An assessment of the complications of open radical cystectomy with and without naso-gastric tubes – is a naso-gastric tube still routinely required?

Mr JM Patterson, Mr M Malki, Mr MD Haynes, Mr DJP Rosario and Mr JWF Catto Academic Urology Unit, University of Sheffield and Department of Urology, Royal Hallamshire Hospital Sheffield Teaching Hospitals NHS Foundation Trust

Introduction

• • Cystectomy is a morbid procedure – RT, GIT and UT/renal complications; mortality Patients dislike nasogastric tubes and they are associated with respiratory complications • • ERAS protocols have been introduced to improve LoS and other morbidity factors Can morbidity be reduced by removing the routine use of NGT?

Methods and patients

• • • • • Null hypothesis: Not using NGT will prolong ileus and increase complications Prospective evaluation of 57 patients undergoing open radical cystectomy Single institution, 3 surgeons 2 surgeons stopped placing NGT, 1 continued 12 month study period, followed up for 6-18 months

Methods and patients

No NGT (n=21)

13 ♂ :8 ♀

NGT (n=36)

30 ♂ :6 ♀

Overall

43 ♂ :14 ♀ Sex Age Procedure duration Blood loss 70.1 (59-83) 4h (2.75-5) 825ml (370-1700) 66.6 (55-80) 5.75h (4-9.33) 1475ml (400-3870) 67.9

5.1h

1245ml Time to bowels open Time to NG out Length of stay 7.35d (med 6d) 12.9d (med 13) 7.51d (med 7d) 4.6d

13.3d (med 12) 7.46d (med 7d) 4.6d

13.16d (med 12) Final pathology: • 15 pT0, 9 pTis, 3 pTa, 4 pT1, 15 pT2, 7 pT3, 4 pT4. • 13 N+ (4 pN1, 8* pN2, 1 pN3) *including an incidental lymphoma in pelvic nodes • 1 M+ (separate vaginal nodule to main tumour-G3pT2). • 11 incidental CaP • 53 Urothelial Ca (+2 Neuroendocrine differentiated), 1 AdenoCa, 1 SqCCa • 2 primary urethrectomy, 1 salvage cystectomy. All ♀ done as ant. exenteration

Results

• • • No difference in LoS (orthotopics excluded) No difference in time to return of GIT transit No difference in rates of DVT/PE or wound dehiscence (nil both groups), or cardiovascular or stomal complications • However, other complications do differ

Results

• Complications – 1 death in each group • 188 days post op in NGT- group – pT4 disease, 79yo • 159 days post op in NGT+ group – post salvage surgery, complications included enterocutaneous fistulae, T3b sarcomatoid tumour, 72yo – NGT related • 4 inserted in NGT- group (19%) – 2 only for 24h, 1 for chronic constipation, 1 for ileus • 4 reinserted in NGT+ group (11%) – 1 resited in PACU, 2 for 24-48h only, 1 for SB complications

Results

• Complications

No NGT

Wound infection Chest infection Nutritional Other infections 3 (14%) 1 (5%) 1 (5%) needed TPN 2 diarrhoea, 1 sepsis ?focus

Others Overall 1 persistent drain output, 1 revision UI anastomosis 10 in 8 patients (38%)

NGT +

10 (28%) 4 (11%) 4 (11%) needed TPN 2 diarrhoea, 1 C Diff, 2 sepsis ?focus, 1 urosepsis 1 enterocutaneous fistula, 2 scrotal haematoma, 1 revision stoma, 1 conversion neobladder to conduit, 1 laparotomy and adhesiolysis 30 in 18 patients (50%)

Discussion

• • • No result statistically significant Trend towards more complications in longer operations (mean duration 5.3 v 4.9h without complication), paralleled by blood loss NGT negatively associated with – respiratory complications – wound infections – overall complications

Conclusions

• Routine NGT placement after open radical cystectomy is not recommended – increased complications in this series – but up to 20% may need NGT insertion • senior clinician decision to avoid unnecessary NGT • Longer operating times seem to be correlated with blood loss, and increased complications