Can a patient who has had a Nissen fundoplication (Nissen fundoplication) have an orogastric (OG) tube?

OG Tube Placement After Nissen Fundoplication

Yes, an orogastric (OG) tube can be placed in a patient who has had a Nissen fundoplication, but it requires careful technique and should ideally be done under fluoroscopic or endoscopic guidance rather than blindly to avoid disrupting the fundoplication wrap. 1

Key Technical Considerations

Standard Placement is Feasible

• OG tubes are routinely placed through natural orifices in patients with various gastric procedures, including those with fundoplications. 1
• The 2011 multidisciplinary guidelines from the Society of Interventional Radiology and American Gastroenterological Association explicitly describe OG tube placement as a standard enteric access technique that can be performed blindly, endoscopically, or with image guidance. 1

Critical Safety Precautions

Avoid blind bedside placement in fundoplication patients:

• While blind OG tube placement is commonly successful in standard patients, radiographic confirmation of proper position is mandatory before use to prevent complications such as esophageal perforation or wrap disruption. 1
• Bedside auscultation alone is unreliable and can miss inappropriate tube locations including esophageal coiling, which could place mechanical stress on the fundoplication. 1

Preferred placement methods:

• Fluoroscopic or endoscopic guidance is strongly recommended to visualize the wrap and ensure the tube passes through without causing trauma or disruption. 1
• This is particularly important because the fundoplication creates altered anatomy at the gastroesophageal junction that increases risk during blind passage. 1

Special Populations Requiring Extra Caution

Pediatric Patients with EA-TEF Repair History

• Children with esophageal atresia repair who subsequently undergo fundoplication have dyskinetic esophageal motility and shortened esophagus, making them particularly vulnerable to wrap disruption. 2
• In this population, the fundoplication failure rate is 33% (compared to 10% in children without EA), often due to upward tension on the wrap. 2
• Any instrumentation including OG tube placement should be performed with extreme caution and preferably under direct visualization. 2

Recent Post-Operative Period

• In the immediate post-operative period following fundoplication, a nasogastric tube is typically positioned during surgery for decompression. 1
• If an OG tube is needed shortly after fundoplication, coordinate with the surgical team to assess wrap integrity before placement. 1

Clinical Pitfalls to Avoid

Do not force the tube:

• If resistance is encountered during passage, stop immediately and obtain imaging or endoscopic assistance rather than applying force that could disrupt the wrap. 1

Recognize wrap complications:

• If the patient has dysphagia, inability to belch, or other symptoms suggesting wrap dysfunction, obtain upper GI imaging before attempting OG placement to assess wrap integrity. 3, 2
• Wrap disruption occurs in up to 33% of high-risk patients (such as those with EA-TEF history), and blind tube placement could worsen an already compromised fundoplication. 2

Consider alternative access:

• If gastric decompression or feeding access is needed long-term in a fundoplication patient, percutaneous endoscopic gastrostomy (PEG) under laparoscopic supervision may be safer than repeated OG tube placements. 4
• Combined laparoscopic and endoscopic PEG placement at the time of fundoplication has been shown safe and allows evaluation of wrap integrity. 4

Practical Algorithm

1. Assess urgency and indication for OG tube placement
2. Review surgical history - timing of fundoplication and any complications
3. Choose guided placement (fluoroscopy or endoscopy) over blind technique whenever possible 1
4. Use appropriate tube size (typically 8-12F) with adequate lubrication 1
5. Confirm position radiographically before any feeding or medication administration 1
6. Monitor for complications including dysphagia, inability to advance tube, or signs of perforation