, when placed on continuous suction, aspirates both the esophagus and the stomach. The patient may drink water or hot tea. This irrigates the tube and serves as a check on function as the swallowed bolus immediately returns from the esophagus. This efficient esophageal aspiration provides some potential problems. The patient with thick, profuse bronchial secretions must be instructed to expectorate into tissues. If such secretions are swallowed, this rapidly plugs the aspiration lumen, requiring prompt irrigation. Also, all nasogastric tubes cause small amounts of nasopharyngeal irritation and bleeding. A few specks
Moss and Friedman
Figure 4. Diagram of esophagogastric aspiration balloon device, with sewrate kimen in duodenum for feeding. (Reprinted with permission of publisher from [ 71.)
of “coffee grounds” returned by the Levin-type tubes (after acidification of the blood) cause no alarm. The same bright red return from the esophagus causes concern unless personnel are prewarned. This modern device also is available in a modified form (still #20 French) but with an additional fine-feeding lumen to be passed through the pylorus at the time of surgery. (Figure 4.) Elemental diet is delivered into the duodenum immediately after the procedure to take advantage of the returning of gastrointestinal function. Utilizing this regimen, we performed elective cholecystectomy in twenty-nine consecutive patients. Length of postoperative hospitalization was 48 hours in five patients, 72 hours in eleven patients, and 96 hours in the remaining thirteen patients, with no complications. This uncontrolled observation upon a small series does not yet permit conclusions regarding the effect upon length of hospital stay of efficient abdominal decompression and early provision of total nutrition after cholecystectomy. A controlled study in several institutions is being organized.
Summary
Gastric aspiration alone utilizing either a Levintype nasogastric tube or a gastrostomy tube is inefficient. The esophagus proved to be a more efficient supplemental site for aspiration of a swallowed bolus. For thirty-one patients, esophagogastric aspiration proved to be approximately twelve times as efficient as aspiration via a Levin-type tube for twenty-four
228
patients or a gastrostomy tube in five patients (residual activity, of 3,35, and 42 per cent, respectively). Radiographic studies of a volunteer swallowing barium with each type of nasogastric tube in place showed efficient removal of the contrast agent by esophageal aspiration. With the Levin-type tube, the bolus promptly traversed the stomach and entered the duodenum along parallel channels remote from the x-ray-visualized gastric tube. Efficient postoperative exclusion of swallowed air clinically and experimentally by esophageal aspiration permits more rapid return of gastrointestinal function and full nutrition and perhaps shortened hospitalization. References 1. Glucksman GL, Kaiser MH, Warren WD: Small intestinal absorption in the immediate postoperative period. Surgery 60: 1020, 1966. 2. Moss G: Nitrogen equilibrium in the early postoperative period. Surg Forum 14: 67, 1963. 3. Moss G: Postoperative decompression and feeding. Swg @necol Obstet 122: 550, 1966. 4. Lorrain J, Page A: Positive nitrogen balance and the prevention of ileus in the immediite postoperative period. Can MedAssoc J 93: 546, 1965. 5. Moss G, Koblenz G: Postoperative positive protein balance: effects upon wound and plasma protein synthesis. Surg Forum 21: 71, 1970. 6. Bierenbaum A, Bova F, Moss G: Postoperative positive protein balance: accelerated oxidative glucose consumption. Surg Forum 24: 81, 1973. 7. Moss G, Bierenbaum A, Bova F, Slavin JA: Postoperative metabolic patterns following immediate total nutritional support: hormonal levels, DNA synthesis, nitrogen balance, and accelerated wound healing. J Surg Res 21: 00, 1976. 8. Levin AL: A new gastroduodenal catheter. JAMA 76: 1007, 1921.
The American Journal of Surgery