J Indian Assoc Pediatr Surg / Jul-Sept 2005 / Vol 10 / Issue 3199

Letter to Editor Full text online at http://www.jiaps.com

Knotting of Feeding Tube Used forKnotting of Feeding Tube Used forKnotting of Feeding Tube Used forKnotting of Feeding Tube Used forKnotting of Feeding Tube Used forBladder Drainage in HypospadiasBladder Drainage in HypospadiasBladder Drainage in HypospadiasBladder Drainage in HypospadiasBladder Drainage in HypospadiasRepairRepairRepairRepairRepair

Sir,Infant feeding tubes are commonly used for the splintageof the neourethra and continuous closed bladder drain-age following urethroplasty. Over-catheterization withsuch thin tubes may result in its coiling and knotting.This is a preventable complication and timely recogni-tion and proper management is essential to avoid furtherdamage.

In a 5-year-old child who had undergone hypospadias re-pair, removal of an over-catheterized 6F infant feedingtube was met with resistance and required lubrication in-and-around the tube with 2% lignocaine jelly while main-taining a constant and gentle traction. The tube success-fully removed was found knotted distally [Figure 1]. Therewas no bleeding or urethral disruption and the subsequenturinary stream was straight and thick.

Knotting is a known complication of placement of tubesin body cavities. Nasogastric tubes, ventriculoatrial cath-eters, ureteral stents, urinary catheters,[1] and urethral

catheters used in hypospadias repair,[2] are all susceptibleto knotting. An intravesically knotted tube may be re-moved by transurethral endoscopy, per urethrum follow-ing lubrication and gentle traction, or by suprapubic route.Transurethral endoscopic removal in the early postopera-tive period is contraindicated following urethroplasty dueto the risk of neourethral disruption. In older children,feeding tubes of 6F or smaller may be removed gentlyper urethrum after meticulous lubrication as learnt fromthis experience. However, undue force during removal ofknotted tubes can lead to serious iatrogenic injuries andmust be attempted only by a senior surgeon. Timely sus-picion is also important and an intravesical feeding tubethat cannot be removed with ease should be consideredas knotted and must be confirmed radiographically.

More importantly over-catheterization must be avoidedto prevent both knotting and troublesome bladder spasms.Over-catherization can be prevented by adhering to thefollowing steps during its insertion:(i) once the tube is introduced into the bladder, slowly

withdraw till the urine stops dribbling (now the tip ofthe feeding tube lies just distal to the internal sphinc-ter);

(ii) pass the tube slowly in again till urine starts to reap-pear (tip is just proximal to the internal sphincter);

(iii)push the tube in a further 2-3 cms and anchor it atthis position with the glans traction suture. Besidespreventing knotting this also avoids troublesome blad-der spasms and straining which results in seepage ofurine around the feeding tube and wetting of thedressing.

R. B. Singh, Nevil M. Pavithran,

Rajeshkumar M. ParameswaranDepartment of Burns & Plastic Surgery, Pt. B. D. Sharma

PGIMS, Rohtak-124001, Haryana, India.E-mail: dr_rb_singh@rediffmail.com

drnevilmallet@yahoo.co.in

REFERENCES

1. Dogra PN, Nabi G, Goel R. Endoscopic removal of knotted urethralcatheter. A point of technique. Urologia Internationalis 2003;71:8-9.

2. Sugar EC, Firlit CF. Knot in urethral catheter due to improper cath-eterization technique. Urology 1983;22:673-4.

Figure 1: The feeding tube successfully removed was found knotteddistally