Efficacy and Necessity Efficacy and Necessity of Nasojejunal Tube of Nasojejunal Tube after Gasrectomy after Gasrectomy

Presented by Dr. Sadjad NoorshafieePresented by Dr. Sadjad NoorshafieeResident of General SurgeryResident of General SurgerySupervised by Dr.A.tavassoliSupervised by Dr.A.tavassoli

General surgeon General surgeon Endoscopic and Minimally Invasive Surgery Endoscopic and Minimally Invasive Surgery

Research CenterResearch Center

BackgroundBackground

• History: more than 300 yearsHistory: more than 300 years

Levine in 1921Levine in 1921

• What is Nasogastric or nasojejunal What is Nasogastric or nasojejunal tube?tube?

• Benefits: Benefits: treatment: abdominal treatment: abdominal distentiondistention

vomiting vomiting diagnosis: GI bleedingdiagnosis: GI bleeding

prophylaxis: Ileus in majorprophylaxis: Ileus in major abdominal operations abdominal operations

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

• Finally ileus leads to over pressure Finally ileus leads to over pressure on anastomosis especially in upper on anastomosis especially in upper GI; this could leads to anastomosis GI; this could leads to anastomosis disruption and leakage; a very disruption and leakage; a very devastating complication.devastating complication.

• This complication is the major cause This complication is the major cause of morbidity and mortality in these of morbidity and mortality in these groups of surgical patients. groups of surgical patients.

• On the other hand, it has been On the other hand, it has been reported that NJ tubes makes more reported that NJ tubes makes more discomfort for patient and increase discomfort for patient and increase the rate of respiratory complications the rate of respiratory complications by abruption of lower esophageal by abruption of lower esophageal functionfunction

• Additionally its benefits are under Additionally its benefits are under question question

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

How this idea How this idea came to us?came to us?

• The aim of this study is to evaluate The aim of this study is to evaluate the efficacy and necessity of the efficacy and necessity of nasojejunal tube after total nasojejunal tube after total gastrectomygastrectomy

Materials and MethodsMaterials and Methods

• interventionalinterventional

• Total gasterectomy with D2 Total gasterectomy with D2 lynphadenectomy and roux-en-y lynphadenectomy and roux-en-y esophagojejunostomyesophagojejunostomy

• (56 patients totally)50 patients enrolled(56 patients totally)50 patients enrolled

• from 2001 to 2008from 2001 to 2008 • approved by the ethical committee approved by the ethical committee

• explained for the patients and informed explained for the patients and informed written consent was takenwritten consent was taken

Exclusion criteriaExclusion criteria

• history of abdominal irradiationhistory of abdominal irradiation • emergency surgeryemergency surgery • operative technical difficulties operative technical difficulties

• additional resections (splenectomy, additional resections (splenectomy, pancreatectomy)pancreatectomy)

• patients were randomly divided into two patients were randomly divided into two groups:25 with tube and 25 withoutgroups:25 with tube and 25 without

• In the tube group, the tube was left in at In the tube group, the tube was left in at least 36 h after operation for continuous least 36 h after operation for continuous drainage until passage of flatus or stool. drainage until passage of flatus or stool.

• In the group of without a tube, the tube In the group of without a tube, the tube was removed when the patient was in the was removed when the patient was in the recovery room. recovery room.

• Diet beginningDiet beginning

• Antibiotic and DVT prophylaxisAntibiotic and DVT prophylaxis

Evaluated factorsEvaluated factors

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

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

resultsresults

• Data were analyzed with fisher exact Data were analyzed with fisher exact test and Man –Whitney test and two test and Man –Whitney test and two groups were compared statisticallygroups were compared statistically

Patients’ demographic and Patients’ demographic and operative characteristicsoperative characteristics

Tumor location in the Tumor location in the studied patientsstudied patients

Tumor location in the Tumor location in the studied patientsstudied patients

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

NJTNJT

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

groupsgroups

Morbidity and mortality Morbidity and mortality rate in two groupsrate in two groups

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

DiscussionDiscussion

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

All abdominal operationsAll abdominal operations

• Cheatham et al. : 3964 patientsCheatham et al. : 3964 patients 19951995 Days of first oral intake were significantly Days of first oral intake were significantly

fewer, and pulmonary complication and fewer, and pulmonary complication and postoperative fever were significantly lower postoperative fever were significantly lower in without NJT group. they experienced an in without NJT group. they experienced an earlier return of bowel function, a marginal earlier return of bowel function, a marginal decrease in wound infection, and ventral decrease in wound infection, and ventral hernia. hernia. Anastomosis leakageAnastomosis leakage was was similar in the two groupssimilar in the two groups

• Nelson et alNelson et al : :same findings in 2005same findings in 2005

After total gasterctomyAfter total gasterctomy

• Yoo et alYoo et al. :. :136 cases 2002136 cases 2002

time to passage of flatus, time to taking time to passage of flatus, time to taking liquid diet, and postoperative liquid diet, and postoperative hospitalization were significantly shorter in hospitalization were significantly shorter in the no-decompression group the no-decompression group

They showed that postoperative insertion They showed that postoperative insertion of NJT was with delay in beginning oral of NJT was with delay in beginning oral intake and longer hospital stay intake and longer hospital stay

• Akbaba et alAkbaba et al. . :66 patients 2004:66 patients 2004

• bloating and vomiting were similar in bloating and vomiting were similar in both groups of with and without NJT, both groups of with and without NJT, but fever and pulmonary but fever and pulmonary complications were higher in NJT complications were higher in NJT groupgroup

• In our study, there was no significant In our study, there was no significant different between two groups in different between two groups in named complicationsnamed complications

• Chang et al.Chang et al. 2003 2003

• There was statistically significant There was statistically significant difference between two groups in the difference between two groups in the view of the rate of patients’ view of the rate of patients’ discomfort. The main complain was discomfort. The main complain was sore throat and sleep disorderssore throat and sleep disorders

• Carrire et alCarrire et al. . 20072007 complains complains about NJT were moderate to severe about NJT were moderate to severe in 72% of cases after total in 72% of cases after total gastrectomy gastrectomy

• It was the same in our studyIt was the same in our study

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

ConclusionConclusion

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