The Anesthetic Management of a Case of Tracheogastric Fistula

A 68-yr-old man developed a tracheogastric fistula after esophageal resection with gastric interposition. We report the anesthetic management of this patient undergoing tracheal repair and fistula closure. Case Report A 68-yr-old male was referred to our institution for surgical management of a tracheogastric fistula. After receiving chemotherapy and radiation therapy, the patient underwent a transhiatal esophagectomy with gastric interposition a month before. Postoperatively he developed copious bilious bronchial secretions and pneumonia. Bronchoscopy revealed a large 3-cm fistula between the distal trachea and the stomach, just above the left main bronchus, with large amounts of gastric fluid leaking into the main bronchi (Fig. 1). The patient was initially treated with clindamycin, ciprofloxacin, and parenteral nutrition.Figure 1: Bronchoscopic view of the 3-cm tracheogastric fistula. LB = left main bronchi; F = tracheogastric fistula.On physical examination, the 55-kg man was dyspneic and looked cachectic but he was hemodynamically stable with a respiratory rate of 26 per minute and a Spo2 of 96% at an Fio2 of 28%. Chest radiographs showed right upper, right lower, and left lower lobe infiltrates as well as bilateral pleural effusions. The patient was premedicated with famotidine 20 mg IV and scopolamine 0.2 mg IM. In the operating room, the patient received midazolam 2 mg IV. After insertion of an arterial line and a thoracic epidural catheter, topical airway anesthesia was provided with 2% viscous lidocaine and with lidocaine spray. Then, with the patient in the sitting position, we proceeded with an awake fiberoptic selective intubation of the left main bronchus, using a 32-cm long, 6.0-mm inner diameter Sheridan microlaryngeal surgery endotracheal tube (Kendall, Mansfield, MA). We then slowly started sevoflurane inhalation using the bronchoscope to intubate the right main bronchus with another identical endotracheal tube (Fig. 2). Thereafter anesthesia was maintained with oxygen, sevoflurane, sufentanil, and rocuronium. The surgery proceeded through a right thoracotomy with the patient in left lateral decubitus position and consisted in taking a large right latissimus dorsi pedicle flap, which was later used for repairing the distal tracheal opening and closing the fistula.Figure 2: View of the patient intubated with two 32-cm long, 6.0-mm inner diameter Sheridan microlaryngeal tubes connected to the breathing circuit.Oxygenation and one-lung ventilation soon became difficult; at one point during surgery, we performed independent ventilation of both lungs using two ventilators. When the left endotracheal tube was removed to allow surgical repair, intubation of the left main bronchus was accomplished across the surgical field using sterile equipment. At the end of the procedure, a standard tracheostomy was performed. The total surgical time was 11 h, and blood loss was estimated at 5.5 L. In the intensive care unit, the patient showed a good immediate postoperative course but soon developed acute respiratory distress syndrome (ARDS). This required the use of pressure control ventilation and positive end-expiratory pressure of 10 cm H2O in order to keep the airway pressures as low as possible while allowing a lower Fio2. Four days after the surgery, the patient developed a small dehiscence of the tracheal repair. Because of the poor general status of the patient at this point, surgery was not considered a viable option. The patient developed multiple organ failure and died on the fifth postoperative day. Discussion We present a case of iatrogenic tracheogastric fistula requiring emergent surgical repair. There are reports about adult tracheoesophageal fistula in the literature (1–3), but our case had the additional challenge of having to deal with copious gastric secretions. Several techniques have been described for providing adequate ventilation for distal tracheal surgery (4–6). These techniques include high-frequency jet ventilation (HFJV), high-frequency positive-pressure ventilation (HFPPV), spontaneous ventilation, and cardiopulmonary bypass. HFJV and HFPPV are supposed to decrease the danger of aspiration resulting from continuous outflow of gas (6), for our patient bilateral aspiration pneumonia was present and a constant flow of gastric secretions was occurring. We decided to secure his airway, and HFPPV and HFJV could not be used safely. Moreover, cardiopulmonary bypass was not a viable option in this setting as the surgery was expected to be lengthy. We also had to be able to perform one-lung ventilation to allow surgical repair, and any regular double-lumen tube involved the risk of aggravating the fistula. We decided to use two separate endotracheal tubes that would be placed in both proximal main bronchi, in order to ventilate both lungs independently. Early extubation is a primary goal of tracheal surgery (5,7). In this particular case we were unable to wean the patient from the ventilator due to his deteriorating pulmonary condition. He finally died from complications of ARDS, resulting from his aspiration pneumonia, extensive thoracic surgery, blood loss, and multiple transfusions.

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