This incident was reported to SALG and subsequently escalated for review by NHS England

An oesophageal temperature probe that was being used during upper GI surgery, migrated intraoperatively into the stomach and was inadvertently trapped in a staple line/anastomosis. There were no device issues, however there were also no alarms or disruption in monitoring to make the team aware of the issue.

Commentary:

A data search across Learn from Patient Safety Events (LFPSE) and the National Reporting and Learning System (NRLS) identified only one similar incident. Additional cases were identified through a literature search and anecdotally via clinical contacts, bringing the total number of similar reports to four.

All cases occurred during Nissen fundoplication or sleeve gastrectomy procedures. Both involve the use of an oesophageal bougie. It was hypothesised that the temperature probe might have been dragged down into the stomach during bougie placement, where it subsequently became caught in the surgical staple line. A contributing factor is the lack of visual markings on some temperature probes, making it difficult for the team to monitor their position intraoperatively.

While the frequency of such events appears low the consequences were significant. One of the patients required prolonged ICU care postoperatively.

Recommendations from the review include:

• Engagement with surgical bodies, for example the Association of Upper Gastrointestinal Surgery of Great Britain and Ireland (AUGIS) and the British Obesity and Metabolic Specialist Society (BOMSS) to develop guidance regarding probe management during such procedures.
• Exploration of collaboration with MHRA on probe design, specifically regarding the addition of visible depth marking

Other forms of invasive temperature monitoring could be considered for patients undergoing upper GI surgery, for example rectal temperature probes.