Managing a patient scheduled for bronchoesophageal fistula repair is challenging for the anesthetist. If appropriate ventilation strategy is not employed, serious complications such as hypoxemia, gastric distension, and pulmonary aspiration can occur. We present the case of a 62-year-old man with a bronchoesophageal fistula in the left main stem bronchus requiring the insertion of a Y-shaped tracheobronchial stent through a rigid bronchoscope, under general anesthesia. We successfully managed this intervention and herein report this case to demonstrate the effectiveness of underwater seal gastrostomy tube drainage used in conjunction with high-frequency jet ventilation during bronchoesophageal fistula stenting.
Bronchoesophageal fistula (BEF) is a pathological communication between the bronchial tree and the esophagus. BEF usually result from aerodigestive malignancies, blunt or penetrating chest trauma, chronic granulomatous infections, or ingestion of foreign bodies and corrosive substances, or it can be congenital [
A 62-year-old man (weight 60 kg, height 170 cm, and BMI: 20.8 kg/m2), chronic smoker and working as a stone breaker for the past 40 years, complained of cough and hemoptysis since 15 years and progressive shortness of breath for last one year. His symptoms got exacerbated and he was admitted to our hospital. Both fiberoptic bronchoscopy (Figure
Bronchoscopy showing the presence of a bronchoesophageal fistula (blue arrow) and an ulcer (red arrow) in the left main bronchus.
Computed tomography of the chest depicting the presence of a bronchoesophageal fistula between the left main bronchus and the esophagus.
The patient was scheduled for the insertion of a Y-shaped covered self-expandable metal stent (CSEMS) (Micro-Tech Y-stent, Nanjing, China) through a rigid bronchoscope, under general anesthesia. Three weeks prior to the scheduled surgery, oral feeding was discontinued for both solids and liquids and a percutaneous endoscopic gastrojejunostomy was performed for enteral feeding. The patient also received total parenteral nutrition, intravenous fluids, antibiotics, and oxygen by face mask. Moreover, a thorough discussion between the interventionist and anesthetist was undertaken regarding the surgical procedure and its anesthetic implications.
In the operation room, Ringer’s lactate drip was started. Standard monitoring included pulse oximetry, electrocardiography, temperature, and invasive blood pressure monitoring via a left radial artery catheter. The gastrostomy tube was suctioned and connected to an underwater seal bottle containing a 10 cm column of water (Figure
Serial arterial blood gas analyses.
Enter |
Preinduction | 15 minutes |
Stent inserted | HFJV |
Entered |
Left | |
---|---|---|---|---|---|---|---|
PaO2 (mmHg) | 75 | 278 | 244 | 105 | 149 | 387 | 110 |
PaCO2 (mmHg) | 38 | 38 | 62 | 76 | 82 | 51 | 42 |
pH | 7.40 | 7.48 | 7.32 | 7.25 | 7.20 | 7.34 | 7.37 |
SpO2 (%) | 97 | 100 | 99 | 97 | 99 | 100 | 99 |
OR, operation room; HFJV, high frequency jet ventilation; PACU, postanesthesia care unit; PaO2, partial pressure of oxygen in blood; PaCO2, partial pressure of carbon dioxide in blood; SpO2, peripheral capillary oxygen saturation.
Patient lying on the operating table with his gastrostomy tube connected to an underwater seal bottle.
Once the stent (size: 18 × 30 mm – L 14 × 30 mm – R 14 × 10 mm) was deployed and its correct position confirmed (Figure
Correct position of the Y-shaped tracheobronchial stent, sealing the left bronchoesophageal fistula.
Anesthesia for patients with BEF requiring tracheobronchial stent insertion is challenging for the anesthetist. The challenges include a shared airway, underlying pulmonary pathologies, and coexisting advanced enterorespiratory malignancies. Furthermore, the use of intermittent positive pressure ventilation (IPPV) causes leakage of air through the BEF leading to two main complications. Firstly, distention of the stomach and probable gastric regurgitation leading to pulmonary soiling. Secondly, ventilation of the fistula accounts for inadequate lung ventilation, hypoxemia, atelectasis, and carbon dioxide (CO2) retention. This case report highlights the various anesthetic considerations for the successful management of BEF.
HFJV has been very effective in this case. In contrast to conventional ventilation, HFJV delivers very small tidal volume (
Furthermore, we used an underwater seal drainage system, whereby the patient’s gastrostomy tube was connected to an underwater seal bottle containing a 10 cm column of water. This strategy increases the resistance to gas flow from the airway to the esophagus. Therefore, gas will leak through the fistula only if the airway pressure exceeds the underwater seal pressure (10 cm H2O). There are several benefits of this technique. Firstly, it accounts for better pulmonary ventilation by minimizing gas outflow through the fistula. Secondly, any gas leak to the stomach will be drained through the gastrostomy tube, not increasing the hydrostatic pressure of the stomach, hence no gastric regurgitation. To the best of our knowledge, a gastric underwater seal has not been used in the management of BEF in adults. This technique has been used in the management of congenital tracheoesophageal fistula (TEF) in infants. Donn et al. [
There are alternative means of providing effective ventilation for the management of enterorespiratory fistulas. For instance, manual jet ventilation (MJV) can be used. MJV offers more efficient ventilation and CO2 elimination compared to HFJV, due to adequate expiratory time and better chest and lung recoil during expiration [
The anesthetic goal for stenting a BEF is to use drugs which are quick in onset, short acting, and readily eliminated. Muscle relaxant is needed to provide optimal relaxation for insertion of the rigid bronchoscope and manipulation of the airway, in order to prevent coughing, laryngospasm, and chest rigidity. We used succinylcholine and performed a rapid sequence induction (RSI). However, succinylcholine is short acting and eventually a top-up dose of another muscle relaxant may be necessary if the patient shows signs of discomfort, starts spontaneous respiration which is hindering with the surgery, or develops airway reflexes. Ideally, rocuronium is the muscle relaxant of choice for this type of intervention. We may use 1.2 mg/kg of rocuronium and perform a RSI. At the end of the surgery, we can promptly antagonize the rocuronium with sugammadex. However, sugammadex is not available in our hospital. Regarding anesthesia maintenance, Wang et al. [
After the placement of the stent, we should advocate the early return of spontaneous respiration, early extubation, and weaning from the ventilator. Therefore, after the intervention, insertion of an LMA is preferred to an endotracheal tube. Endotracheal intubation requires a deeper depth of anesthesia, which will prolong the recovery, and it may also cause coughing and laryngospasm which may cause displacement of the newly placed stent.
Besides all these aspects, a key determining factor is constant and effective communication and cooperation between the interventionist and anesthetist, which plays a pivotal role in the success of this surgery.
In conclusion, anesthetic management for BEF stenting is challenging. However, we successfully managed the surgery using HFJV in conjunction with an underwater seal gastrostomy tube drainage system. The latter has played a crucial role in the success of our case and is a novel strategy for BEF management in adults. Nevertheless, we will consider enhancing our management, in view of optimizing our anesthetic plan for similar eventual interventions. Various other ways to manage a case of BEF have been reported in medical literature. Anyhow, whatever method is chosen, a planned and multidisciplinary approach to successfully tackle this complex issue of bronchoesophageal fistula will be required.
Written informed consent by the patient was obtained regarding the submission of this case report.
Nitish Fokeerah is the first author.
The authors declare that there is no conflict of interests regarding the publication of this paper.
Source of funding is Anesthesiology Department of the First Affiliated Hospital of Chongqing Medical University.