To the Editor:
We report an unusual complication that occurred after the insertion of a nasogastric tube (NG) in an infant. This 3-week-old, ASA physical status 1 girl was scheduled for a pyloromyotomy. Her preoperative NG was removed before induction of anesthesia and a new one (Argyle[TM] feeding tube, Sherwood Medical, size Ch 8, external diameter 2.7 mm x 107 cm) was easily inserted during surgery. Its correct position was then confirmed by air insufflation and slight dilation of the stomach, which allowed the surgeon to test the adequacy of the pyloromyotomy and the absence of any mucosal tear. Recovery was uneventful.
Several hours later, the ward nurse attempted to mobilize the NG because it seemed to be occluded. During these maneuvers, a loop of the NG appeared once in the mouth, but it soon became impossible to move the NG either up- or downward. A fluoroscopic control showed a knot in the NG tube at the level of the oropharynx (see Figure 1). We decided to remove the tube in the operating room during brief sedation (intravenous propofol): the NG was cut at the level of the nostril and retrieved orally with a Magill forceps under direct visual control with a laryngoscope. A new NG was then easily inserted under fluoroscopic control. We hypothesized that the NG was initially inserted too far, which allowed a part of it to form a loop and a knot in the oropharynx during the nurse's maneuvers.
In conclusion, this unusual complication of NG placement must be kept in mind when any difficulty occurs during its mobilization, as blind traction could have catastrophic consequences. If any doubt exists, the NG should be checked by a radiograph. This case should also remind us to avoid inserting a NG too far.
Ives Michel, MD
Francis Veyckemans, MD
Michel Van Boven, MD
Service d'Anesthesiologie; Universite Catholique de Louvain; Cliniques Universitaires Saint-Luc; 1200 Brussels, Belgium