World J Surg (2009) 33:1793–1794 DOI 10.1007/s00268-009-0132-1

INVITED COMMENTARY

A Randomized Clinical Trial of Frozen vs. Standard Nasogastric Tube Placement Doron Kopelman

Published online: 15 July 2009 Ó Socie´te´ Internationale de Chirurgie 2009

All of us, surgeons, must have witnessed the scene of an anesthesiologist standing over the head of the sleeping patient with both hands, or at least six blood-stained fingers, deep in the patient’s widely opened mouth, trying to guide the insubordinate nasogastric tube (NGT) down to its correct position. At the beginning of the 21st century, abundant with minimally invasive, image-guided, robotic technologies, this low-tech maneuver—how to insert NGT—may appear to be insignificant, but it is crucial. In the article published in this issue of the Journal, Chun et al. have conducted a two-arm, prospective, randomized study, comparing the insertion of a NGT filled with water and frozen in anesthetized, intubated patients to a control group [1]. They found that the insertion of a frozen NGT has a significantly higher success rate. There are more than a few techniques reported in the literature to facilitate NGT insertion in patients under anesthesia. Some of them involve similar principles like filling the NGT with water in room temperature, filling it with cold water, including the well-known approach of cooling or freezing of the NGT itself. A Google search using the phrase ‘‘NG tube insertion’’ and ‘‘freezing’’ yielded several sources recommending freezing of the NGT to assist in placement. A major drawback of this study is its small number of patients, not allowing assessing

D. Kopelman (&) Surgery Department ‘‘Emek’’ Medical Center, Afula, The Technion, Israel Institute of Technology, Haifa, Israel e-mail: [email protected]

the actual morbidity associated with passing a stiff NGT. One could argue that stiffening of the NGT could result in increased risk of accidental pyriform sinus perforation: there may be a trade off between the increased rigidity that facilitates successful insertion and the potential cost of increased morbidity. The current trend seems to favor insertion under a direct visual control as the preferred solution for difficult cases. Upper gastrointestinal endoscopy often is used to introduce nasogastric tubes [2]. Using a flexible fiberoptic nasoendoscope introduced through the nostril for direct vision control of the NGT insertion has been described [3]. A recent study suggests that video laryngoscope facilitates NGT insertion [4]. Other studies presented endoscopically assisted nasogastric tube placement over a guidewire, as a useful option in difficult cases of esophageal strictures [5]. The use of endoscopic video-assisted technologies sounds logical and promising and with the development of dedicated, simple, and user-friendly devices these may become the methods of choice. Nevertheless, hardening–freezing the NGT to facilitate insertion may be useful as a low-tech alternative to facilitate insertion in unconscious, nonswallowing patients. The fact that hardened-by-freezing tubes are easier to insert is old knowledge. Certain difficult-to-insert tubes, such as the Sengstaken-Blackmore tube, are always kept ready in the refrigerator. We also have to remember that the harder the tube is the more prone it is to inflict damage during insertion. This is why the opposite is true when passing the NGT in a conscious patient who can swallow. Here, the softer the tube the more easily and less traumatically it is swallowed by the patient. Thus, before insertion, immerse the tube in hot water for a few minutes and lubricate! This prospective study is worthy of our attention mainly because of the enormous respect that all of us owe to the

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NGT and its historical role in surgery, and because of the daily nature of this technical problem that should have long ago been solved.

References 1. Chun DH, Kim NY, Shin YS (2009) A randomized clinical trial of frozen vs. standard nasogastric tube placement. World J Surg. doi:10.1007/s00268-009-0144-x

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World J Surg (2009) 33:1793–1794 2. Bordas JM, Llach J, Mondelo F, Teres J (1996) Nasogastric tube insertion over a guide wire placed with a thin transnasal endoscope. Gastrointest Endosc 43:83 3. Karagama YG, Lancaster JL, Karkanevatos A (2001) Nasogastric tube insertion using flexible fiberoptic nasoendoscope. Hosp Med 62:336–337 4. Roberts JR, Halstead J (2009) Passage of a nasogastric tube in an intubated patient facilitated by a video laryngoscope. J Emerg Med (Epub ahead of print) 5. Shukla NK, Goel AK, Seenu V, Nanda R, Deo SV, Kriplani AK (1994) Endoscopically guided placement of nasogastric tubes in patients with oesophageal carcinoma with absolute dysphagia: report of a 3-year experience. J Surg Oncol 56:217–220