Why is a Ryle's (nasogastric) tube used in choledocholithotomy?

Role of Nasogastric Tube in Choledocholithotomy

Nasogastric tubes should not be routinely used in choledocholithotomy procedures as they provide no clinical benefit and may increase complications and length of hospital stay. 1

Rationale for Avoiding Routine NG Tube Use

Evidence Against Routine Use

• The Enhanced Recovery After Surgery (ERAS) Society strongly recommends against routine nasogastric tube placement following liver surgery, including choledocholithotomy, based on high-quality evidence 1
• Multiple studies have shown that prophylactic nasogastric intubation:
  • Does not offer postoperative benefits
  • May increase hospital length of stay
  • Can lead to higher rates of respiratory complications

Potential Complications of NG Tubes

• Increased risk of pulmonary complications (atelectasis, pneumonia)
• Pharyngolaryngitis
• Patient discomfort
• Delayed return of bowel function
• Increased risk of reflux during laparotomy 1

Historical Context

Historically, nasogastric tubes were routinely placed after abdominal procedures including biliary surgery due to concerns about:

1. Postoperative abdominal distention
2. Nausea and vomiting
3. Gastric decompression
4. Prevention of aspiration

However, modern evidence has consistently demonstrated that these theoretical benefits do not materialize in clinical practice, and the risks outweigh any potential benefits.

Specific Situations Where NG Tubes May Be Indicated

While routine use is not recommended, there are specific circumstances where temporary nasogastric tube placement may be appropriate:

1. Intraoperative Use: An orogastric tube may be used if the stomach was inadvertently inflated during endotracheal intubation, but should be removed before reversal of anesthesia 1

2. Postoperative Ileus: In cases of prolonged postoperative ileus with significant abdominal distention and vomiting

3. Specific Biliary Procedures: In elective cholecystectomy with choledocholithotomy, an NG tube may be placed temporarily until the patient regains intestinal motility, but this is not a routine requirement 1

Enhanced Recovery Protocols for Choledocholithotomy

Modern ERAS protocols for biliary surgery recommend:

• Avoiding routine nasogastric decompression
• Early oral feeding (within 24 hours postoperatively)
• Early mobilization
• Adequate pain control
• Optimal fluid management

These measures collectively promote faster recovery and shorter hospital stays compared to traditional approaches that included routine NG tube placement.

Management Recommendations

1. Preoperative: Do not place NG tubes prophylactically before choledocholithotomy

2. Intraoperative: If an orogastric tube is placed for gastric decompression during surgery, remove it before reversal of anesthesia

3. Postoperative:

   • Initiate oral intake as soon as the patient is fully awake
   • Monitor for signs of ileus or vomiting
   • Only place an NG tube if clinically indicated by significant symptoms

Conclusion

The practice of routine nasogastric tube placement after choledocholithotomy is outdated and not supported by current evidence. Modern perioperative care focuses on enhanced recovery protocols that avoid unnecessary interventions that may delay recovery or increase complications.