Original Communications| Volume 130, ISSUE 5, P788-791, November 2001

Nasogastric intubation causes gastroesophageal reflux in patients undergoing elective laparotomy


      Background. The routine use of nasogastric tubes in patients undergoing elective abdominal operation is associated with an increased incidence of postoperative fever, atelectasis, and pneumonia. Previous studies have shown that nasogastric tubes have no significant effect on the incidence of gastroesophageal reflux or on lower esophageal sphincter pressure in healthy volunteers. We hypothesized that nasogastric intubation in patients undergoing laparotomy reduces lower esophageal sphincter pressure and promotes gastroesophageal reflux in the perioperative period. Methods. A prospective randomized case-control study was undertaken in which 15 consenting patients, admitted electively for bowel surgery, were randomized into 2 groups. Group 1 underwent nasogastric intubation after induction of anesthesia, and Group 2 did not. All patients had manometry and pH probes placed with the aid of endoscopic vision at the lower esophageal sphincter and distal esophagus, respectively. Nasogastric tubes, where present, were left on free drainage, and sphincter pressures and pH were recorded continuously during a 24-hour period. Data were analyzed with 1-way analysis of variance. Results. The mean number of reflux episodes (defined as pH < 4) in the nasogastric tube group was 137 compared with a median of 8 episodes in the group managed without nasogastric tubes (P =.006). The median duration of the longest episode of reflux was 132 minutes in Group 1 and 1 minute in Group 2 (P =.001). A mean of 13.3 episodes of reflux lasted longer than 5 minutes in Group 1, with pH less than 4 for 37.4% of the 24 hours. This was in contrast to Group 2 where a mean of 0.13 episodes lasted longer than 5 minutes (P =.001) and pH less than 4 for 0.2% of total time (P =.001). The mean lower esophageal sphincter pressures were lower in Group 1. Conclusions. These findings demonstrate that patients undergoing elective laparotomy with routine nasogastric tube placement have significant gastroesophageal reflux in the perioperative period and a reduced ability to clear refluxed acid from the distal esophagus. Due to the associated risk of postoperative pulmonary complications, we recommend that nasogastric intubation be performed on a selective rather than routine basis. (Surgery 2001;130:788-91.)
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        • Paine LJ
        • Carlson HA
        • Wangensreen OH.
        The postoperative control of distension, nausea, and vomiting.
        JAMA. 1933; 100: 1910-1917
        • McIver MA
        • Benedict EB
        • Cline JW.
        Postoperative gaseous distension of the abdomen.
        Arch Surg. 1926; 155: 1197-1199
        • Wolff BG
        • Pemberton JH
        • van Heerden JA
        • Beart RW
        • Nivatvong S
        • Devine RM
        • et al.
        Elective colon and rectal surgery without nasogastric decompression.
        Ann Surg. 1989; 209: 670-675
        • MacRae HM
        • Fischer JD
        • Yakimets WW.
        Routine omission of nasogastric intubation after gastrointestinal surgery.
        Can J Surg. 1992; 35: 625-628
        • Bauer JJ
        • Gelernt IM
        • Salky BA
        • Kreel I.
        Is routine nasogastric decompression really necessary?.
        Ann Surg. 1985; 201: 233-236
        • Eade GG
        • Metheny D
        • Lundmark VO.
        An evaluation of the practice of the placement of routine postoperative nasogastric suction.
        Surg Gynaecol Obstet. 1955; 101: 275-279
        • Cheatham ML
        • Chapman WC
        • Key SP
        • Sawyers JL.
        A meta-analysis of selective versus routine nasogastric decompression after elective laparotomy.
        Ann Surg. 1995; 221: 469-478
        • Garibaldi RA
        • Britt MR
        • Coleman ML
        • Reading JC
        • Pace NL.
        Risk factors for postoperative pneumonia.
        Am J Med. 1981; 70: 677-680
        • Ephgrave KS
        • Kleiman-Wexler R
        • Pfaller M
        • Booth B
        • Werkmeister L
        • Young S.
        Postoperative pneumonia: a prospective study of risk factors and morbidity.
        Surgery. 1993; 114: 815-821
        • Nagler R
        • Wolfsohn AW
        • Lowman RM
        • Spiro HM.
        Effect of gastric intubation on normal mechanisms preventing gastro-esophageal reflux.
        N Engl J Med. 1960; 262: 1325-1326
        • Nagler R
        • Spiro HM.
        Persistent gastro-esophageal reflux induced during prolonged gastric intubation.
        N Engl J Med. 1963; 269: 495-500
        • Vinnik IE
        • Kern F.
        The effect of gastric intubation on esophageal pH.
        Gastroenterology. 1964; 47: 388-394
        • Kuo B
        • Castell DO.
        The effect of nasogastric intubation on gastroesophageal reflux: a comparison of different tube sizes.
        Am J Gastroenterol. 1995; 90: 1804-1807
        • Russell GN
        • Yan PC
        • Tran J
        • Innes P
        • Thomas SD
        • Barry PD
        • et al.
        Gastroesophageal reflux and tracheobronchial contamination after cardiac surgery: should a nasogastric tube be routine?.
        Anesth Analg. 1996; 83: 228-232
        • Dent J.
        A new technique for continuous sphincter pressure measurement.
        Gastroenterol. 1976; 71: 263-267
        • Dilorenzo C
        • Dooley CP
        • Valenzuela JE.
        Response of the lower esophageal sphincter to alterations of intra-abdominal pressure.
        Dig Dis Sci. 1989; 34: 1606-1610
        • Guyton AC.
        Secretory functions of the alimentary tract.
        in: 8th ed. Textbook of medial physiology. WB Saunders, Philadelphia1991: 709-725
        • Mittal RK
        • Stewart WR
        • Schirmer BD.
        Effect of a catheter in the pharynx on the frequency of transient lower esophageal sphincter relaxations.
        Gastroenterology. 1992; 103: 1236-1240
        • Ferrer M
        • Torsten TB
        • Torres A
        • Hernandez C
        • Piera C.
        Effect of nasogastric tube size on gastroesophageal reflux and microaspiration in intubated patients.
        Ann Intern Med. 1999; 130: 991-994
        • Galatos AD
        • Raptopoulos D.
        Gastro-esophageal reflux during anesthesia in the dog: the effect of age, positioning, and type of surgical procedure.
        Vet Rec. 1995; 137: 513-516
        • Mossa AR
        • Hart ME
        • Easter DW.
        Surgical complications.
        in: 15th ed. Textbook of surgery: the biological basis of modern surgical practice. WB Saunders, Philadelphia1997: 341-359
        • Little AG
        • DeMeester TR
        • Rezai-Fadek K.
        Abnormal gastric emptying in patients with gastro-esophageal reflux.
        Surg Forum. 1997; 28: 347-348
        • Chase F.
        Role of delayed gastric emptying in the etiology of aspiration pneumonia.
        Am J Obstet Gynecol. 1948; 56: 673-679
        • Helm JR
        • Dodds WJ
        • Pelc LR.
        Effect of esophageal emptying and saliva on clearance of acid from the esophagus.
        N Engl J Med. 1984; 310: 284-288
        • Helm JF
        • Reidel DR
        • Dodds WJ.
        Determinants of esophageal acid clearance in normal subjects.
        Gastroenterology. 1983; 85: 607-612
        • Helm JF
        • Dodds WJ
        • Hogan WJ.
        Acid neutralizing capacity of human saliva.
        Gastroenterology. 1982; 83: 69-74
        • Bennett JR.
        Symposium of gastro-esophageal reflux and its complications, sect. 5: the physicians problem.
        Gut. 1973; 14: 246-259
        • Skinner DB
        • Booth DJ.
        Assessment of distal esophageal function in patients with hiatus hernia and/or gastro-esophageal reflux.
        Ann Surg. 1970; 172: 627-637
        • Wernly JA
        • DeMeester TR
        • Bryant GH
        • Wang CI
        • Smith RB
        • Skinner DB.
        Intra-abdominal pressure and manometric data of the distal esophageal sphincter and their relationship to gastro-esophageal reflux.
        Arch Surg. 1980; 115: 534-539
        • Winter DC
        • Brennan NJ
        • O'Sullivan GC
        RIRD: Reflux induced respiratory disorders.
        J Ir Coll Physicians Surg. 1997; 26: 202-210