Doing it right


“It is concluded that nasogastric suction should not be used routinely following abdominal surgery." This is the concluding statement from a paper presented at the Pacific Coast Surgical Association and published in the American Journal of Surgery more than 50 years ago (Am. J. Surg 1957;94:257-61).

Since then innumerable randomized controlled trials and meta-analyses have confirmed that nasogastric tubes inserted prophylactically after abdominal surgery, even when gastrointestinal anastomoses have been constructed, are unnecessary. So how did this incontrovertible evidence impact my practice and that of most of my surgical colleagues? Not at all, at least not for many years. We continued our routine of torturing postoperative patients with nasogastric tubes because it had been drummed into us during residency and because we were uncomfortable not doing so. But why did we persist after convincing evidence to the contrary emerged?

Unfortunately it is not uncommon that even when good evidence exists, we fail to incorporate it into decision-making. The comfort we enjoy with our standard way of doing things is often preferred to the discomfort – cognitive dissonance – we experience when confronted with mounting empirical evidence that challenges our beliefs. All too often, the cognitive dissonance is reduced by holding on to those notions with which we are most comfortable and ignoring or rejecting new information no matter how valid.

What is the harm? In the case of prophylactic nasogastric tubes, considerable discomfort has unnecessarily complicated the postoperative courses of millions of patients. Many trials have shown that aspiration and pneumonia, the adverse events for which the tubes were placed to prevent, occurred more frequently in patients with than those without nasogastric tubes.

Prophylactic gastric decompression is but one of many practices that have been continued long after their efficacy was disproven. How many radical mastectomies were performed after modified radical mastectomy, and then later partial mastectomy with radiation were shown with irrefutable data to provide equal survival with less disfigurement and fewer complications such as arm lymphedema? For many years after the indications for tonsillectomy were narrowed, this procedure continued to be more commonly done than was appropriate based on the evidence available.

Some hold on to their cherished habits more persistently and longer than others. In order to maintain consonance and avoid the stress of dissonance, I have known surgeons who have retained nearly all of the practices they learned from their mentors during residency long past their utility. Such individuals may insist that they alone prep their patients and that long outmoded suture and instruments be maintained on the operating room supply list. When new, and often proven to be superior, instruments, sutures, and pathways of care for their patients are introduced in their institutions, they find it difficult or even impossible to change.

In an era when the few controlled trials and meta-analyses available were buried within a surgical literature that was difficult to access and the term evidence-based surgery was not yet a part of our lexicon, such a rigid posture was often tolerated. I would hope that in most institutions and departments of surgery this is no longer the case. We live in a time when the imperatives of renewal and reevaluation of our practices are increasing. Therefore, reviewing new evidence, even that which goes against our established notions, and incorporating new proven methods, are essential to maintaining the highest standard of patient care.

Although many gray areas remain and there is often more than one best way to manage a surgical patient, our treatments should be based on the best evidence available rather than on what we learned 5, 10, or even 30 years ago. Fortunately, such evidence is now readily accessible. A notable example is “Evidence-based decisions in surgery,” surgical practice guidelines recently introduced by the American College of Surgeons (ACS) under the guidance of Dr. Lewis Flint.

“Evidence-based decisions in surgery” presently consists of 15 modules of the most common diseases and conditions encountered by general surgeons. These modules can be easily accessed by ACS Fellows on any mobile device at the point-of-care ( Surgical recommendations along with the strength of evidence (weak, moderate, or strong) for each are presented in an easy-to-interpret format. The modules have been developed by American College of Surgeons staff and been peer-reviewed by the Best Practices Workgroup of the College’s Board of Governors and by representatives of the Advisory Council for General Surgery. A consensus of the reviewers was used to determine the content of each module. It is emphasized that the purpose of these modules is to guide rather than dictate decision-making.

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