- Case report
- Open Access
Collaborating with interventional pulmonology in managing a massive tracheoesophageal fistula that extends from cricoid to carina: a case report
© The Author(s) 2017
- Received: 6 November 2017
- Accepted: 24 November 2017
- Published: 4 December 2017
Tracheoesophageal fistulas (TEF) present a perioperative management challenge. A 62 year-old man with esophageal carcinoma presented with a large tracheoesophageal fistula extending most of the trachea. Previously, the patient had two overlapping esophageal and one tracheal stent placed, but he developed progressive tracheal disruption due to esophageal stent perforation near the level of the cricoid. This case describes the anesthetic management of tracheal stent placement for an expanding TEF. Management included a spontaneous breathing inhalation induction followed by ventilation through a supraglottic device—laryngeal mask airway (LMA). Finally, during rigid bronchoscopy, a combination of bag ventilation and jet ventilation was utilized.
- Tracheoesophageal fistula
- Tracheal stent
- Esophageal stent
- Jet ventilation
The presence of a large tracheoesophageal fistula (TEF) poses an airway management challenge to the anesthesiologist. Despite an abundance of literature describing various techniques to mitigate the attendant risks during the perioperative period, there does not exist a consensus on the best approach for induction and maintenance of anesthesia [1, 2]. Myriad possibilities have been put forth and most providers have their preferred technique, but there is no evidence that one is superior to another . It is known that positive pressure ventilation should be avoided whenever possible because air will pass through the point of least resistance—across the TEF and into the stomach . The majority of literature dedicated to this topic centers on pediatric patients and management of congenital TEF. Less common are reports and studies citing management techniques for iatrogenic or acquired TEF in the adult population . The use of laryngeal mask airway for insertion of a stent has been reported [6–8], and several techniques have been reported in the anesthesia literature including using a fogarty catheter to occlude the TEF during ventilation, intentional mainstem intubation to avoid ventilating across the TEF, and even using a guidewire to bypass a tracheal stricture and TEF [9–11]. The risks of anesthesia for adults and children with TEF overlap in many ways, but what is not known is the best technique for ventilating a patient with a large TEF .
We present the case of a 62-year-old man former cigarette smoker with locally recurrent unresectable squamous cell carcinoma of the esophagus previously treated with concurrent chemotherapy and radiation. He presented with worsening cough, secretions, and halitosis due to malignant TEF. The TEF was managed by an outside institution with two sequential overlapping esophageal stents and subsequently one uncovered self-expanding metallic tracheal stent (18 mm) due to progressive extension of the fistula. Concurrently, he was receiving weekly carboplatin and paclitaxel for HPV-negative T3N2cM0 base of tongue squamous cell carcinoma.
After 2 weeks of antibiotic therapy (total planned course 4 weeks), we performed a rigid bronchoscopy to address the new TEF and proximal granulation. The patient was preoxygenated with the head of the bed elevated and the existing gastrostomy tube was placed to suction. After 5 min of preoxygenation, inhalation induction was initiated with 8% sevoflurane.
A propofol infusion was initiated concurrently and infused at rates 100–120 mcg/kg/min for the entire case—titrated initially to maintain spontaneous ventilation. The combination of sevoflurance and propofol was chosen because inhalational agent cannot be administered during rigid bronchoscopy—the patient would require total intravenous anesthesia during the rigid bronchoscopy. The patient breathed spontaneously throughout induction without positive-pressure assistance. A laryngeal mask airway (LMA size 4) was placed without difficulty, and flexible bronchoscopy was initiated. FiO2 100% at 3–10 L/min with sevoflurane 1% were maintained throughout the case, and oxygen saturations remained at 100%. An initial remifentanil bolus of 1 mcg/kg and infusion rate of 0.3 mcg/kg/min was administered.
After taking careful airway measurements, a Dumon tracheal stent was customized and loaded into the stent deployer. Upon completion of the flexible bronchoscopy, the remifentanil infusion was increased to 0.4 mcg/kg min and pt. became apneic. The LMA was removed and the rigid bronchoscope was inserted.
Direct visualization of the airway via flexible bronchoscopy did not reveal worsening tracheal disruption throughout the procedure. The LMA was replaced; propofol, remifentanil, and sevoflurane were discontinued; and the patient resumed spontaneous ventilations throughout emergence.
The patient tolerated the procedure well and no immediate complications were noted. Six weeks after the procedure, the patient was clinically stable.
This case presented an airway and ventilation challenge as jet ventilation could worsen the tracheoesophageal fistula (TEF) and result in gastric overinflation. We were met with the usual challenges of TEF management but were further limited because of the location of our patient’s TEF. Given the location near the cricoid and the need to place a tracheal stent in the upper trachea, we exhausted the usual possibilities. The interventional pulmonologist required rigid bronchoscopy to correctly deploy the tracheal silicone stent, as additional self-expanding metallic stenting would have further extended the fistula. We were, therefore, unable to intubate with a conventional endotracheal tube or utilize a technique that had previously been successful for this patient—performing flexible bronchoscopy through a supraglottic airway. In order to decrease these risks, we connected the existing gastrostomy tube to wall suction and also minimized jet ventilation time by first using a supraglottic airway (i-gel, Intersurgical Inc., East Syracuse, NY) for inspection and bronchoscopic measurements. When we were ready for stent deployment, we utilized what many authors describe as second best option (after spontaneous ventilation) in ventilating a TEF. We performed “gentle bagging” by connecting our anesthesia circuit to the side port of the rigid scope. As soon as stent position was confirmed, we were able to jet ventilate more deliberately and complete the rigid bronchoscopy. Our goals in this case were consistent with the perioperative goals of all TEF cases—we wanted to provide general anesthesia and adequate ventilation to the lungs without ventilating the TEF. We were not able to utilize conventional techniques given the location and size of the TEF, so we implemented a stepwise sequence of maneuvers: (1) decompress stomach and apply continuous suction to the gastrostomy, (2) induce with spontaneous ventilation and perform flexible bronchoscopy via a supraglottic airway, (3) bag ventilate through side port of rigid bronchoscope until deployment of stent, and (4) judicious jet ventilation.
This case underscores the need for further investigation to define the best approach to managing TEF in adult patients . Furthermore, most literature on this topic describes only TEF near or below the carina. To our knowledge, this is the first case report of successful rigid bronchoscopy for a TEF of this size and location.
This research was funded in part through the NIH/NCI Cancer Center Support Grant P30 CA00874.
All authors had substantial contributions to the conception of the case report. All authors were active participants in the drafting and revising of the case report. All authors approved of final version of manuscript. All authors agree to be accountable for all aspects of the work. All authors were directly involved in this patient’s care in the operating room and contributed to the writing and editing of this manuscript. MC captured and edited the images for the manuscript. RP researched and wrote the patient background and pulmonary history. EL researched and wrote the anesthetic care portion of the manuscript. LT researched and wrote conclusion and introduction and served as the overall editor.
Consent for publication
Written informed consent was obtained from the patient for use of data and images in publication pursuant to our institutional guidelines. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
The authors declare that they have no competing interests.
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