a nasogastric tube is utilized routinely by many bariatric surgeons to assist creation of gastrojejunal anastomosis during roux - en - y gastric bypass or duodenojejunal anastomosis during biliopancreatic diversion . however , inadvertent stapling or suturing of the nasogastric tube has been known as a potential complication of this technique . we describe a successful endoscopic removal of an inadvertently sutured nasogastric tube at the level of the duodenojejunal anastomosis in a 30-year - old woman undergoing a robotically assisted laparoscopic biliopancreatic diversion with duodenal switch for super morbid obesity . endoscopic technique is a feasible and safe minimally invasive technique to release a retained nasogastric tube with preservation of the newly created anastomosis . this option gives major advantages of avoiding a re - operation , as well as the potential general anesthetic complications . in many bariatric centers , a nasogastric tube ( ngt ) is utilized routinely when creating the gastrojejunal anastomosis during a roux - en - y gastric bypass or the duodenojejunal anastomosis in a duodenal switch . one potential complication of this technique includes inadvertent stapling or suturing of the ngt depending on the type of anastomosis performed . we describe the successful endoscopic removal of an inadvertently sutured ngt at the level of the duodenojejunal anastomosis during a robotically assisted laparoscopic biliopancreatic diversion with duodenal switch ( r - lbpd / ds ) . a 30-year - old woman with a body mass index ( bmi ) of 44.5 underwent an uneventful r - lbpd / ds . the operation had included the use of a # 16-fr red rubber ngt to guide the creation of the robotically assisted double - layered handsewn duodenojejunal anastomosis . on postoperative day ( pod ) # 1 , the patient complained of significant epigastric pain during attempts to remove the ngt , which appeared to be fixated to a point on the foregut structure . on endoscopic re - evaluation under twilight anesthesia in the operating room , the ngt was found to have been inadvertently sutured at the level of the duodenojejunal anastomosis ( figure 1 ) . an endoscopic cutter was initially introduced via a regular front - view gastroscope , however the challenging degree of angulation resulted in inadequate visualization . we then switched to a sideview ercp scope which provided superior view and more favorable angulation toward the anastomosis ( figure 2 ) . the endoscopic cutter was successfully utilized to cut and release the ngt , leaving the anastomotic suture intact . the anastomosis was carefully inspected , which appeared to be intact and watertight ( figure 3 ) . endoscopic view of an inadvertently sutured nasogastric tube at the level of duodenojejunal anastomosis using a regular front - view gastroscope . progressive effort to cut and release the retained nasogastric tube using an endoscopic cutter guided by a side - view ercp scope . a radiologic evaluation of the anastomosis was obtained with gastrografin upper gi series on pod # 3 , which ruled out anastomotic leak or obstruction . a clear liquid diet was subsequently introduced without problems . the patient continued to make an unremarkable recovery , and she was discharged on pod # 5 . at 1 month postoperatively , an upper gi endoscopy was performed where an intact and patent anastomosis was seen . at 6-month follow - up , the patient has achieved excellent weight loss with complete resolution of her obesity - related comorbidities . regular office visits are scheduled as per bariatric protocol at 9 , 12 , 18 months postoperatively , and yearly thereafter . a gastrografin upper gi series is reserved for clinical signs and symptoms of upper gi obstruction in the future , followed by an upper gi endoscopy with possible balloon dilatation if clinically indicated . in bariatric surgery , a recognized complication of gastric banding is erosion and subsequent intragastric migration of the band causing potentially serious problems such as obstruction , gastric perforation , and intra - abdominal sepsis . endoscopic removal of intragastric foreign body , mainly eroded gastric band or silastic ring from the historically popular vertical band gatroplasty ( vbg ) in the early 1980 's has been described . vbg involves partitioning the stomach with a vertical staple line and restricting the pouch outlet using a gortex band which can erode through the vertical staple line or through the lesser curvature into the gastric pouch . it occurs in 1% to 3% of patients and presents with symptoms of obstruction , weight gain , nausea , pain , and bleeding . utilizing this minimally invasive endoscopic technique , a surgical removal of the bands neto at al reported a 95% success rate of endoscopic removal of eroded gastric bands due to erosion . symptoms occurred at an average of 16.3 months ( range 6 - 36 ) postoperatively and included pain ( 31% ) , port infection ( 27% ) , and weight regain ( 25% ) of the patients . a comparable technical success was reported in 7 patients by regusci et al . in the case described in this report , a flexible endoscopic cutter was used for removal of a retained nasogastric tube that had been inadvertently sutured during creation of a robotically assisted duodenojejunal anastomosis . the patient was taken for an endoscopic exploration in the operating room with plan to proceed with laparoscopic / open exploration  redo anastomosis should the endoscopic approach fail or the anastomosis become disrupted . initially , a regular ( front - view ) gastroscope was used , but visualization was poor because of the parallel direction of the nasogastric tube and the gastroscope . an adequate triangulation was later obtained using a side - view endoscopic retrograde cholangiopancreatography ( ercp ) scope in collaboration with a gastrointestinal endoscopist . after the release , the anastomosis was found to be intact endoscopically , and this was subsequently confirmed radiologically . laparoscopic exploration with possible creation of a new anastomosis was able to be avoided . in the report of endoscopic removal of eroded adjustable gastric band by neto at all , three were treated conservatively , one was treated by laparoscopy , and one was treated by abdominal puncture using the veress needle . in the current case , flexible endoscopy is safe , feasible , and effective in retrieving a retained foreign body after upper intestinal surgery . a laparoscopic approach with possible repair / re - creation of the anastomosis should be reserved as the next option only when the endoscopic approach fails .
context : a nasogastric tube is utilized routinely by many bariatric surgeons to assist creation of gastrojejunal anastomosis during roux - en - y gastric bypass or duodenojejunal anastomosis during biliopancreatic diversion . however , inadvertent stapling or suturing of the nasogastric tube has been known as a potential complication of this technique.case report : we describe a successful endoscopic removal of an inadvertently sutured nasogastric tube at the level of the duodenojejunal anastomosis in a 30-year - old woman undergoing a robotically assisted laparoscopic biliopancreatic diversion with duodenal switch for super morbid obesity.conclusions:endoscopic technique is a feasible and safe minimally invasive technique to release a retained nasogastric tube with preservation of the newly created anastomosis . 
 this option gives major advantages of avoiding a re - operation , as well as the potential general anesthetic complications .