Retroperitoneal Migration of a Malpositioned Nasogastric Tube Following Panfacial Fracture Surgery.

A 63-year-old man with panfacial fracture was transferred to our hospital. Open reduction and internal fixation of the fracture was performed, followed by nasogastric tube insertion under general anesthesia. Location of the tube was checked by epigastric auscultation and chest radiography intraoperatively. Although the tube was displaced to the left on the radiography, its position was deemed appropriate because the tip was located below the diaphragm. Postoperative computed tomography revealed that the tube had entered into the trachea, penetrated the lung and diaphragm, and migrated into the retroperitoneal space. Pleural effusion and pneumonia were also detected. The patient was successfully treated with thoracic drainage and antibiotic therapy. This case demonstrates that nasogastric tube malposition can be overlooked despite epigastric auscultation and radiographic confirmation of the tube tip alone. Careful assessment of the entire course of the tube, rather than the tip alone, is essential to avoid this potentially life-threatening complication.