1Department of General Surgery, Faculty of Medicine, Alexandria University, Alexandria, Egypt; 2Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China; 3Department of Surgical Oncology, Oncology Center, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia *Corresponding Author’s e-mail: aazzam70@yahoo.com إزالة أنبوب أنفي-معدي مشتبك مع مفاغرة املريء من نوع Roux-en-Y عن طريق اخلطأ بعد استئصال كلي ملعدة مصابة بالسرطان تقرير حالة واستعراض املنشورات السابقة اأمين زكي عزام، كرمي اأمين عزام، طارق اأمني abstract: Nasogastric tubes (NGTs) are important for feeding, stenting and decompression after gastrointestinal surgeries, particularly in the upper gastrointestinal tract. Resistance in the removal of a NGT is a rare surgical complication and may be due to a knot in the tube or a stitch anchoring the tube to an anastomosis. We report a 41-year-old male patient who was admitted to the King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia, in 2015 with stomach cancer. He underwent a radical total gastrectomy with a Roux-en-Y oesopha- gojejunostomy. One week after the surgery, removal of the NGT was attempted; however, this was very difficult and the proximal end of the tube was cut off as a temporary measure. Six weeks later, an upper gastrointestinal tract endoscopy revealed that the distal end of the NGT had been accidentally stitched to the Roux-en-Y oesophagojejunostomy. The stitch was removed and the rest of the NGT was successfully extracted using a snare. Keywords: Enteral Nutrition; Gastrointestinal Intubation; Roux-en-Y Anastomosis; Gastrectomy; Case Report; Saudi Arabia. امللخ�ص: اأنابيب املعدة االأنفية مهمة للتغذية وتفتيح اأو اإزالة ال�سغط على املنطقة اجلراحية يف قناة اله�سم، باالأخ�ض يف اجلزء العلوي للجهاز اله�سمي، لكن مقاومة هذه االأنابيب لالإزالة تعترب من امل�ساعفات اجلراحية النادرة احلدوث التي قد يكون املت�سبب فيها هو عقدة يف االأنبوب اأو غرزة ت�سبك االأنبوب باملفاغرة، نعر�ض هنا حالة عن مري�ض يبلغ من العمر 41 عامًا مت اإدخاله اإىل م�ست�سفى امللك في�سل التخ�س�سي ومركز االأبحاث يف الريا�ض باململكة العربية ال�سعودية يف عام 2015 وكان م�سابًا ب�رصطان املعدة، خ�سع لعملية ا�ستئ�سال املعدة الكلي ومفاغرة املريء مع ال�سائم بطريقة Roux-en-Y، بعد اأ�سبوع واحد من اجلراحة، مت حماولة اإزالة اأنبوب املعدة االأنفي، مع اله�سمي للجهاز منظارعلوي عمل مت اأ�سابيع �ستة بعد اأنه اإال موؤقت، كتدبري جراحيًا االأنبوب طرف نهاية قطع قرر ال�سعوبة، من �َسْيٍء فاكت�سف اأن طرف االأنبوب البعيد قد مت خياطته عن طريق اخلطاأ مع الفاغرة، فتمت اإزالة الغرزة وا�ستئ�سال بقية االأنبوب العالق بنجاح با�ستخدام اأداة انتزاع جراحي )�ِسنار(. الكلمات املفتاحية: التغذية املعوية؛ التنبيب املعدي؛ مفاغرة Roux-en-Y؛ ا�ستئ�سال املعدة؛ تقرير حالة؛ اململكة العربية ال�سعودية. Removal of Nasogastric Tube Accidentally Stitched to Roux-en-Y Oesophagojejunostomy Following a Radical Gastrectomy for Stomach Cancer Case report and review of the literature *Ayman Z. Azzam,1,3 Kareem A. Azzam,2 Tarek Amin3 Sultan Qaboos University Med J, February 2018, Vol. 18, Iss. 1, pp. e110–111, Epub. 4 Apr 18 Submitted 2 Nov 17 Revision Req. 24 Dec 17; Revision Recd. 30 Dec 17 Accepted 18 Jan 18 case report doi: 10.18295/squmj.2018.18.01.020 Case Report A 41-year-old male patient was admitted to the King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia, in 2015 with stomach cancer. He subsequently underwent a radical total gastrectomy with a Roux-en-Y oesophagojejunostomy, intraopera- tive radiation and hyperthermic intraperitoneal chemo- therapy. Immediately following the procedure, the patient was extubated and sent to the Intensive Care Unit in a satisfactory condition. During the postopera- tive period, oral feeding was discontinued for one week and the patient was fed via NGT. Clinical laboratory tests The placement of a nasogastric tube (ngt)for feeding, stenting and gastric decomp-ression is common after major surgeries—esp- ecially gastrointestinal surgeries with critical anast- omoses, such as a radical total gastrectomy and Roux- en-Y oesophagojejunostomy—and rarely results in com- plications.1,2 The accidental stitching of an NGT to a gastrointestinal anastomosis is an infrequent surgical complication.3–5 This report describes the successful removal of an NGT which had been accidentally stitched to an anastomosis in a patient with stomach cancer after a radical total gastrectomy and Roux-en-Y oesophagojejunostomy. Ayman Z. Azzam, Kareem A. Azzam and Tarek Amin Case Report | e111 were performed on a daily basis. One week after the surgery, a contrast meal was administered, which showed that the anastomosis was widely patent with no evid- ence of leakage or obstruction. The decision was made to remove the NGT so that the patient could begin a clear liquid diet. However, the NGT was very resistant and could not be removed by conventional means. An upper gastrointestinal tract (UGIT) endoscopy was not considered an option so early due to the risk of rupturing the anastomosis. Surgical exploration was also not a viable choice so as to avoid a prolonged hospital stay and any delay in initiating a postoperative chemotherapy regimen. After an otolaryngology consultation, the removal of the NGT was attempted under general anaesthesia. The patient was intubated and a mouth gag was used to open the patient’s mouth in order to examine the oral cavity. The nasal cavity and the nasopharynx were examined via surgical telescope and the NGT was found to be freely mobile. An upper rigid oesophagoscopy was also performed, but the cause of the difficulty in removing the NGT could not be identified. Accordingly, the proximal portion of the NGT relative to the nose was cut off, leaving behind the distal portion for later removal once the patient had completely recovered. The patient tolerated the procedure well with no complications. A second contrast meal administered the following day showed no evidence of leakage, enabling the patient to start a liquid-based diet and undergo postoperative chemotherapy treatment. Six weeks later, an UGIT endoscopy was done and revealed that the distal end of the NGT had been accidentally fixed with a single stitch to the Roux-en-Y oesopha- gojejunostomy. Subsequently, the stitch was cut and the remaining portion of the NGT was removed using an endoscopic snare. Soon after, the patient was discharged in good condition. Discussion Unexpected complications can arise during the insertion or removal of an NGT. Following gastric surgery, such as a radical gastrectomy, a mechanically stuck NGT can be indicative of a stitch anchoring the tube. The accidental iatrogenic suturing of an NGT is a rare complication but may nevertheless occur, especially if the NGT passes through an anastomosis.3–5 This serious complication is difficult to manage due to its rarity; moreover, little information is available in the literature to provide guidance for physicians when dealing with such complications.6 Any attempt to forcibly remove the NGT should be avoided as this may lead to serious complications, including dehiscence of the anasto- mosis, perforation of the gut and profuse bleeding.7 In the current case, removing as much of the prox- imal end of the NGT as possible was beneficial as it enabled the patient to continue eating, decreased his hospital stay and permitted the early initiation of postoperative chemotherapy, while allowing sufficient time for the anastomosis to heal. In addition, an UGIT endoscopy was deemed the investigation of choice as it allows for the complete assessment and diagnosis of the problem as well as the relatively safe removal of the NGT. However, an endoscopy may itself cause dehiscence of the anastomosis, especially if performed at an early postoperative stage when the anastomosis has not yet completely healed.8 As such, this procedure should be delayed for at least two weeks after the surgery, based on the wound healing process and the strength of the suture material.5 Conclusion Difficulty in the removal of an NGT following gastric surgery involving a Roux-en-Y oesophagojejunostomy may be due to the presence of a stitch anchoring the tube to the anastomosis, as in the present case. Initially, partial removal of the proximal end of the NGT is recommended to allow sufficient time for the anasto- mosis to heal; subsequently, the distal end of the tube can be removed at a later date via UGIT endoscopy. References 1. Akbaba S, Kayaalp C, Savkilioglu M. Nasogastric decomp- ression after total gastrectomy. Hepatogastroenterology 2004; 51:1881–5. 2. Santhanam V, Margarson M. Removal of self-knotted naso- gastric tube: Technical note. Int J Oral Maxillofac Surg 2008; 37:384–5. doi: 10.1016/j.ijom.2007.11.020. 3. Urschel JD, Stockburger HJ. Endoscopic extraction of an entrapped nasogastric tube. Am Surg 1990; 56:730–2. 4. Reissman P, Udassin R, Goldin E, Durst AL. Management of an inadvertently sutured nasogastric tube after Nissen fundo- plication. Gastrointest Endosc 1994; 40:260–1. doi: 10.1016/ S0016-5107(94)70191-1. 5. Chen CN, Lee WJ, Cheng TJ, Chang KJ. Endoscopic removal of nasogastric tube sutured unintentionally to gastrojejunos- tomy. Surg Laparosc Endosc 1997; 7:359–60. 6. Hirwa KD, Toshniwal N. Knotted nasogastric tube in the posterior nasopharynx: A case report. Qatar Med J 2016; 2016:11. doi: 10.5339/qmj.2016.11. 7. Mahmood A, Joseph E, Robinson RB, Akhras J, McKany M, Gordon W. The role of endoscopy in nasogastric tube removal following esophageal surgery: A case report. Int J Surg 2007; 5:342–4. doi: 10.1016/j.ijsu.2007.04.020. 8. ASGE Standards of Practice Committee; Ben-Menachem T, Decker GA, Early DS, Evans J, Fanelli RD, et al. Adverse events of upper GI endoscopy. Gastrointest Endosc 2012; 76:707–18. doi: 10.1016/j.gie.2012.03.252. https://doi.org/10.1016/j.ijom.2007.11.020 https://doi.org/10.1016/S0016-5107%2894%2970191-1 https://doi.org/10.1016/S0016-5107%2894%2970191-1 https://doi.org/10.5339/qmj.2016.11 https://doi.org/10.1016/j.ijsu.2007.04.020 https://doi.org/10.1016/j.gie.2012.03.252