2026 FSA Podium and Poster Abstracts

INTRODUCTION: Pulmonary aspiration is a lethal complication perioperatively with significant morbidity and mortality with bowel obstruction being a risk factor. The prevention approach of a nasogastric tube (NGT) for decompression can be complicated by contraindications surrounding recent and ongoing upper gastrointestinal (GI) bleeding. This case highlights a high-volume aspiration even during induction of anesthesia in a patient with a bowel obstruction with a relatively recent esophageal variceal banding.

CASE PRESENTATION: An 84-year-old man with recurrent pancreatic adenocarcinoma, portal venous thrombosis with stents, chronic splenic vein occlusion, esophageal varices with recent banding, recurrent ascites requiring biweekly paracentesis, prior myocardial infarction with coronary stenting, and multiple abdominal hernias presented with severe abdominal pain, nausea, vomiting, and syncope. On admission, the CT imaging showed an incarcerated umbilical hernia with small bowel obstruction without perforation or ischemia. An exploratory laparotomy followed with hernia reduction and repair.

With his recent upper GI bleeding with and esophageal variceal banding 10 days prior, the surgical team declined preoperative NGT placement due to concern for rebleeding. On induction, the patient had profuse coffee-ground emesis exceeding 500 mL of aspiration with an immediate SpO2 desaturation. There was a brief misunderstanding with the anesthesia team and nursing staff on optimal positioning (head-up versus head-down). The patient was promptly placed head-down and was rapidly intubated with video laryngoscopy, while simultaneously suctioned with the “big stick”, a vented ~1cm open tipped suction catheter. There was no difficulty with the airway or view of the cords using this technique, followed by bronchoscopy. He developed hemodynamic instability requiring vasopressor support and arterial line placement.

Following bronchoscopy and bronchoalveolar lavage (BAL), the patient’s SpO2 returned to baseline. He remained intubated overnight. Broad-spectrum antibiotics were initiated for concern for aspiration pneumonitis. Chest imaging demonstrated transient perihilar opacities without focal consolidation, with no significant concern for aspiration pneumonia. He was extubated on postoperative day one. An NGT was placed on ICU arrival for decompression without evidence of recurrent GI bleeding. He later experienced postoperative ileus requiring reinsertion of the NGT, with eventual return of bowel function. He was discharged to inpatient rehabilitation after continued recovery.

DISCUSSION: Aspiration during induction and the challenges posed by competing risks in patients with recent GI bleeding and bowel obstruction can be challenging to balance. Although routine NGT placement after variceal banding is not recommended, nonbleeding varices are not an absolute contraindication, and aspiration risk may outweigh rebleeding concerns beyond the highest-risk post-banding period. Many sources site waiting 24 to 48 hours. Early multidisciplinary discussion, selective gastric decompression, and standardized intra-induction aspiration management, including clear positioning protocols, are critical to mitigating preventable anesthesia-related harm. This situation also could have been mitigated with an awake fiberoptic intubation approach. One final point is the age-old argument of whether direct laryngoscopy is a “better” technique than video laryngoscopy when appropriate positioning and suction are available.