• Jingjing Deng, Ting Pan, Hui Li, Qing Lin, and Yuenong Zhang.
• Department of Surgery and Anesthesia, The Third Affiliated Hospital of Sun Yatsen University Yuedong Hospital, Meizhou city, Guangdong Province, China.
• Medicine (Baltimore). 2022 Oct 28; 101 (43): e31203e31203.

RationaleGastric tube implantation is a routine part of preoperative preparation. Indwelling gastric tubes in patients under general anesthesia maintain gastrointestinal decompression and prevent gastrointestinal expansion.Patient ConcernsGastric tube insertion can be associated with many complications, of which gastric tube knotting is a rare and often overlooked complication.DiagnosesKnotting together of gastric and tracheal tubes.InterventionsDuring the operation, the gastric tube was explored by endoscope and hand.LessonsRare complications of knotted gastric and endotracheal tubes are identified and treated promptly.ConclusionWe recommend that the gastric tube be intubated first before insertion of the endotracheal tube, and visualization tools should be used in time if the insertion of the gastric tube is unsuccessful.Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.

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