P029: BALANCING AIRWAY CONTROL AND SURGICAL ACCESS IN TRACHEOGASTRIC FISTULA REPAIR: A CASE REPORT
Skylar Harmon; Madina Akhmetkaliyeva; Alimzhan Begulov; Ryan Shienbaum, MD
HCA Florida Aventura Hospital
Introduction: Tracheogastric fistula closure poses unique challenges in the setting of general anesthesia, particularly in balancing surgical access with respiratory management. This case report examines the complexities in managing such cases.
Methods: A 71-year-old female with a medical history of COPD, CHF, and prior esophageal cancer s/p esophagectomy, presented to the ED by EMS with dyspnea and wheezing, exacerbated by severe dysphagia and vomiting. EMS reported home O2Sat of 66%. On Chest X-Ray she was found to have a patchy infiltrate in the right lower lobe and was admitted for further work-up and management. The patient was treated with antibiotics for suspected Mycoplasma pneumonia, however shortness of breath and chronic dysphagia persisted.
On hospital day 6, barium esophagram revealed a tracheogastric fistula at around the level of the manubrium. On day 8, bronchoscopic closure of the fistula was performed using a 10 mm Amplatzer occluder device, necessitating careful anesthesia management.
Prior to beginning the procedure there was no combined plan outlined by the surgery and anesthesia team. During the procedure, a 7.5 endotracheal tube (ETT) was employed and posed several challenges. Initially positioned at 21 cm depth, a leak was noted, presumably from the fistula, which resolved when the tube was adjusted to 24 cm. To facilitate surgery, the ETT cuff was intentionally deflated and retracted towards the vocal cords during exploration, though this compromised airway management. The surgical team’s use of a wire during bronchoscopy also increased risk of cuff perforation. Despite these issues, a smaller ETT tube might have mitigated tube displacement but was deemed inappropriate given the patient’s condition requiring post-procedural intubation.
Results: Post-surgery, the patient remained on mechanical ventilation and was transferred to the SICU, with post-operative Chest XR showing correct ETT placement 5 cm above the carina with minimal complications. Extubation occurred on post-op day 1 after a successful spontaneous breathing trial. On day 10 dysphagia persisted with generalized weakness and repeat swallow evaluation was recommended and performed day 12 confirmed fistula closure. The patient was discharged on hospital day 14 and was recommended to follow up with PCP in 1 week.
Discussion/Conclusion: This case underscores the critical collaboration between surgical and anesthesia teams in managing tracheogastric fistulas. Recommendations include pre-operative imaging to precisely locate fistulas, facilitating better ETT planning and surgical access strategies. Detailed pre-procedure discussions are crucial to optimize ventilation strategies, including adapting ETT sizes or considering a rapid transition to monitored anesthesia care (MAC) if feasible, ensuring patient safety and procedural efficiency.
In conclusion, managing tracheogastric fistulas requires meticulous planning and interdisciplinary coordination. Future cases can benefit from enhanced imaging and strategic planning to navigate the complexities of anesthesia and surgical repair effectively.