Skipping the use of a nasogastric (NG) tube after esophageal cancer surgery may not be as safe as the routine five-day decompression, according to results published in The Lancet Regional Health that suggest using the tube could lower the risk of anastomotic leaks.
Esophageal and gastroesophageal junction cancers are among the deadliest cancers worldwide, responsible for more than 500,000 deaths each year, according to the study’s authors. Surgical removal of the esophagus, or esophagectomy, remains the primary treatment option for patients with curable disease.
While this procedure increases the chance of long-term survival, it carries a high risk of serious complications. Pneumonia is the most common postoperative issue, but an anastomotic leak—when the surgical connection between the esophagus and stomach fails—is often the most dangerous.
To lower these risks, surgeons in many centers continue to use NG tubes after surgery. The tube drains and decompresses the stomach, with the goal of reducing pressure on the surgical joint, limiting the chance of leaks and preventing aspiration into the lungs.
At the same time, NG tubes are increasingly being questioned. They are one of the last areas in gastrointestinal surgery where routine use persists, even as other surgical fields have moved toward minimizing or eliminating them.
Additional studies have also raised questions on the use.
For instance, research published in the Journal of Thoracic Disease reported that routine NG decompression after gastrointestinal surgery did not significantly lower the risk of leaks or pulmonary complications. In addition, studies in gastric cancer surgery, including those cited in the International Surgery Journal, found that early removal of NG tubes can be safe and may help speed recovery.
Patient comfort has also emerged as an important factor.
A review in the World Journal of Gastroenterology noted that NG tubes are consistently associated with discomfort and can even raise the risk of respiratory problems. In addition, Enhanced Recovery After Surgery (ERAS) guidelines recommend avoiding routine NG tube placement after esophagectomy unless there is a specific clinical need.
However, many surgeons have been reluctant to abandon NG tubes without stronger evidence from randomized controlled trials (RCTs).
The new Lancet study aimed to fill that gap by providing high-quality data on the risks and benefits of omitting NG decompression after esophagectomy.
The trial was a multicenter RCT conducted at 12 university hospitals across Sweden, Norway, Denmark and Finland. Eligible patients were adults with resectable, or removable, esophageal or gastroesophageal junction cancer who were scheduled for surgery with a gastric tube.
After giving consent, patients were randomized 1:1 into two groups: immediate removal of the NG tube after surgery (intervention group) or routine NG decompression for five days (control group).
Randomization was grouped by sex, neoadjuvant therapy, anastomotic site and hospital. Surgeries were performed by experienced oncologic surgeons following local standards.
The primary outcome was the rate of anastomotic leaks. The secondary outcomes included complication severity, pneumonia, length of hospital stay, intensive care use and both 30- and 90-day mortality.
CT scans were also performed on day seven and were reviewed by blinded radiologists to ensure objective detection of leaks.
Between January 2022 and March 2024, 564 patients were screened, and 448 were enrolled in the trial. Out of these patients, 217 were assigned to immediate NG-tube removal and 231 to standard five-day decompression. Most participants were men (82%) with an average age of 67.5, and a majority had locally advanced disease.
Data revealed that 95 patients in the control group did not complete the full five days of decompression, often due to discomfort or accidental removal. In the intervention group, 9 patients required NG tube placement after surgery because of bloating or poor emptying.
Anastomotic leaks occurred in 83 patients. Rates were higher in the no-tube group (22.1%) compared with the NG-tube group (15.2%). This difference This difference meant the study could not prove that taking the tube out right away was just as safe. Most leaks were managed with endoscopic or interventional treatments, and survival outcomes remained similar between groups.
Serious complications occurred in about 42% of patients, and pneumonia was slightly more common in the no-tube group, though the difference was not statistically significant. Thirty- and 90-day mortality rates were low and comparable across both arms.
The trial’s strengths stand out for a number of reasons.
It was large and conducted across multiple centers, making the findings more relatable of real-world practice. Patient follow-up was also strong, and blinded radiologist review of CT scans strengthened the reliability of leak detection.
Additionally, the intervention was simple—NG tube or no NG tube—without altering other forms of care.
However, limitations exist.
A significant number of patients in the control group did not complete the full five-day NG tube protocol, potentially weakening the comparison. The study also did not address the optimal duration of NG tube use, leaving uncertainty about whether shorter decompression might be safe. The open-label design could have introduced bias, although the blinded imaging review helps mitigate this risk.
The authors of the study advise caution before changing clinical practice. While ERAS guidelines favor avoiding routine NG tube use, this trial suggests that immediate removal may increase the risk of leaks, even if other outcomes remain similar. Until more research clarifies the safest approach, the authors stated that routine NG tube decompression after esophagectomy should continue.