Department of General Surgery, Lokmanya Tilak Municipal Medical College and General Hospital, Sion (W) Mumbai, Maharashtra, India.

The use of a naso-jejunal tube for early post-operative enteral fefeding and gastric decompression in gastric and duodenal surgeries is a routine and accepted intra-operative procedure [1]. The naso-jejunal tube is passed distal to the site of perforation to facilitate this [2].  Apart from the known common complications of naso-jejunal tube insertion like throat discomfort, epistaxis, tube blockage, misplacement, knotting and kinking [3,4], one of the rare complications is entrapment of tube in a suture bite while suturing the site of perforation. There are very few cases reporting this as a complication and its successful removal is a clinical challenge to the surgeon or endoscopist and may significantly affect the outcome of the patient in terms of morbidity associated with a second surgery.

A 40-year-old man presented to the casualty with complaints of severe pain in abdomen with fever and vomiting for 2 days. On clinical examination his pulse rate was 130 beats/min and his blood pressure was 100/70 mm of Hg. His abdomen was rigid and guarded with diffuse tenderness all over. His X-ray chest showed gas under diaphragm. Diagnosis of perforative peritonitis was made. After resuscitation he was taken for emergency exploratory laparotomy. Intra-operatively there was a perforation of 0.5×0.5 cm in the first part of duodenum. A naso-jejunal tube was inserted beyond the site of perforation and a modified Graham’s omental patch repair was done. On post-operative day 5, patient began receiving nutrition thorough naso-jejunal tube. On post-operative day 7, an attempt was made to remove the naso-jejunal tube, but significant resistance was encountered and the tube could not be removed. An X-ray erect abdomen was performed to confirm the position of naso-jejunal tube and rule out any kink or knotting before giving it a second attempt. X-ray showed no kink or knot, and a second attempt was made the next day with the same result. It was then decided to perform a gastroscopy to look for entrapment of the tube in suture. The gastroscopy revealed that entrapment of the naso-jejunal tube in a Mersilk thread in first part of duodenum at the site of perforation. The decision was made to wait for one more week and wait for the thread to become loose so as to be able to pull the naso-jejunal tube out of the duodenum to perform the procedure safely. During this period the patient was kept on full diet. 

To prevent such iatrogenic complication, meticulous suturing is essential to ensure the tube is not inadvertently included in the suture bite. This can be achieved using a plane forceps to depress the tube or by lifting the anterior wall of bowel/stomach by stay sutures [5]. If such a complication does occur, an endoscopic approach may significantly improve the patient’s outcome, by avoiding a need for major re-do surgery. 

an exploratory laparotomy for pre-pyloric perforation [7].

Although prevention is preferable, using a needle knife papillotome to cut the suture thread causing entrapment can be a safe and simple technique when in the pylorus. Such endoscopic procedures are economical, timesaving and minimally invasive, significantly improving the patient’s outcome by reducing morbidity associated with a redo-surgery and alleviating the surgeon’s stress by avoiding a major open surgery. 

Contributors: MAG: concept, design, intellectual content, data analysis, literature search, manuscript review; SJK: literature search, data acquisition, manuscript preparation, manuscript editing; AGB: literature search, manuscript preparation; PHP: literature search, data acquisition, manuscript editing. SJK will act as a study guarantor. All authors approved the final version of this manuscript and are responsible for all aspects of this study.

Funding: None; Competing interests: None stated.