Patient eel thyself

A 50-year-old man presented to a Hong Kong emergency department with abdominal pain. He had signs of peritonitis on physical examination. An x-ray of the abdomen revealed the presence of an eel in the left lower quadrant [yellow arrows].

He told the surgeons that he had placed an eel in his rectum hoping it would alleviate his constipation. The eel had other ideas. At surgery, the eel was found in the peritoneal cavity having escaped the rectum by biting through its anterior wall. The photo below shows it attempting to bite the splenic flexure of the colon.

The eel, which measured 50 cm long, was removed and the rectum was divided. An end colostomy was performed. The patient did well and was discharged after a week-long hospitalization.

The authors said this was the first reported case of rectal perforation caused by insertion of a live animal.

I’ll see your NG tube in the brain and raise you …

Two years ago, I blogged about a fatal case of a nasogastric tube entering the right internal jugular vein. I thought I had seen the most bizarre misplaced NG tube, but here is possibly a worse case.

A symptomatic recurrence of a tumor at the clivus (skull base) led to the admission of a 57-year-old man. The original tumor was removed by craniotomy many years before followed by radiation therapy to the area. He had multiple comorbidities including obesity.

The recurrence was resected transnasally using endoscopy. Postoperatively the patient suffered several complications. An attempt to place a percutaneous feeding tube failed due to the patient’s size. A nasogastric feeding tube was inserted using endoscopic visualization to confirm the tube’s entry into the esophagus.

The feeding tube fell out a few days later and was replaced at the bedside by an on-call physician without visual control of the tip. Just after it was put in, the patient developed left-sided weakness. The tip of the tube was below the diaphragm on an abdominal x-ray, but a CT scan of the head showed the tube had entered the skull and gone down the spinal canal.

The tube was removed in the operating room. A small leak of cerebrospinal fluid was found and closed. Unfortunately, the patient became permanently quadriplegic and died after 7 more months of hospitalization.

The physician who tried to replace the feeding tube failed to appreciate the need to see the tip of the tube as it went in and was unaware that an open feeding gastrostomy was scheduled for that same day. The authors stressed poor communication was a factor leading to this bad outcome, and they established policies to prevent it happening again.

They also did a thorough literature search and found 11 reports of NG tubes being placed in the cranial vault. That’s more such cases than I thought.

Let’s hope NG tube in the spine doesn’t follow suit.

 

Skeptical Scalpel is a retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last 8 years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog has had more than 3,000,000 page views, and he has over 19,000 followers on Twitter