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Is postoperative gastric decompression really necessary?
Is Postoperative Gastric Decompression Really Necessary? WiLLiAM H. ISBISTER, MD, FRCSE, Manchester, England
"The practice o/ preventhtg complications which never occur or never should occur is so widespread that the preoperative and postoperatit~e care of path'nts has become a most complicated procedure ]or the doctor and a most troublesome time ]or the path, at" [/].
The beginning of a new decade is a good time tc reexamine one of the long-established traditions of abdominal surgery. Postoperative gastric aspiration, by either nasogastric tube or gastrostomy, is widely practiced on both sides of the Atlantic Ocean. There arc, however, some surgeons who now practice abdominal surgery without using any form of postoperative gastric decompression. It is with these surgeons that I should like to side, and add a plea for the ~bolition of the routine use of gastric suction after major abdomiDal sur~,ery. It is agreed that some form of postoperative gastric decompression may sometimes be necessary, such as for the hypotonic dilated stomach of pyloric obstruction or for a hypotonic and distended gastrointestinal tract after prolonged intestinal obstruction. A recent report [2] from England shows that even with prolonged pyloric obstruction, postoperative suction was quite unnecessary when preoperative gastric decompression had been adequate. I f gastric distention or retention develops or is suspected in a patient postoperatively, a nasogastric tube can always be introduced. Compliefftions attributed t o nasogastric intestinal intubation include damage to the nasal passages, laryngeal injury leading to vocal cord paralysis, perforation of the esophagus or stomach, inability to remove the tube because of knotting within the stomach, electrolyte imbalar,ce, and pulmonary complications. It has been claimed that many of these complications can be avoided by the use of tube gastrostomy, but this procedure is not without its own hazards. The best way to avoid all of these complications would be t o forego unnecessary gastric decompression in the postoperative period. The advocates of "tubeless" abdominal surgery argue that not only is it difficult by aspiration to remove all fluid from the stomach, but that it is probably better not to attempt it since such removal complicates accurate fluid replacement. They reason that the principal use of postoperative gastric suction is to remove ingested air, and if this ingestion can be prevented, suction is not necessary. In fact, air swallowing may be aggravated Volume 120, October 1970
by a nasogastric tube that in itself prevents normal deglutition. By limiting oral feeding until bowel sounds are heard, flatus is passed, and the patient feels hunger, these surgeons claim that the swallowing of air is prevented and thus the need for gastric decompression is eliminated. Their patients have been easier to manage with respect to fluid and electrolyte repl~leement, have required less medical and nursing care, and have had fewer pulmonary problems than their counterparts with intubation. It has been shown experimentally that intestinal secretory activity is depressed until motility returns, and hence active peristalsis is available by the time secretions reach a significant amount. Since motility is norreally depressed for such a short time, and since air swallowing in the absence of a nasogastric tube is at a mi~imum, it is my view that it is not necessary even to prohibit oral fluid intake in the immediate postoperative period. In a small personal series of patients it was found that a gradually increasing postoperative arm fluid regimen was without complication ~after major abdominal surgery and when no form of postoperative gastric decompression was used. In this same investigation in which patients were matched with respect to age, sex, and typeof operation. it was apparent that the presence of a nasogastric tube for postoperative gastrointestinal aspiration did not diminish the incidence of vomiting, ileus, or abodminat distention; on the contrary, a tube seemed tQ be a fat.. tar contributing to the development of pulmonary, complications and thus indirectly to wound complications. If tubes are really unnecessary in the vast majority of patients, their routine use seems pointless and contributes needlessly to the postoperative discomfort of the patient. It is hoped that in the coming decade more surgeons will be emboldened to break from the tradition of routinely employing nasogastric decompression after abdominal operations. Patients who have undergone abdominal surgery will thus be spared a procedure for "preventing complications which never occur" and which in itself is not without hazard. References i. Fe~uson LK: Simplicity in surge~. SurgGynec Obstet 88:539,1949. 2. Hend~WG:Tubeless gastric surgew. BH~ Med J 1:1736, 1962. 511
"The practice o/ preventhtg complications which never occur or never should occur is so widespread that the preoperative and postoperatit~e care of path'nts has become a most complicated procedure ]or the doctor and a most troublesome time ]or the path, at" [/].
The beginning of a new decade is a good time tc reexamine one of the long-established traditions of abdominal surgery. Postoperative gastric aspiration, by either nasogastric tube or gastrostomy, is widely practiced on both sides of the Atlantic Ocean. There arc, however, some surgeons who now practice abdominal surgery without using any form of postoperative gastric decompression. It is with these surgeons that I should like to side, and add a plea for the ~bolition of the routine use of gastric suction after major abdomiDal sur~,ery. It is agreed that some form of postoperative gastric decompression may sometimes be necessary, such as for the hypotonic dilated stomach of pyloric obstruction or for a hypotonic and distended gastrointestinal tract after prolonged intestinal obstruction. A recent report [2] from England shows that even with prolonged pyloric obstruction, postoperative suction was quite unnecessary when preoperative gastric decompression had been adequate. I f gastric distention or retention develops or is suspected in a patient postoperatively, a nasogastric tube can always be introduced. Compliefftions attributed t o nasogastric intestinal intubation include damage to the nasal passages, laryngeal injury leading to vocal cord paralysis, perforation of the esophagus or stomach, inability to remove the tube because of knotting within the stomach, electrolyte imbalar,ce, and pulmonary complications. It has been claimed that many of these complications can be avoided by the use of tube gastrostomy, but this procedure is not without its own hazards. The best way to avoid all of these complications would be t o forego unnecessary gastric decompression in the postoperative period. The advocates of "tubeless" abdominal surgery argue that not only is it difficult by aspiration to remove all fluid from the stomach, but that it is probably better not to attempt it since such removal complicates accurate fluid replacement. They reason that the principal use of postoperative gastric suction is to remove ingested air, and if this ingestion can be prevented, suction is not necessary. In fact, air swallowing may be aggravated Volume 120, October 1970
by a nasogastric tube that in itself prevents normal deglutition. By limiting oral feeding until bowel sounds are heard, flatus is passed, and the patient feels hunger, these surgeons claim that the swallowing of air is prevented and thus the need for gastric decompression is eliminated. Their patients have been easier to manage with respect to fluid and electrolyte repl~leement, have required less medical and nursing care, and have had fewer pulmonary problems than their counterparts with intubation. It has been shown experimentally that intestinal secretory activity is depressed until motility returns, and hence active peristalsis is available by the time secretions reach a significant amount. Since motility is norreally depressed for such a short time, and since air swallowing in the absence of a nasogastric tube is at a mi~imum, it is my view that it is not necessary even to prohibit oral fluid intake in the immediate postoperative period. In a small personal series of patients it was found that a gradually increasing postoperative arm fluid regimen was without complication ~after major abdominal surgery and when no form of postoperative gastric decompression was used. In this same investigation in which patients were matched with respect to age, sex, and typeof operation. it was apparent that the presence of a nasogastric tube for postoperative gastrointestinal aspiration did not diminish the incidence of vomiting, ileus, or abodminat distention; on the contrary, a tube seemed tQ be a fat.. tar contributing to the development of pulmonary, complications and thus indirectly to wound complications. If tubes are really unnecessary in the vast majority of patients, their routine use seems pointless and contributes needlessly to the postoperative discomfort of the patient. It is hoped that in the coming decade more surgeons will be emboldened to break from the tradition of routinely employing nasogastric decompression after abdominal operations. Patients who have undergone abdominal surgery will thus be spared a procedure for "preventing complications which never occur" and which in itself is not without hazard. References i. Fe~uson LK: Simplicity in surge~. SurgGynec Obstet 88:539,1949. 2. Hend~WG:Tubeless gastric surgew. BH~ Med J 1:1736, 1962. 511