Although surgical gastrostomy is not a technically troublesome surgery, the procedure may be accompanied by unfavorable outcomes. Most complications occur early in the post-operative period and include feeding tube dislodgment, stomal infection, peritonitis, and pneumonia. The authors report the case of an 83-year-old man who underwent a surgical gastrostomy because of a swallowing disorder after an ischemic stroke. Nine months after the procedure, the feeding tube dislodged and a new tube was inserted with a certain delay and with some difficulty, causing a false path and consequently an intrabdominal abscess after diet infusion. The outcome was fatal. The authors call attention for meticulous care with the insertion of feeding tubes and advise the performance of imaging control to assure its precise positioning.
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