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Year : 2021  |  Volume : 14  |  Issue : 1  |  Page : 100-102  

Inadvertent esophageal migration of endotracheal tube used to guide orogastric tube: An unfortunate complication in an intubated patient

Department of Anaesthesiology, Seth G.S. Medical College and K.E.M. Hospital, Mumbai, Maharashtra, India

Date of Submission22-Dec-2019
Date of Decision26-Feb-2020
Date of Acceptance25-Jun-2020
Date of Web Publication22-Jan-2021

Correspondence Address:
Gauri Raman Gangakhedkar
13/14, Chandangad Apartments, Next to Rahul Nagar, Near Karve Putala, Kothrud, Pune - 411 038, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjdrdypu.mjdrdypu_347_19

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In patients undergoing ambulatory laparoscopic surgeries, Ryles tubes are required only for the purpose of intraoperative gastric decompression. Insertion of nasogastric tubes can lead to nasal trauma, and hence, oral tubes provide a feasible alternative. In contrast to the nasopharyngeal cavity, whose anatomical orientation allows ease of insertion into the esophagus, oral insertion of Ryles tube is difficult on account of a larger cavity and potential for coiling. Various aids are often used to ease the insertion of these orogastric tubes. One such aid is the use of an oral endotracheal tube (ETT). This case report aims to bring to light, and the inadvertent complications may occur with the improper use of these aids, which in our case, was the misplacement of the said oral ETT.

Keywords: Adverse event, complication, endoscopic removal, endotracheal tube, foreign body, orogastric tube

How to cite this article:
Gangakhedkar GR, Buddhi M, Toal S, Soitkar R, Patel RD, Sundaram S. Inadvertent esophageal migration of endotracheal tube used to guide orogastric tube: An unfortunate complication in an intubated patient. Med J DY Patil Vidyapeeth 2021;14:100-2

How to cite this URL:
Gangakhedkar GR, Buddhi M, Toal S, Soitkar R, Patel RD, Sundaram S. Inadvertent esophageal migration of endotracheal tube used to guide orogastric tube: An unfortunate complication in an intubated patient. Med J DY Patil Vidyapeeth [serial online] 2021 [cited 2021 Feb 27];14:100-2. Available from: https://www.mjdrdypv.org/text.asp?2021/14/1/100/307680

  Introduction Top

Insertion of orogastric or nasogastric tube relies on swallowing movements in conscious patients. In anesthetized patients, the absence of these leads to difficulty in insertion.[1] In addition to first attempt failure rates as high as 50%, it results in another significant and disturbing complication in the form of trauma, to the nasal and pharyngeal mucosa or larynx, and can lead to hoarseness.[1],[2] Although orogastric tubes (OGTs) are associated with fewer complications than nasogastric tubes, they have been known to cause their share. Thus, looking for alternate means of insertion in the form of tools such as forceps, various head positions, the use of a guidewire to increase the stiffness of the tube, and the use of reverse Sellick's maneuver, becomes a need rather than an indulgence.[3] This case report describes the complication that arose from losing the oral guiding tube that was used to ease OGT insertion.

  Case Report Top

A 22-year-old American Society of Anesthesiology (ASA) Grade-I female patient was posted for laparoscopic cholecystectomy. After administration of general anesthesia, using an institutional protocol, the patient was intubated using a cuffed 7-mm internal diameter (Portex) endotracheal tube (ETT), and standard ASA monitoring was instituted. A 12Fr OGT was to be inserted for intraoperative gastric decompression. To ease the insertion, an uncuffed ETT of 6.0-mm (Rusch) internal diameter was inserted in the oropharynx, as a guide [Figure 1]. During the process of insertion, the universal connector on the guide ETT accidentally got disconnected from the tube and the tube migrated to the esophagus. It could not be visualized on direct laryngoscopy or video laryngoscopy using C-MAC D-blade. Due to the logistic complexities, an intraoperative endoscopic retrieval was not feasible. The patient was extubated after an uneventful surgical course and was asymptomatic. After explaining the nature and implications of the complication to the patient and her relatives, she was shifted to the endoscopy suite. Here, she underwent an oesophagogastroduodenoscopy under monitored anesthesia care. The ETT was visualized at 22 cm from the incisors. The endoscopists were able to successfully retrieve ETT with ease using a snare [Figure 2]. The patient remained vitally stable throughout the procedure.
Figure 1: (a) Original method of insertion (b) proposed modification withholding the tube in hand during insertion (c) proposed modification with the removal of the connector during insertion

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Figure 2: Visualisation and endoscopic retrieval of the endotracheal tube

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  Discussion Top

Ours is a high-volume tertiary care center where over 1800 elective general surgical procedures are performed annually with nearly one-third them being ambulatory laparoscopic procedures, where OGTs would suffice. There is evidence to suggest that the use of oral guide tubes results in a significant decrease in the incidence of kinking and malposition.[2],[3] To assist their insertion, we first insert a well-lubricated uncuffed oral ETT (6.0 mm Rusch), like the insertion of an oropharyngeal airway. The anesthetist then inserts the OGT using this tube as a conduit with the dominant hand while stabilizing the assembly with their nondominant hand. Over the past 1 year alone, we have inserted OGTs in 580 patients using this technique. The uncuffed tube is removed once the OGT is in place. In concurrence with a study by Kwon et al., we find that insertion becomes easier and faster.[2] Where we differ from their approach is our choice to use a smaller tube 6.0 mm as opposed to 8.5 of uncuffed variety rather than cutting off the tips of cuffed tubes. Their study reports a 16% incidence of mucosal bleeds which could be attributed to the difficulty in the insertion of the large-sized guide tube.

There is evidence to recommend the use of preslit tubes over the method suggested by Kwon et al. where they cut the tube off with sterile scissors after the OGT is in place.[1],[2],[4] Alflen et al., showed the ease of intubation and faster intubation times, using another modification of the ETT, called the “gastric guide tube” (VBM, Germany) for insertion.[3] The proximal end is funnel-shaped and the shaft is slit to allow easy removal of the same once its purpose is served.

Gomes et al. described the esophageal migration of the nasal guide tube used to insert a nasogastric tube in three cases. Two of these were retrieved by endoscopy, while one required gastrostomy.[5] Unfortunately, the logistic complexities in our institute did not permit the intraoperative retrieval of the ETT, which would have eliminated the necessity for a second procedure.

Another therapeutic alternative was the use of a rigid bronchoscope or esophagoscope. However, the use of the same is not without complications. In their clinical experience with rigid bronchoscopy over 27 years, Hsu et al. have removed 2758 foreign bodies from the esophagus.[6] Even a center as experienced as theirs, noted a complication rate of 0.2%, with perforation occurring in six patients and one patient losing their life. Moreover, rigid endoscopes are more challenging as they consist of a single channel through which visualization, suctioning, and tube recovery must be carried out. Magnification of the image or telecasting the image on the screen is also not feasible.

Our inopportune accident led us to make changes in our protocol. While Gomes et al. chose the use of tape to fix the universal connector with the tube, we decided to remove the connectors from the tube and insert the OGT up to the tip of the tube before insertion.[5] In addition, we have started using Portex rather than Rusch tubes, to aid radiographic visualization using the blue line, if required. We also ensure that at least 5 cm of the tube is visible outside the mouth to allow an easy grip [Figure 1]. We are pleased to report that we have not had any further incidents after that.

  Conclusion Top

The use of ETTs to aid the insertion of OGTs indubitably reduces the time required, the incidence of trauma, and the requirement of instrumentation for the procedure. While we were fortunate enough to be able to retrieve the tube, with minimal harm to the patient, it resulted in an additional invasive procedure for the patient. This case report only serves to highlight that all procedures come with an inherent risk of adverse outcomes. Not only should such outcomes be anticipated but also regular checks must be in place to prevent recurrences.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflict of interest.

  References Top

Fakhari S, Bilehjani E, Negargar S, Mirinazhad M, Azarfarin R. Split endotraceal tube as a guide tube for gastric tube insertion in anesthetized patients: A randomized clinical trial. J Cardiovasc Thorac Res 2009;1:17-22.  Back to cited text no. 1
Kwon OS, Cho GC, Jo CH, Cho YS. Endotracheal tube-assisted orogastric tube insertion in intubated patients in an ED. Am J Emerg Med 2015;33:177-80.  Back to cited text no. 2
Alflen C, Kriege M, Schmidtmann I, Noppens RR, Piepho T. Orogastric tube insertion using the new gastric tube guide: First experiences from a manikin study. BMC Anesthesiol 2017;17:54.  Back to cited text no. 3
Liu GP, Xue FS, Li RP, Sun C, Yang GZ. Measures to facilitate endotracheal tube-assisted orogastric tube insertion. Am J Emerg Med 2015;33:304.  Back to cited text no. 4
Gomes RM, Raj PP, Kumar SS, Palanivelu C. Prevention of migration of endotracheal tubes used for aided nasogastric tube placement in anaesthetized patients. Indian J Anaesth 2015;59:261-2.  Back to cited text no. 5
[PUBMED]  [Full text]  
Hsu WC, Sheen TS, Lin CD, Tan CT, Yeh TH, Lee SY. Clinical experiences of removing foreign bodies in the airway and esophagus with a rigid endoscope: A series of 3217 cases from 1970 to 1996. Otolaryngol Head Neck Surg 2000;122:450-4.  Back to cited text no. 6


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