Endoscopic removal of a fractured nasojejunal tube in the duodenum

A 40-year-old man, with no significant history of past illness, presented to our emergency department with classic features of perforation peritonitis. Exploratory laparotomy showed duodenal perforation, which was closed with an omental patch. Before suturing the perforation, however, a nasojejunal tube was inserted for feeding. The postoperative period was uneventful and the patient was allowed oral feeding 1 week later. After 2 weeks, the nasojejunal tube was removed with some difficulty with its distal part missing. Abdominal radiography showed the distal end of the nasojejunal tube retained inside the intestine ([Fig. 1]). Upper gastrointestinal endoscopy showed narrowing of the D1–D2 junction with the proximal end of the fractured part of the nasojejunal tube lying just beyond the junction. We tried to grasp this end of the fractured tube with punch biopsy forceps but failed. We then decided to use a polypectomy snare to grasp the proximal end and the fractured tube was removed successfully ([Fig. 2] and [Video 1]).

Fig. 1 Antero-posterior X-ray of the abdomen in a 40-year-old man who underwent sutural closure of a duodenal perforation: there is a fractured nasojejunal tube lying inside the duodenum and the jejunum.

Fig. 2 a The fractured nasojejunal tube being removed endoscopically with a polypectomy snare. b The fractured nasojejunal tube after removal.

Endoscopic removal of fractured nasojejunal tube using a polypectomy snare.

The nasojejunal tube was probably sutured along with the duodenal wall during closure of the duodenal perforation, and thus it fractured during removal. There is little literature on endoscopic removal of such long foreign bodies. Only a few case reports had been published on endoscopic retrieval of sutured, knotted, or fragmented nasogastric tubes from the stomach or the posterior pharynx in humans as well as in animals [1] [2] [3] [4]. Thus, utmost care should be taken while suturing the bowel with any tube inside, however, endoscopic techniques can be used successfully to retrieve broken tubes.

Endoscopy_UCTN_Code_CPL_1AH_2AI

• References

• 1 Cappell MS, Scarpa PJ, Nadler S et al. Complications of nasoenteral tubes. Intragastric tube knotting and intragastric tube breakage. J Clin Gastroenterol 1992; 14: 144-147
• 2 Cribb NC, Kenney DG, Reid-Burke R. Removal of a nasogastric tube fragment from the stomach of a standing horse. Can Vet J 2012; 53: 83-85
• 3 Dinsmore RC, Benson JF. Endoscopic removal of a knotted nasogastric tube lodged in the posterior nasopharynx. South Med J 1999; 92: 1005-1007
• 4 Sucandy I, Antanavicius G. A novel use of endoscopic cutter: Endoscopic retrieval of a retained nasogastric tube following a robotically assisted laparoscopic biliopancreatic diversion with duodenal switch. N Am J Med Sci 2011; 3: 486-488