The Cochrane collaboration's exhaustive literature reviews
have an enviable reputation for settling controversial
debates and overturning accepted clinical wisdom. In a
review in the latest edition of The Cochrane Database
of Systematic Reviews, the almost universal practice
of inserting a nasogastric tube in patients who have just
undergone abdominal surgery gets the Cochrane treatment.
For decades it's been assumed that
this technique speeded recovery and the return of normal
intestinal function. Not so, says the Cochrane research.
In fact, it says, "routine nasogastric decompression
does not accomplish any of its intended goals and so
should be abandoned in favour of selective use."
The rationale behind nasogastric
decompression is simple. Any abdominal surgery, be it
for stomach cancer, injury, gynecological disorder,
or appendicitis, is likely to lead to a temporary cessation
of bowel activity. This is the overriding reason for
prolonged hospital stays in these patients.
Faced with this problem, and lacking
evidence one way or the other, the doctors of yesteryear
understandably concluded that keeping the digestive
tract empty would help it restart sooner. "Hospital
stay has been the buzzword of the last 20 years because
that's what costs all the money," says lead author Dr
Richard Nelson, a colorectal surgeon at the University
of Illinois College of Medicine. "We'd send everybody
home the same day if we thought they could eat."
Nasogastric tubes were also widely
credited with reducing rates of nausea and aspiration
pneumonia. "It was just routine. It sounded good, sounded
rational," says Dr Nelson. "When I was a resident every
person who had a cut in their tummy had a nasogastric
tube put in when they went to sleep and we left it in
until they had a formed stool eight to 10 days later."
TUBELESS
RECOVERY
The first doubts regarding the practice surfaced with
a 1995 review of abdominal surgery trials which suggested
that while nasogastric tubes might help with bloating
and vomiting, they did not lead to better outcomes or
reduced hospital stays. The latest review includes 28
studies which randomized a total of 4,194 patients to
either tube or no tube, the latter category including
patients who had a tube inserted for less than 24 hours
after surgery. It emerged that patients who did not
use a nasogastric tube had significantly faster recovery
of bowel function.
There were no significant differences
between the two groups in other study endpoints, but
tubeless patients appeared to run a slightly greater
risk of wound infection and ventral hernia, counterbalanced
by a slightly lesser risk of pulmonary complications.
Dr Neil Hyman, chair of the American
Society of Colon and Rectal Surgeons' Standards Committee,
is responsible for producing guidelines for abdominal
surgeons. He doubts that the nasogastric tube is going
to be disappearing anytime soon. "The reason that most
people do things is because at one point somebody told
them in their training it was the right thing. There's
no surgeon who wants to do the wrong thing."
That said, says Dr Nelson, a Cochrane
recommendation carries a lot of weight. "Some Cochrane
reviews answer questions so definitively that you think,
'Let's put this issue to bed.' If the doctor says you're
going to wake up with a tube in your nose, the informed
patient has a right to ask 'Why?'"
Cochrane
Database Syst Rev Jan
25, 2005
|
