Stomach drainage after vagotomy and pyloroplasty

Bio-ecological control of perioperative and ITU morbidity

BACKGROUND

Perioperative and intensive therapy unit (ITU) morbidity and mortality has remained unchanged during the past several decades, and this at an unacceptably high level. It is most likely, in the EU countries annually, that more than 1 million people suffer severe sepsis and some 300,000 die. Pharmaceutical attempts at prevention and treatment have, despite extensive efforts, hitherto failed to improve outcome more significantly. Much supports the fact that sepsis and its severe consequences are results of a malfunctioning innate immune system, impaired by both lifestyle and disease. A series of mostly simple measures to prevent further deterioration of the immune system, and to boost it, is recommended. Among the measures recommended are some modifications of surgical and postoperative management: restricted use of antibiotics, attempts made to maintain salivation and GI secretions, omission of prophylactic gastric decompression, postoperative drainage and preoperative bowel preparation, restricted use of stored blood, avoidance of overload with nutrients, uninterrupted enteral nutrition but also tight blood glucose control, supply of antioxidants, administration of prebiotic fibre and probiotic lactic acid bacteria. Nutritional control of postoperative morbidity includes use of so-called synbiotics, e.g. a combination of bioactive lactic acid bacteria (LAB) and bioactive plant fibres.

RESULTS

Dramatic reduction in (in reality, almost abolishment of) septic morbidity is reported following supplementation of specific bioactive lactic bacteria in combination with prebiotic plant fibres, as tried in controlled studies in connection with extensive abdominal operations, liver transplantation and severe acute pancreatitis.

Assessment of routine elimination of postoperative nasogastric decompression after Roux-en-Y gastric bypass

BACKGROUND

Anastomotic disruption after surgical intervention is an infrequent complication, but may lead to severe morbidity and mortality when it occurs. Of the various gastric procedures, the Roux-en-Y gastric bypass (RYGB) has one of the highest risks for anastomotic leakage. Consequently, a nasogastric tube (NGT) is frequently placed when these operations are performed. Most studies examining the outcomes for patients without postoperative NGTs have been relatively small with groups of patients undergoing a variety of operations. Assessing the incidence of anastomotic leaks by routine elimination of postoperative NGTs requires a large number of patients. In this study, we assessed the safety and efficacy of routine elimination of NGTs in a large cohort of patients undergoing a single operation.

METHODS

We reviewed our experience with 1067 patients who underwent RYGB at the UCLA medical center. Fifty-six patients had NGTs routinely placed before the implementation of a standard protocol, which eliminated postoperative NGT decompression. The complication rate for the RYGB patient cohort with and without postoperative NGT was compared.

RESULTS

We found no difference in the complication rates between the 2 groups (Fisher exact test; P =.21).

CONCLUSIONS

Our findings suggest that routine placement of an NGT after RYGB is unnecessary.

A meta-analysis of selective versus routine nasogastric decompression after elective laparotomy

OBJECTIVE

A meta-analysis of all published clinical trials comparing selective versus routine nasogastric decompression was performed in an attempt to evaluate the need for nasogastric decompression after elective laparotomy.

BACKGROUND

Many studies have suggested that routine nasogastric decompression is unnecessary after elective laparotomy and may be associated with an increased incidence of complications. Despite these reports, many surgeons continue to practice routine nasogastric decompression, believing that its use significantly decreases the risk of postoperative nausea, vomiting, aspiration, wound dehiscence, and anastomotic leak.

METHODS

A comprehensive search of the English language medical literature was performed to identify all published clinical trials evaluating nasogastric decompression. Twenty-six trials (3964 patients) met inclusion criteria. The outcome data extracted from each trial were subsequently "pooled" and analyzed for significant differences using the Mantel-Haenszel estimation of combined relative risk.

RESULTS

Fever, atelectasis, and pneumonia were significantly less common and days to first oral intake were significantly fewer in patients managed without nasogastric tubes. Meta-analysis based on study quality revealed significantly fewer pulmonary complications, but significantly greater abdominal distension and vomiting in patients managed without nasogastric tubes. Routine nasogastric decompression did not decrease the incidence of any other complication.

CONCLUSIONS

Although patients may develop abdominal distension or vomiting without a nasogastric tube, this is not associated with an increase in complications or length of stay. For every patient requiring insertion of a nasogastric tube in the postoperative period, at least 20 patients will not require nasogastric decompression. Routine nasogastric decompression is not supported by meta-analysis of the literature.

An analysis of when patients eat after gastrojejunostomy

Eighty-five patients who underwent a gastrojejunostomy either alone or in conjunction with vagotomy or gastric resection were evaluated for the day of beginning an oral intake adequate enough to sustain nonoliguric output. This occurred on the average by the seventh to eighth postoperative day, by which time at least 78% of patients were consuming an adequate oral intake. Adequate liquid intake occurred on the average 5.3 days in the absence of vagotomy and 8.8 days in the presence of vagotomy. However, this significant difference is accounted for by the patients who had gastrojejunostomy with vagotomy. Vagotomy with antrectomy, antrectomy alone, and subtotal gastrectomy were not significantly different. The apparent influence of vagotomy on gastrojejunostomy may be due to a type II statistical error. However, 92% of patients who had vagotomy with pyloroplasty consumed adequate liquids by the seventh postoperative day compared with 56% of patients who had vagotomy with gastrojejunostomy.

Is routine use of the nasogastric tube justified in upper abdominal surgery?

Three hundred patients who underwent upper abdominal operations were studied. One hundred fifty patients were treated by insertion of a nasogastric tube, and 150 patients were treated without it. The incidence of postoperative pneumonia was 10 times higher in the patients treated with a nasogastric tube. Pneumonia was directly related to the patient's age and the duration of the tube's use. In view of the disadvantages and complications of the nasogastric tube, its routine use appears unjustified. It should be reserved as a tool for treating postoperative complications such as paralytic ileus and acute gastric dilatation.

The value of gastrostomy in the surgery of aortic aneurysms

A retrospective study was made of the progress of 205 patients after operation for abdominal aortic aneurysm with special reference to the method of gastric decompression used. Forty-six patients had a gastrostomy, and their mean length of stay in hospital was 8 days less, a highly significant difference.

A randomized prospective trial comparing three established methods of gastric decompression after vagotomy

One hundred and thirty-two patients who were about to undergo vagotomy and drainage were randomly allocated nasogastric tubes, gastrostomy tubes, or no decompression postoperatively. Significantly fewer patients with no decompression developed respiratory infections postoperatively. The role of smoking in the production of post-operative chest complications was again confirmed. Neither the choice of decompression nor its absence appeared to affect postoperative electrolyte control. Postoperative dysphagia was more common in the group with a nasogastric tube. Wound infections were commoner in the gastrostomy group. While most patients with gastrostomies expressed a preference for this type of decompression a proportion of those with nasogastric tubes expressed a preference for a gastrostomy.

Gastric emptying of solid meals after truncal vagotomy and pyloroplasty in human subjects

Gastric emptying of isotopically labelled solid meals was studied in normal human subjects and in patients at different intervals after truncal vagotomy and Heineke-Mikulicz pyloroplasty. One to four weeks after vagotomy and pyloroplasty gastric emptying was delayed grossly in some patients regardless of the completeness of vagotomy. Patients with gross delay had symptoms of gastric retention. Eight weeks later emptying had returned towards normal and one or more years after vagotomy and pyloroplasty emptying was within the normal range.A subthreshold dose of carbachol injected during the course of emptying of a meal in some of the postvagotomy patients had no detectable influence on the rate of emptying of the meal.