A rare case of nasoenteric tube perforation of posterior nasopharynx into the peritoneum
Mohamed A, Khawja S, Munie S, Sacco J, Killu K, and Blyden D. A rare case of nasoenteric tube perforation of posterior nasopharynx into the peritoneum. Crit Care Med 2019; 47(1).
Crit Care Med
Learning Objectives: The association of malnutrition with surgical morbidity and mortality is well recognized. Thus, nutrition is among the corner stone of optimal surgical management. If possible, the preferred route for nutritional delivery is via enteral means. A commonly employed route for tube feed delivery is nasoenteric tubes. The most employed technique for insertion is blind intubation. This may result in malposition. If unrecognized, it may result in devastating complications such as pneumothorax and death. We describe a unique complication using the CorTrak system.
Methods: A 60-year-old male was found down, unresponsive, reportedly surrounded by vomit. His medical history included alcohol abuse. He was treated for aspiration pneumonia, alcohol withdrawal, and acute kidney injury (AKI). As part of his treatment, the patient was begun on enteral feeds. A CorTrak dobhoff device was inserted via blind intubation. Following insertion, an abdominal xray confirmed placement. In the following days, the patient's abdomen became more distended, and he became anuric. Computed Tomography revealed the feeding tube was extraluminal to the stomach. He was taken to the operating room with concerns for an esophageal perforation, and abdominal compartment syndrome. An upper endoscopy could not visualize the feeding tube in the esophagus or in the stomach. An endoscopy of the nasal cavity showed the feeding tube to be perforating into the nasopharynx. An exploratory laparotomy was done and found the feeding tube in the lesser sac. The abdomen was washed out, and an Abthera temporary closure device was placed. On post operative day two, patient was returned to the operating room where a gastrostomy tube was placed, and the abdomen was closed. He was taken to the ICU for supportive management and was eventually discharged to a skilled nursing facility extubated, off dialysis, and in stable condition.
Results: To our knowledge, the outlined case is the first perforation into the peritoneal cavity using the CorTrak system. The feeding tube perforated through the posterior nasopharanynx, traversed the mediastinum via the paraesophageal space, into the lesser sac. The management of the esophageal perforation was nonoperative. Focus was turned towards the patient's abdominal compartment syndrome, abdominal source control, and foreign body removal. As seamless as they may seem, blind intubation of nasoenteric feeding tubes still carry with them potentially devastating complications, as illustrated by this case.