Do nasogastric or nasoenteric tubes improve outcomes from adhesional small bowel obstruction: a systematic review and meta-analysis

BMC Surgery Al-Mashat et al. BMC Surgery (2025) 25:545 https://doi.org/10.1186/s12893-025-03207-x Open Access S YS T E M AT I C R E V I E W Do nasogastric or nasoenteric tubes improve outcomes from adhesional small bowel obstruction: a systematic review and metaanalysis Ali Al-Mashat1,2, Anaan Fareed1,2, Tharindu Senanayake1,2, Stephen Ridley Smith1,2,3* and Jonathan Gani1,2 Abstract Objectives To compare outcomes of nasogastric (NGT) or nasoenteric tube decompression against no decompression in the non-operative management of adhesional small bowel obstruction (ASBO) using a systematic review and meta-analysis. Methods Database searches up to February 2025 were conducted using Cochrane Library, EMBASE, MEDLINE and SCOPUS. Abstract screening and data extraction were performed by two independent reviewers. Patients aged 18 and above were included. Studies were excluded if they compared NGTs to long tube devices or if the primary aetiology of SBO was not adhesions. Quality appraisal was conducted using the Newcastle Ottawa Scale and metaanalysis was performed using RevMan Web Software. Results Searches yielded 1442 studies, of which 4 met the inclusion criteria, comprising a total of 1219 patients undergoing non-operative management for ASBO. These were all retrospective cohort studies. Within these studies, a total of 732 patients had a nasogastric or nasoenteric tube inserted for ASBO while 487 patients were managed without one. NGT use had a non-significant trend toward increased operative intervention, with a pooled odds ratio of 2.58 (95% CI: 0.77 to 8.65; p = 0.09, I² = 82%). Three studies compared bowel resection rates; NGT use was not associated with a statistically significant increased risk of bowel resection (OR 2.31; 95% CI: 0.86–6.16; p = 0.10). All studies reported a longer length of hospital stay in the NGT group. Conclusions The available evidence is sparse, limited in design and quality, and marked by high heterogeneity, making it insufficient to draw a definitive conclusion regarding the role of NGTs in ASBO. High-quality evidence from a randomised controlled trial is needed to guide future practice. Trial registration PROSPERO (CRD: CRD42021256098). Keywords Nasogastric tube, Adhesional small bowel obstruction, Operative management *Correspondence: Stephen Ridley Smith 1 Surgical Services, John Hunter Hospital, Newcastle, NSW, Australia 2 School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia 3 Department of General Surgery, Calvary Mater Hospital, Newcastle, NSW, Australia © Crown 2025. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Al-Mashat et al. BMC Surgery (2025) 25:545 Introduction Adhesive small bowel obstruction (ASBO) accounts for approximately 74% of small bowel obstruction cases, with its incidence continuing to rise [1, 2]. ASBOs are often managed non-operatively, except in cases with peritonitis, ischaemia, or strangulation. Non-operative management has been shown to be effective in approximately 70–90% of ASBO patients [3]. In contrast, SBOs caused by hernias, malignancies, strictures, or foreign bodies frequently require surgical intervention. Surgical management is associated with greater morbidity and mortality in ASBO patients, particularly if delayed [4, 5]. Furthermore, according to the Royal Australasian College of Surgeons Collaborative Hospitals Audit of Surgical Mortality (CHASM) data, small bowel resection for obstruction is the third leading cause of operative deaths [6]. Thus, the main priorities in ASBO management are early recognition of patients requiring surgical intervention and, when possible, timely resolution through nonoperative management. The cornerstone of non-operative management in ASBO has traditionally been the ‘drip and suck’ approach, involving intestinal decompression via a nasogastric (NGT) or nasoenteric tube [7], as recommended by the Bologna Guidelines from the World Journal of Emergency Surgery. Water-soluble contrast administration is a well-established intervention in the non-operative management of ASBO, with high-quality evidence supporting its diagnostic and therapeutic benefits, including reducing the need for surgery [8–10]. In contrast, despite its long-standing use, the value of NGT decompression remains unclear. Recently, a national survey of Australian surgeons highlighted controversy with its application and a shift towards its selective use in ASBO [11]. Given the significant risks and patient discomfort associated with NGT insertion [12, 13], a review of the evidence surrounding its use is needed to guide future practice and improve outcomes in patients with ASBO. Methods Research question Does NGT or nasoenteric tube decompression improve outcomes in adults with ASBO? Protocol and registration A protocol was designed in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) 2020 checklist [14], and was registered prospectively under the PROSPERO systematic review database registration, CRD: CRD42021256098. Eligibility criteria Studies were selected according to predefined inclusion and exclusion criteria. Page 2 of 15 Inclusion Criteria: •  Studies involving adult patients (≥ 18 years). •  Studies where the population included patients with ASBO, with a specified prior history of abdominal surgery. •  Studies comparing nasogastric or nasoenteric (e.g. long-tube) decompression against no decompression. •  Studies reporting outcomes including operative intervention, bowel resection or bowel necrosis, length of hospital stay, time to resolution, respiratory complications (including pneumonia), mortality, and resolution with water-soluble contrast administration. Exclusion Criteria: •  Studies involving paediatric populations (< 18 years). •  Studies in which SBO was primarily due to causes other than adhesions (e.g., malignancy, hernias, inflammatory bowel disease or paralytic ileus). •  Studies focused on ASBO presentations requiring immediate surgical intervention. For the purposes of this review, the “NGT group” refers to patients who received either a nasogastric or nasoenteric tube. 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