Nasogastric tube accidentally stitched to the stomach during laparoscopic antireflux surgery

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An overweight 59-year-old lady with a 6-cm hiatus hernia and reflux esophagitis underwent a laparoscopic antireflux procedure. After reduction of the stomach into the abdomen, the crura of the diaphragm were approximated behind the esophagus and an anterior fundoplication was created, using interrupted nonabsorbable stitches, to approximate the mobilized gastric fundus to the right crus ([Fig. 1]). The nasogastric tube was left in situ, the plan being to remove it next day. Surprisingly, though, repeated attempts to remove the nasogastric tube postoperatively were unsuccessful. The tube was arrested at 45 cm aboral and further attempts at pulling on it were clearly unsafe. A decision was taken for urgent endoscopy.

At endoscopy, the tube was found to be entangled in one of the stitches ([Fig. 2]). A diathermy snare was used to cut the stitch and the nasogastric tube was easily removed. After endoscopy, the patient did very well and was discharged home the same day. Follow-up after 3 weeks showed a very good recovery.

Fig. 1 Laparoscopic view: the liver is retracted by Nathanson’s retractor. The upper two stitches fix the stomach to the right crus; the lower two approximate the right to the left crus. The second stitch (arrow) is probably the one that entangled the nasogastric tube.

Fig. 2 Endoscopic view (J maneuver): the nasogastric tube is transfixed by one of the fundoplication stitches (arrow).

Inadvertent suturing of the nasogastric tube is a rare but potentially serious complication of gastric surgery and does seem to occur from time to time [1] [2] [3]. It is probably more prone to occur in laparoscopic than in open surgery due to the loss of tactile feedback in the former. A high index of suspicion is essential when a nasogastric tube is mechanically “stuck” after gastric surgery. A rough attempt to remove the tube at that point is dangerous and may lead to gut perforation or significant bleeding. Gastroscopy is the investigation of choice. It allows appropriate assessment of the problem and safe retrieval of the tube.

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References

• 1 Urschel J D, Stockburger H J. Endoscopic extraction of an entrapped nasogastric tube.  Am Surg. 1990;  56 730-732
• 2 Reissman P, Udassin R, Goldin E. et al . Management of an inadvertently sutured nasogastric tube after Nissen fundoplication.  Gastrointest Endosc. 1994;  40(2 Pt 1) 260-261
• 3 Chen C N, Lee W J, Cheng T J. et al . Endoscopic removal of nasogastric tube sutured unintentionally to gastrojejunostomy.  Surg Laparosc Endosc. 1997;  7 359-360