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Nasointestinal tubes (NIT)

• N = 830 patients across 4 studies:
• N = 436 were treated with nasointestinal tubes (NIT)
• N = 394 were treated with NGT decompression

• This paper had no specific data on the populations included in the studies.

• Randomized-controlled Trials (RCTs) and/or case-control studies.
• Clinical and radiologic diagnosis of SBO.
• Confirmed SBO at operation or autopsy.

• Large bowel obstruction.
• Studies with incomplete data.
• Studies with limited outcomes.
• Studies with multiple publications

• Nasointestinal tube (NIT) insertion (past the pylorus) for management of SBO.

• Nasogastric tube (NGT) insertion for management of SBO.

• Immediate hospitalization

• Successful treatment of SBO without operative management

• Management for partial SBO.
• Post-operative complications (including death).

• No significant difference between NIT and NGT in avoiding operative intervention in SBO [OR 2.19 (0.59 - 8.15)].
• No statistically significant difference in the rate of non-operation between NIT and NGT in partial SBO [OR 1.04 (0.23 - 4.60)].
• There is a statistically significant higher rate of postoperative complications in NIT compared to NGT [OR 2.13 (1.09-4.15)].

• There are no reliable conclusions on the superiority of NIT compared to NGT decompression in treatment of SBO (both complete and partial).
• There is a higher incidence of postoperative complications associated with NIT decompression.

OCEBM Levels of Evidence Working Group. "The Oxford Levels of Evidence 2". OCEBM

Therapeutic efficacy (i.e., resolution of symptoms, avoiding surgery)

• Prospective randomized control trial (P, RCT)

• Sample size = 186 patients were enrolled
• n = 96 were in the ileus tube (NIT) group
• n = 90 were in the NGT group

• 60% male
• Age range: 19- 86 years

• Clinical signs and symptoms of acute SBO.
• Diagnosis of ASBO by plain abdominal film or CT confirmed by 2 attending radiologists.
• Hospital admission within 12h after obstruction onset.

• Indications for immediate surgery (signs of peritonitis or strangulation).
• Contraindications to endoscopy.
• Postoperative adynamic obstruction or malignancy.
• Treatment at OSH prior to admission.

• Triple lumen endoscopic ileus tube insertion by consistent staff technicians into the duodenum.

• Nasogastric tube (NGT) inserted from nose to stomach.

• 7 days after hospital admission.

• Therapeutic effectiveness (meaning clinical or radiological improvement which encompassed relief of abdominal symptoms, decreased drainage volume, disappearance of air-fluid levels or reduced gas and fluid in bowel loops).

• Rate of surgery, effectiveness rate for recurrent adhesive small bowl obstruction.

• The ileus tube group experienced a significantly shorter time for relief of clinical symptoms and improvement in the findings of the abdominal radiograph (4.1 ± 2.3 d vs 8.5 ± 5.0 d) (p < 0.01).
• The overall effectiveness rate was up to 89.6% in the ileus tube group and 46.7% in the NGT group (p <  0.01).
• 10.4% of the patients in the ileus tube group and 53.3% of the NGT group underwent surgery (p < 0.01).

• ~ 2.3 as related to surgery

• Ileus tube is more effective for the treatment of adhesive SBO than NGT and leads to lower rates of surgery.

• Academic Hospital in China

OCEBM Levels of Evidence Working Group. "The Oxford Levels of Evidence 2". OCEBM

• Prospective, randomized control trial (P, RCT)

• Sample size = 55 patients were included:
• n = 27 were treated with long tube
• n = 28 were treated with NG decompression

• Mean age was 60 in long tube group and 58 in NGT group
• 51.8% male in long tube (LT)
• 42.8% male in NGT

• Prior intra-abdominal surgery.
• Clinical signs and symptoms consistent with SBO.
• Radiologic diagnosis of SBO confirmed by an attending radiologist.

• Patients with early postoperative SBO (occurring less than 30 days after celiotomy).
• Patients with SBO in conjunction with Crohn's disease, documented malignancy, incarcerated hernia, or mesenteric vascular disease.
• Patients requiring immediate surgery for signs of ischemic bowel (abdominal tenderness, fever, tachycardia, or leukocytosis).

• Long tube placement (confirmed by radiograph) and if in the incorrect spot was advanced to distal antrum fluoroscopically.

• Nasogastric (NGT) decompression

• Inpatient admission at 30 days out in the operative group

• Determine the success of nonoperative treatment.

• Morbidity of surgical intervention (deaths, complications).

• 13 managed with NGT (46%) and 8 with LT (30%) (P = 0.16) required operative intervention.

• Patients with adhesive SBO should get a trial of tube decompression but there was no difference between the tubes used.

• Multiple academic hospital centers in New York

OCEBM Levels of Evidence Working Group. "The Oxford Levels of Evidence 2". OCEBM

Nonoperative management without nasogastric decompression

Emergency Department academic urban tertiary care center

• Retrospective cohort study

• Total Sample Size = 181 patients were included
• n = 93 received nasogastric decompression
• n = 88 no NG decompression

• 46% of all patients were female (49% of patients receiving nasogastric decompression were female and 43% who did not receive nasogastric decompression were female)
• Median age was 60 years of age

• Patients with ICD-9 linked diagnoses related to SBO (intussusception, paralytic ileus, volvulus, impaction of intestine unspecified, gallstone ileus, fecal impaction, other impaction of intestine, intestinal or peritoneal adhesions with obstruction, other specified intestinal obstruction, unspecified intestinal obstruction).
• Attending radiologist CT scan read consistent with "definite" or "likely/early" SBO

• Patients without confirmatory CT or with read of "no evidence of SBO".
• Patients with alternate diagnoses (fecal impaction, constipation, large bowel obstruction).

• Nasogastric decompression

• Treatment without nasogastric decompression

• Duration was hospital length of stay

• Determine the association of nasogastric decompression with the rate of surgical intervention, bowel ischemia, and hospital length of stay

• Sub-analysis to compare mortality rates and bowel resection.
• Early predictors of surgery in patients with SBO

• Patients greater than >70 years old and with a prior history of CAD, malignancy or SBO were more likely to get NG decompression (p <0.05).
• There was an increased hospital LOS for NG decompression versus those who did not receive NG decompression (median LOS 5 v. 3, p < 0.0001).
• There was no change in reduction in rates of surgery, bowel resection, or death in patients who received NG decompression.

• NG decompression was not associated with reduced rates of surgery or death but was associated with longer hospital LOS.

• Single urban tertiary care center (Emergency Department, George Washington University, USA)

OCEBM Levels of Evidence Working Group. "The Oxford Levels of Evidence 2". OCEBM

• Retrospective cohort study

• Sample size = 290 total patients
• N = 235 patients received NGT placement
• N = 55 did not receive NGT placement

• Average age of all patients was 58 years (NGT 58.1, non NGT 54.96)
• N = 173 (59.6%) patients were female (NGT 59.6%, non-NGT 60%)

• Clinical signs and symptoms of SBO.
• Confirmatory radiographic evidence (CT or XR).

• Clinically obvious incarcerated hernia.
• Patients with early post-operative SBO.
• Patients who underwent operative intervention (later analysis).

• NGT placement

• No NGT placement

• Duration was hospital length of stay

• Rate of operative interventions. Days to the resolution of SBO

• Hospital LOS. Rate of respiratory and other complications.
• Discharge disposition (rehabilitation vs. home)

• NGT placement was not associated with success of nonoperative management and avoidance of surgery (p = 0.08).
• Days to resolution of SBO (2.97 v. 1.63) and hospital LOS (9.57 v. 3.13) were significantly increased in patients with an NGT, excluding those who received operative intervention (p < 0.001).
• Patients who received NGT decompression had significantly higher rates of overall complications, pneumonia, and respiratory failure (p <0.001, = 0.007, = 0.013).
• Patients who received NGT decompression also had aa significantly higher rate of discharge to rehabilitation facility or nursing home (p = 0.004).

• NGT decompression is not associated with successful avoidance of nonoperative management, and it is not without risk of complications.
• This suggests that there are patients with SBO who can be managed more safely without NGT placement.

• Single, academic urban tertiary care center (Department of Surgery, Yale School of Medicine, New Haven, Connecticut)

OCEBM Levels of Evidence Working Group. "The Oxford Levels of Evidence 2". OCEBM

• Retrospective cohort study

• Sample size = 288 patients
• N = 140 received NGT or long tube placement.
• N = 144 received nonoperative management without tube placement/gastric decompression.

• Average age in NGT/LT group was 76 years old, in the non-NGT group was 69.5 years old.
• 47.1% of NGT/LT group were female, and 58.2% of the non-NGT group were female.

• Diagnosis of adhesive SBO based on clinical symptoms (nausea, vomiting, or abdominal pain) and radiographic findings (CT/XR)

• Patient with SBO suggestive of nonadhesive etiologies (paralytic ileus, incarcerated hernia, fecal impaction, intra-abdominal malignancy, and early post-operative SBO within 4 weeks after abdominal surgery).
• Patients immediately taken for emergency surgery with signs of strangulation or peritonitis.

• Gastric decompression with NGT placement or long-tube placement (past the pylorus).

• Nonoperative management without gastric decompression.

• Duration was the hospital length of stay.

• Determine if NGT/long-tube decompression reduced vomiting in patients with adhesive SBO.

• Pneumonia after admission.
• Need for surgery.
• Mortality.
• Hospital LOS.
• Time to PO intake.

• There was no statistically significant difference in vomiting after admission in the NGT/long-tube group versus the non-NGT group (12.9% v. 18.9%, p =0.16).
• There was no significant difference in rates of pneumonia (NGT 1.4% v. non-NGT 0%, p=0.235), need for surgery (12.9% v. 7.4%, p = 0.126), or mortality (1.4% v. 0%, p= 0.235).
• Hospital length of stay and time to oral intake was shorter in the non-NGT group (LOS 10 v. 8, p =0.011; time to oral intake 5 v. 4, p < 0.001).

• This retrospective study suggests that NGT/long-tube decompression does not prevent vomiting and may not reduce rates of surgery.

• JA Shizuoka Kohseiren Enshu Hospital, Hamamatsu, Japan

OCEBM Levels of Evidence Working Group. "The Oxford Levels of Evidence 2". OCEBM