Dear Sir,

I read with interest the manuscript entitled “Should Gastric Decompression be a Routine Procedure in Patients Who Undergo Pylorus-Preserving Pancreatoduodenectomy?” [1] Although the study was impressive, I feel that there are some points that must be discussed.

Nasogastric tube placement after abdominal surgery has been a standard procedure for many decades. Mayo once remarked that he “would rather have a resident with a nasogastric tube in his pocket than a stethoscope [2].” The first to challenge the necessity of nasogastric tube (NG) tube decompression after surgery was Gerber [3]. Cheatham and associates published the first large-scale meta-analysis of the use of prophylactic postoperative NG tubes in 1995 [4]. Prophylactic NG decompression fails to improve bowel function, length of stay, and prevent anastomotic leak, wound complications, pulmonary complications, and abdominal discomfort. Although these studies concluded that routine NG tube decompression after alimentary tract surgery is unnecessary, many surgeons believed that NG protects intestinal anastomoses and shortens hospital stay [4]. Clinicians’ behavior is often driven by more implicit or unconscious processes such as habits. The countless repetitions of behavior create a habit [5]. Evidence-based medicine has been an important paradigm shift; however, it’s principal weakness is that the design of many important trials simply does not reflect everyday clinical practice. Although there are many papers against prophylactic NG tube decompression, I still use prophylactic NG tube following gastro intestinal anastomoses. Changing the clinical habit is harder than changing sleeping habits. Sometimes NG is beneficial for surgeon.

I want to ask the authors: Have they changed the clinical habits (not use routine gastric decompression in patients who undergo pylorus-preserving pancreatoduodenectomy) radically?