Surgical Surprise and a Ryle's Tube Misadventure: An Intraoperative Gastric Perforation.

Nasogastric tube (NGT) insertion is routinely performed for enteral feeding and gastric decompression and is generally considered safe. However, it can lead to complications ranging from minor discomfort, epistaxis, and sinusitis to severe events such as respiratory injury, esophageal perforation, and, rarely, gastrointestinal perforation. Among these, gastric perforation in adults is extremely uncommon. We describe the case of a 47-year-old woman with carcinoma of the left lateral tongue who underwent near-total glossectomy with bilateral neck dissection, tracheostomy, and reconstruction. After a difficult nasal intubation, a 16F NGT was inserted intraoperatively. During surgery, persistent oliguria and progressive abdominal distention raised suspicion of intra-abdominal pathology. Exploratory laparotomy revealed perforation of the posterior gastric wall caused by the Ryle's tube. The defect was repaired using a Graham's omental patch, and the primary procedure was completed. The patient recovered uneventfully. This case highlights that even routine NGT placement can lead to rare but life-threatening complications. Careful technique, vigilance for atypical intraoperative signs, and reliable confirmation of tube position, preferably through radiographic verification, are essential to prevent and promptly manage such adverse events.