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Nasogastric intubation: is it necessary?

I am certainly pleased to see yet another study that has shown in a scientifically valid manner that routine nasogastric intubation following elective colorectal operations is unnecessary. The study by Feo et al. in the present issue of the journal is quite well designed, as during the 2 year study period the authors deliberately excluded patients with prior abdominal operations, cancer of the lower rectum requiring low anterior or abdominoperineal resection, and individuals with metastatic disease. 1 Both preand postoperative management were well controlled and well defined. In addition to the parameters studied by most authors, such as morbidity, particularly including nausea and vomiting, resumption of intestinal function and length of hospital stay, Feo et al. also queried the patients about their well-being using the 36 item short form health survey (SF-36). Furthermore, a cost analysis was undertaken in their study. One hundred patients were well matched between the two groups relative to surgical procedure and postoperative analgesic management, although interestingly enough the length of surgery in the early oral feeding group was a mean of 20 min shorter than were the operations in the nasogastric group ( P < 0.05). There were no significant differences between the two groups relative to postoperative morbidity with the exception of nausea, vomiting, and persistent vomiting requiring nasogastric intubation. Similarly, there were no differences between the SF-36 score and overall hospital cost. The authors noted a significantly shorter length of surgery in the non-nasogastric tube group and an absence of any detectable differences in either cost or in SF-36 outcome in the postoperative period between the two groups. In addition, there were also significantly increased incidences of nausea, vomiting and nasogastric intubation in the non-nasogastric tube group. After synthesis of these findings, Feo et al. concluded that patients undergoing an elective colorectal resection can be managed without postoperative nasogastric catheters. I agree with the findings and conclusions of Feo et al., as we have performed two prospective randomized trials that addressed the same issue and reached the same conclusions. 2,3 Our findings were similar in that approximately 11% of patients required nasogastric intubation – not unlike the 20% in the non-nasogastric tube group in the Feo et al. study. The issue becomes whether one chooses to ‘punish’ the 80–89% of patients who do not otherwise require a nasogastric tube to save the minimal morbidity with, albeit, perhaps psychological trauma of postoperative nasogastric intubation in the 11–20% of patients who will require such a tube. However, since there were no significant differences in any of the three referenced studies relative to wound dehiscence or cardiopulmonary complications both of which might be feared sequelae of postoperative nausea and vomiting, there does not seem to be any compelling reason to exercise this counter-intuitive logic of punishing the vast majority of patients to save the few individuals who might require nasogastric intubation. The more prudent course of action based upon this very nicely designed and well executed study, as well as our two previous trials, would be to continue to find ways to eliminate the need for nasogastric intubation in the 11–20% of patients who still require it. Such measures could include: appropriate choices of postoperative analgesia, whether patient controlled analgesia device or epidural catheterization, early ambulation with aggressive patient mobilization, use of adjuvant medications perhaps commenced in the preoperative period to assist with the resumption of postoperative bowel function and the elimination or reduction of postANZ J. Surg. 2004; 74 : 296–297