Duodenal perforation as a complication of routine endoscopic nasoenteral feeding tube placement

Laparoscopic repair of a large duodenal perforation secondary to an indwelling nasogastric tube in a tracheotomized adult

Laparoscopic repair of perforated duodenal ulcers is safe and effective in centers with experience and increasingly performed by laparoscopic surgeons. However, the role of laparoscopy for the management of large duodenal perforations (>1 cm) is unclear. To date, no experience has been reported with emergency laparoscopic repair of large perforations for gastroduodenal ulcers. The commonest reason for conversion to open surgery is a perforation size of more than 1 cm. This paper reports a case of a large duodenal perforation due to a nasogastric tube in a 26-year-old male who had undergone a tracheostomy, following a cut-throat injury. This large perforation was successfully diagnosed and repaired laparoscopically. This is probably the first paper in the English literature to report duodenal perforation due to a nasogastric tube in an adult and also the first report of a successful laparoscopic repair of a large duodenal perforation.

Duodenal perforation due to a kink in a nasojejunal feeding tube in a patient with severe acute pancreatitis: a case report

Introduction

Nasojejunal feeding tube placement can be achieved by fluoroscopic or endoscopic techniques. Significant complications due to nasojejunal feeding tube placement, such as hydrothorax, duodenal perforation and retroperitoneal emphysema, are very rare. We present a case of massive retroperitoneal emphysema and abscess because of duodenal perforation caused by a kink in a nasojejunal feeding tube.

Case presentation

A 34-year-old Chinese woman was admitted to our intensive care unit due to hypertriglyceridemia and severe acute pancreatitis. As she suffered from acute respiratory distress syndrome and required mechanical ventilation, a nasojejunal feeding tube was placed by transnasal endoscopic technique. The procedure took place at her bedside. Half a month later, she had a high fever and abdominal distension. An abdominal radiography was performed and showed that the nasojejunal feeding tube was kinking on the third portion of the duodenum and the tip of the nasojejunal feeding tube was inserted into the right retroperitoneum on the second portion of the duodenum.

Conclusion

When a nasojejunal feeding tube is placed through the transnasal endoscopic technique, an abdominal radiography should be used to confirm the tube's position and indicate if it is kinking or beyond the ligament of Treitz.

Duodenal perforation caused by a transpyloric tube in a critically ill infant

OBJECTIVE

We describe the case of a 2-mo-old infant who weighed 3.5 kg, had alveolar interstitial pneumopathy on mechanical ventilation, and developed a duodenal perforation due to a 6-Fr polyurethane transpyloric tube.

METHODS AND RESULTS

Abdominal ultrasound showed the tube to be within the intestinal lumen. Due to this diagnostic error, nutrition was administered through the tube and the patient developed severe peritonitis. Laparotomy showed a perforation due to the transpyloric tube at the level of the union of the second and third portions of the duodenum. The perforation was sutured but the patient developed new intestinal perforations with severe progressive intestinal damage, leading to multiorgan failure and death.

CONCLUSIONS

If there is a clinical suspicion of intestinal perforation secondary to insertion of a transpyloric tube, the position of the tube must be confirmed by radiographic and echographic techniques. In case of doubt, the tube should be withdrawn and endoscopic or contrast radiographic evaluation must be performed.

Management of iatrogenic perforation

Iatrogenic perforation of the gastrointestinal tract is a medical emergency and is inevitable. An endoscopist must maintain a high index of suspicion despite minimal or atypical symptoms and negative radiologic studies, because perforation is a complication with tremendous morbidity and mortality. The endoscopist must know how to manage this complication appropriately and to seek immediate surgical consultation. There is ongoing controversy about when a patient should undergo nonoperative or surgical therapy. An evidence-based approach to manage iatrogenic perforation is not possible. The trend in the modern era is to less invasive, nonoperative therapy, given advancements in ICU care and antibiotics. Laparoscopy or laparoscopic-assisted (minilaparotomy) surgery is also being increasingly used with outcomes comparable with conventional laparotomy. Experience and advancements in accessories have enabled endoscopic repair of iatrogenic perforation in many situations [84]. The management algorithms provided synthesize the pertinent literature into reasonable guidelines to follow. Ultimately, an individualized approach must be taken to manage the patient with an iatrogenic perforation.