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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 3  |  Issue : 2  |  Page : 28-33

Clinical analysis of common complications induced by long nasointestinal tubes: A retrospective cohort study


1 Graduate School of Dalian Medical University, Dalian, Liaoning, China
2 Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China

Date of Submission19-Nov-2017
Date of Acceptance28-Mar-2018
Date of Web Publication27-Jun-2018

Correspondence Address:
Prof. Guixin Zhang
Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, Liaoning
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ts.ts_22_17

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  Abstract 


Aim: The aim of this study was to discuss the common complications induced by long nasointestinal tubes (LTs) and prophylactic therapeutic measures. Methods: A retrospective analysis was performed, consisting of 88 patients treated with LT for acute bowel obstruction (including 61 patients who underwent plication of the small intestine by LT). Our study included 75 patients with an adhesive bowel obstruction, 5 patients with a malignant intestinal obstruction, 4 patients with an early postoperative inflammatory bowel obstruction, and 4 patients with a fecal obstruction. Results: The prevalence of nasopharyngeal discomfort and pain was 95.4%, and 44.3% of patients had an electrolyte disorder and another 3.4% were diagnosed with aspiration pneumonia. Among 25% of patients who had catheter-related accidents (15.9% with tube obstructions, 5.6% with unexpected catheter shedding, 1.1% with anterior balloon rupture, and 2.3% with catheter expelled from the anus), no tube breakage occurred. Conclusion: Nasopharyngeal discomfort and pain, electrolyte disorders, and tube obstructions are common complications when using LTs. Although their incidence rate is low, aspiration pneumonia, intestinal hemorrhage, perforation, and necrosis are more severe complications. Such severe complications should be taken seriously, and prophylactic therapeutic measures must be taken to minimize their occurrence. In general, the use of LTs is safe, effective, and worthy of wide use in clinical practice.

Keywords: Bowel obstruction, complication, long nasointestinal tube, therapy


How to cite this article:
Wang K, Yang G, Han C, Bi W, Zhang G. Clinical analysis of common complications induced by long nasointestinal tubes: A retrospective cohort study. Transl Surg 2018;3:28-33

How to cite this URL:
Wang K, Yang G, Han C, Bi W, Zhang G. Clinical analysis of common complications induced by long nasointestinal tubes: A retrospective cohort study. Transl Surg [serial online] 2018 [cited 2018 Nov 17];3:28-33. Available from: http://www.translsurg.com/text.asp?2018/3/2/28/235391




  Introduction Top


Acute bowel obstructions are caused by a blockage of luminal contents to the distal intestine, accompanied by a series of pathophysiologic changes and relevant clinical manifestations.[1] Bowel obstructions cause increased water absorption of chyme due to the expansion of the intestinal wall, the limitation of peristalsis, and the prolonged time of chyme passing. This aggravates the obstruction. Acute bowel obstruction is one of the most common acute abdomen problems with a relatively high mortality rate (5%–10%), which not only changes the anatomic structure of the gut but also leads to a decrease in physiological function. Further, the mortality rate has been shown to increase to 20% when strangulation occurs.[2]

The treatment options for acute bowel obstruction mainly include conservative care and surgery. The goal of treatment is to fully drain the luminal contents and decrease the enteric pressure. Gastrointestinal decompression is the most efficient method to treat acute bowel obstruction, unless the tendency for strangulated intestinal obstruction is considered.[3] Traditional decompression uses a nasogastric tube placed into the stomach and the proximal small intestine to produce negative pressure drainage and decrease the bowel pressure, thereby blocking the vicious cycle of the underlying pathophysiological process.[4] However, due to its length, the traditional nasogastric tube can only suction a portion of the retained gas and liquid in the stomach (the length of insertion can only reach 45–55 cm). Therefore, the traditional nasogastric tube can only relieve the clinical manifestations of upper bowel obstructions, and the overall outcome is unsatisfactory.

A long nasointestinal tube (LT) was first designed and manufactured by the Japanese, and it has been widely used clinically since the 1980s. The tube can be placed in the pylorus and even can reach the Treitz ligament. When the anterior balloon expands, the tube continues to move forward with the function of peristalsis and gravity to the proximal end of the obstruction. Abdominal adhesion occurs in approximately 95% of patients who undergo abdominal surgery.[5] Thus, postoperative adhesions are inevitable under such circumstances, and the most effective method to avoid bowel obstruction is to restrict the range and relieve the degree of adhesion formation. Traditional surgery for intestinal obstruction relieves obstructions but can easily injury the serosa, making it difficult to repair the gut and forming a wider and more disordered adhesion.[6] Due to its good flexibility and minimal damage to the intestinal wall, LT can be used in intestinal plication to make the gut regular arrangement, prevent postoperative obstruction caused by volvulus and adhesion, and reduce the recurrence rate of postoperative adhesive bowel obstruction.

In recent years, due to improved technology, LTs have been extensively used in acute bowel obstruction and intestinal plication domestically and have achieved good results.[7],[8],[9] As complications are unavoidable, relevant precautions should be practiced to avoid severe outcomes. By summarizing clinical data from 88 patients (including 61 patients who underwent intestinal plication) in our department between 2006 and 2012, this article aims at analyzing the common complications when using LT as well as discussing important precautions.


  Methods Top


Clinical data

A total of 88 patients (59 males and 29 females) were treated with LT for acute bowel obstruction in our department between 2006 and 2012, including 61 patients who underwent intestinal plication by LT. Our study included 75 patients with adhesive bowel obstruction. Five patients had a malignant intestinal obstruction. Early postoperative inflammatory small bowel obstruction (EPISBO) occurred in 4 patients and 4 cases of fecal obstruction. The inclusion criteria were defined as follows: (1) all patients were enrolled with typical symptoms of bowel obstruction (abdominal pain and distension, vomiting, and an inability to pass flatus and feces); (2) plain radiographs or computed tomography scans of the abdomen indicated bowel obstruction; and (3) all patients were treated with LTs to decompress or to perform intestinal plication by LTs. Conversely, the exclusive criteria were defined as follows: (1) patients with severe cardiopulmonary insufficiency and (2) patients unable to cooperate with treatment. This study was approved by the Regional Ethics Committee of our hospital (Ethics References No: YJ-KY-FB-2015-21) and all patients provided informed consent.

Instruments

We currently use a nasointestinal obstruction tube kit (Create Medic Company, Tokyo, Japan) [Figure 1] and [Figure 2]. The catheter is a pure silica transparent tube with three channels (suction channel, injection channel, and balloon channel) and two balloons (anterior balloon and posterior balloon). The catheter is 300 cm long. The anterior balloon is used to inject sterile water to help advance the tube in the small intestine, and the posterior balloon is used for contrast radiography. The guidewire has a length of 350 cm and a diameter of 1.24 mm. The end of the tube is moniliform and made of both stainless steel and silica gel, making the catheter flexible enough to pass the pylorus easily, even when encountering bending and intestinal folds. The flexibility of the catheter causes less harm to the wall. Thus, the tube may be applied to intestinal plication for making the gut regular arrangement and preventing palindromia postoperatively.
Figure 1: Long nasointestinal tube and its guidewire

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Figure 2: Structure of the long nasointestinal tube (including guidewire, channels, and balloons)

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Indications

Simple bowel obstruction

Simple bowel obstruction refers to mechanical blockage of luminal content, without disorder of the blood supply to a relevant segment of the intestines. Significant clinical research suggests that compared with traditional nasogastric tubes, LT is capable of decreasing the pressure and relieving abdominal pain and distension within 1–2 days by aspirating the liquid accumulated in the gut more effectively.[10] Moreover, selective small intestine radiography through LT provides explicit information about the degree of luminal stenosis, which influences the chosen therapy. Research has shown that compared to conventional surgery, LT used in intestinal plication is an ideal method in the treatment of acute bowel obstruction. This is due to its low relapse rate and a delay in relapse, which makes it deserve a wider application in the clinic.[11] Furthermore, other research efforts have affirmed that the use of LT can greatly reduce the occurrence of postoperative adhesive obstruction.[12] Moreover, when patients are in the recovery stage, they can resume a normal diet with LT, and it is convenient to decompression when abdominal signs suggest re-obstruction.

Strangulating obstruction

Strangulating obstruction, which usually involves a closed loop obstruction in which the blood supply to a segment of the intestine is compromised, can lead to secondary bowel necrosis, bowel perforation, or more severe complications unless the patient receives immediate treatment and emergency surgery. Preoperative intubation of an LT can relieve clinical manifestations and reduce the surgery risks by aspirating the liquid in the intestinal cavity.

Early postoperative inflammatory small bowel obstruction

EPISBO refers to a kind of adhesive obstruction with both mechanical and dynamic dysfunction due to edema and exudation of the bowel wall following abdominal surgery trauma or intraperitoneal inflammation in the early postoperative stage (within 2 weeks).[13] EPISBO occurs mostly in patients who undergo a wide range of long surgical operations, have excessive blood loss, severe trauma, and recurring symptoms of obstruction, and who are older. Plain radiographs of the abdomen can show signs of obstruction, such as air-fluid levels. However, more specific pathologic changes, such as thickened intestinal walls and intestinal loops, can only be observed with computed tomography imaging.[14] Due to the particular pathological mechanism of EPISBO and the high risk of reoperation in the short term, we tend to offer conservative therapies (mainly to effectively decompress) in clinical trials.[15]

Malignant bowel obstruction

Malignant bowel obstruction (MBO) refers to the distal obstruction of the ligament of Treitz, for which abdominal or pelvic malignant tumors or correlated treatment is responsible. Patients who present with MBO are typically in the late stage with a bad general situation and complicated abdominal findings. The risks associated with emergency surgery can be diminished with the use of a LT. Research has indicated that by placing a LT in patients with a confirmed MBO, the general status and quality of life are improved, clinical manifestations are relieved, survival time is increased, and postoperative complications are decreased. Accordingly, these intubations are propitious to the surgical procedure.[16],[17]

Intubation

Endoscopic-guided approach

Among all enrolled patients, 27 patients used an endoscopic-guided approach for intubation. Here, patients are placed in the left lateral recumbent position and received oral dyclonine as a topical anesthetic. Endoscopic scanning is essential to ascertain the condition of the esophagus, stomach, and duodenum. As the alimentary canal is confirmed to be clear by endoscopy, foreign body forceps will send the guide to the descending or horizontal part of the duodenum or further to the ligament of Treitz. After 10–15 mL of sterilized distilled water is injected into the anterior balloon, the guidewire and gastroscope are slowly withdrawn.

Intestinal plication

The remaining 61 patients were intubated through intestinal plication. Preoperative intubation of LT into the duodenum is of great importance for enterolysis, intestinal partial cystectomy, or enteroanastomosis. Specifically, as surgical procedures are performed, surgeons can advance the entire tube to the small intestine, even exceeding 15 cm beyond the anastomosis site, by injecting 10 mL of sterilized distilled water to the anterior balloon. After LT is well placed, the surgeon thoroughly cleans peritoneal cavity and closes abdomen.

Therapies

Apart from decompression or intestinal plication through LT intubation and some basic treatment, such as fasting food and water, precautions of infections, and nutrition support, the patients were also given the following treatment:

  1. Protection of gastric mucosa and promotion of gastrointestinal motility: operations, trauma, or some other elements that are responsible for keeping our body under stress may have a direct harm to gastric mucosa. The application of proton-pump inhibitors, H2-receptor antagonists, and mucosa protectants is critical for therapy, regarding its protective effect for gastrorrhagia
  2. Application of somatostatin: Research has shown that somatostatin can overwhelmingly function mainly through the following mechanisms: (a) it drastically decreases the excretion of digestive juices [18] and (b) it decreases the loss of body fluids, minimizes damage to the intestinal mucosa, and relieves the luminal dilation and endotoxemia [19]
  3. Therapy to relieve constipation: patients are suggested to ingest liquid paraffin or sesame oil orally (or we inject liquid paraffin into the LT). Both methods are aimed at lubricating the luminal cavity to pass flatus and feces freely
  4. Chinese traditional medicine and acupuncture: according to our retrospective study, acupuncture and Chinese traditional medicine are both effective. We usually choose the Zusanli or Tianshu acupoint for acupuncture and perform coloclysis with a major purgative decoction with which we can accelerate peristalsis of the small intestine.


Statistical analysis

Statistical analysis was performed in Microsoft Excel 2010 (USA).


  Results Top


Among the patients, the oldest was 96 years and the youngest was 16 years, and the average age was 52.4 years. The time of LT decompression varies with each patient's condition: the average was 6.8 days (range 2–20 days). The prevalence of nasopharynx discomfort and pain was 95.4%; nearly 44.3% of the patients had electrolyte disorders and another 3.4% were diagnosed with aspiration pneumonia, including 1 male and 2 females, who were all transferred into Intensive Care Unit (ICU) and treated with anti-infectives, nutritional support, and assisted ventilation through endotracheal intubation, after which they were all discharged from the hospital after recovery. Of the patients, 25% sustained catheter-related accidents (15.9% for tube obstruction, 5.6% for unexpected catheter shedding, 1.1% for anterior balloon rupture, and 2.3% in which the guide was dislodged and eliminated through the anus) and no tube fragmentation occurred. During this study, intestinal hemorrhage, perforation, and necrosis were not observed, and we did not note any complications directly leading to patient death [Table 1]. Two patients, who underwent secondary intestinal plication because of EPISBO, died of severe abdominal infections and poor physical condition.
Table 1: Common complications of long gastrointestinal tubes

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  Discussion Top


Compared with traditional nasogastric decompression and intestinal plication, the LT method shows an unreplaceable superiority in reducing the incidence of postoperative re-obstruction and promoting the quality of life. Thus, LTs have been widely applied in the current therapeutic strategies of acute small bowel obstruction and intestinal plication [Figure 3] and [Figure 4].
Figure 3: Preoperative X-ray film showed air-liquid level and obvious obstruction signs

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Figure 4: X-ray film of the 5th day after surgery showed air-liquid level disappeared; intestinal obstruction was obviously relieved

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Nasopharynx discomfort and pain is one of the most common complications. As soon as a LT is inserted, varying degrees of nasopharynx discomfort and pain often appear, in addition to the following risk factors: (1) the existing sphincter in the nasopharynx; (2) ample endings of sensory nerves; and (3) intubation resulting in repeated injury and stimulation.[20] To relieve this discomfort, the following measures are effective: (a) soft intubation; (b) trickling liquid paraffin into the nose to protect the nasal mucosa from aridity and anabrosis; (c) oral nursing twice a day, and rinse the mouth with warm water, thus making it wet and clean; (d) applying normal saline with the addition of ambroxol for atomization twice a day can humidify the nasopharynx and eliminate sputum; and (e) adjusting the tube slightly according to patient complaints. The majority of patients can achieve relief after the above measures are taken.

Electrolyte disorders are the most common complication of bowel obstruction. In our study, six patients had hyponatremia, five patients had hypokalemia, and the remaining patients had both hyponatremia and hypokalemia. After active treatment, the electrolyte disorders in most cases can be corrected. For patients in the early stage of bowel obstruction, the reason for electrolyte disorders is bad appetite, vomiting quantities of bile, and gastric acids. Nevertheless, for patients who undergo surgery, the postoperative absorption dysfunction and long duration of fasting should be taken into account. Another main cause for hypokalemia is the loss of electrolytes due to LT; thus, LT decompresses to relieve the edema of the intestinal walls and aspirates digestive juices.

To decrease the occurrence of electrolyte disorders, the following can be adopted: (a) monitoring electrolytes and giving adequate potassium and sodium; (b) using somatostatin to inhibit the excretion of digestive juice and reduce the loss of electrolytes;[18] (c) returning the patient to a normal diet when their status improves and bowel function returns; and (d) administering electrolyte tablets orally for the recovery of intestinal motility.

Aspiration pneumonia is one of the most severe complications and features an abrupt change in patient condition. It can result in respiratory failure or acute respiratory distress syndrome (ARDS), which may directly lead to patient death. Three patients (1 male and 2 females; 63, 41, and 43 years of age, respectively) were diagnosed with aspiration pneumonia. Their symptoms included a sudden spasmodic cough, shortness of breath, and severe dyspnea, followed by obvious anoxia. Based on the above-mentioned symptoms and signs, as well as the corresponding laboratory examination and thoracic computed tomography scanning, these three patients were diagnosed with aspiration pneumonia at the time oxygen uptake, anti-infectives, phlegm-eliminating drugs, and nutritional support were administered. When patients did not improve, they were transferred to ICU for further treatment with endotracheal intubation and ventilation. Ultimately, the patients were discharged from the hospital after a full recovery.

Aspiration pneumonia is mainly caused by inhalation of oral and gastric countercurrent contents. Regarding prevention, patients with LTs may take a position of the head toward one side and hold high, and then take drugs to inhibit reflux, including antacids, mucosal protection, and prokinetic agents. At the same time, strengthen mouth care to preventing oral infection lesions, and suction secretions timely and completely to avoid aggravating aspiration pneumonia.[21] Nutritional support, improvement of physical conditions, and metabolic disorder correction guarantee the healing of pneumonitis. Patients with a definite history of foreign body inhalation should immediately have the foreign body removed under fibrobronchoscopy, be monitored with blood gas analysis, and have routine blood tests and other laboratory tests. With active measures taken, if it is still difficult to relieve hypoxemia, endotracheal intubation and ventilator-assisted breathing would be the most effective methods. Active anti-infective treatments are a necessity in relieving manifestations; antibiotics are advised to use within 48 h after inhalation is discovered.[22] Repeated bacterial cultivation can help to identify sensitive bacterium so as to apply specific antibiotics; however, the use of broad-spectrum antibiotics is of great significance based on experience. Since aspiration pneumonia is generally accompanied with anaerobic infection, anaerobic-sensitive drugs, such as metronidazole and clindamycin, can be administered together if necessary. Nevertheless, under such circumstances, the abuse of antibiotics for refractory severe infections, such as Tienam, is available. One must be vigilant against the superinfection and pseudomembranous enteritis brought by long-term use of antibiotics.

Catheter-related accidents were also frequent in our trials. Specifically, tube obstruction, unexpected catheter shedding, guides dislodged from the anus, and anterior balloon ruptures occurred with incidences of 15.9%, 5.6%, 2.3%, and 1.1%, respectively. No tube breakage occurred. Methods to prevent and manage catheter-related accidents are suggested as follows: (a) check in advance to ensure the tube is unobstructed and there is no rupture of balloon; (b) inject sterilized distilled water (<30 mL) slowly into the balloon to avoid rupture; (c) when the catheter considered to be obstructed or drainage is less day-after-day, we suggest irrigating the tube using normal saline (20–30 mL) to check whether or not the decreased drainage is caused by tube obstruction; (d) when the guide is dislodged from the anus, the guide may be returned to the body by adjusting its position or cutting off the front and removing the tube; (e) before drawing out the catheter, we require the patients to have liquid paraffin orally (30–50 mL) for sufficient lubrication. Withdrawal of the catheter should be slow and gentle without force under resistance to prevent the gut from damage and the tube from fracture; and (f) the necessity and importance of tube intubation should be explained to patients' family, and they should be informed about nursing safety.

Intestinal hemorrhage, perforation, and necrosis are rare and severe complications. We did not observe hemorrhage, perforation, or necrosis in our study; however, once these complications occur, severe abdominal infections and peritonitis will threaten the patient's life. These complications are probably related to obstruction and intestinal disease. Using LT for decompression, physicians should note the property and color of drainage fluids because different colors suggest a relevant diagnosis as follows: (a) blood- or coffee-like liquids indicate intestinal hemorrhage or strangulated intestinal obstruction and (b) abdominal tenderness, rebound tenderness, and muscular tension, known as peritoneal irritation signs, suggest that the patient may have an intestinal perforation. Regulating the suction pressure properly and carefully (always 0.02 MPa) is recommended during therapy. Intestinal wall attachment to suction holes should be avoided to avoid intestinal necrosis due to blocked blood supply. Another risk factor is injection drugs too rapidly through LT for therapeutic purpose, resulting in a dramatic increase in enteric pressure. Consequently, intestinal necrosis appears as a result of a disturbance of the blood supply that is caused by compression. To avoid chronic damage to the walls or more severe complications, when injecting water into the air vent again, it is not advised to have the same amount as before (10–15 mL is sufficient). When intestinal hemorrhage, perforation, or necrosis occur, physicians should react at once and take corresponding therapeutic methods to avoid acute diffuse peritonitis or infectious shock occurring, both of which may lead to death.

There are some drawbacks of this study that need to be discussed. First, the number of cases is not enough to cover all possible complications. Second, due to the limited number of cases, the number of observation days per patient is also limited. Third, as all patients were from our hospital, the study may have a single-center bias.

Overall, nasopharyngeal discomfort and pain, electrolyte disorders, and tube obstruction are the most common complications when applying LT. Aspiration pneumonia, intestinal hemorrhage, perforation, and necrosis are the most severe complications with a relatively lower incidence rate. The complications mentioned above should be taken seriously and corresponding precautionary measures should be taken to keep patients from deteriorating. According to our study, with the assistance of symptomatic treatment corresponding to the relevant complication, the effectiveness and safety of LTs are approved and worth being widely promoted in clinical therapy strategies.

Financial support and sponsorship

The present study was financially supported by grants from the Natural Science Foundation of China (Grant No. 81303110) and Basic Research Projects of Key Laboratory of Liaoning Provincial Education Department (Grant No. LZ2015028).

Conflicts of interest

There are no conflicts of interest.



 
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