Anesth Analg 2008; 106:1218-1219
© 2008 International Anesthesia Research Society
doi: 10.1213/ane.0b013e3181684fbb
CRITICAL CARE AND TRAUMA
Section Editor:
Jukka Takala
Sealing of a Tracheoesophageal Fistula Using a Sengstaken-Blakemore Tube for Mechanical Ventilation During General Anesthesia
Junya Nakada, MD, PhD*,
Sayo Nagai, MD ,
Masao Nishira, MD*,
Renko Hosoda, MD, PhD*,
Tatsuya Matsura, MD, PhD , and
Yoshimi Inagaki, MD, PhD
From the *Department of Anesthesiology, Aichi Cancer Center Hospital, Nagoya, Japan; and Department of Anesthesiology and Critical Care Medicine, Division of Medical Biochemistry, Tottori University Faculty of Medicine, Yonago, Japan.
Address correspondence and reprint requests to Junya Nakada, MD, PhD, Department of Anesthesiology, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa, Nagoya 464-8681, Japan. Address email to jn{at}aichi-cc.jp.
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Abstract
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A 78-yr-old man was admitted to our hospital because of repeated episodes of pneumonia. Both fiberoptic bronchoscopy and esophagoscopy revealed a large tracheoesophageal fistula and protrusion of the metal stent from the esophagus into the trachea. Placement of a Dumon stent was planned for sealing this fistula under general anesthesia. Anesthetic management is difficult because of the care needed to prevent aspiration of esophageal contents and diversion of oxygen through the fistula into the stomach from the trachea when patients are under mechanical ventilation. Our method of sealing a large tracheoesophageal fistula with a Sengstaken-Blakemore tube was performed successfully.
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Introduction
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Tracheoesophageal fistula is a condition encountered fairly often by physicians specializing in the respiratory tract, but it may not be familiar to anesthesiologists. Anesthetic management for insertion of a Dumon stent to seal a large tracheoesophageal fistula is difficult because of the care needed to prevent aspiration of esophageal contents and diversion of oxygen through the fistula into the stomach from the trachea when patients are under mechanical ventilation. Only one report has described the use of a hand-made device for sealing a fistula in the perioperative period.1 In this context, we considered that the use of a Sengstaken-Blakemore tube (S-B tube) might be beneficial when attempting to seal a tracheoesophageal fistula. Here we present a report of the successful use of a S-B tube for this purpose, and the establishment of a safe procedure for manual and mechanical ventilation.
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CASE REPORT
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A 78-yr-old man (height 156 cm, weight 41 kg) was admitted to our hospital because of repeated episodes of pneumonia. He had undergone palliative surgery to place a metal stent (Ultraflex) in the esophagus for relief of stenosis due to esophageal cancer (Stage IVa; T4 N2). He had begun to suffer symptoms such as coughing, fever, and dyspnea due to aspiration pneumonia from 4 mo after the operation. Both fiberoptic bronchoscopy and esophagoscopy revealed a large tracheoesophageal fistula in the midtrachea and protrusion of the metal stent from the esophagus into the trachea. Placement of a Dumon stent was planned for sealing this fistula under general anesthesia.
We administered no preanesthetic medication, and routine monitoring was used. Under local anesthesia, an IV catheter was inserted into a vein on the dorsum of the left hand, and a 22-gauge catheter was inserted into the left radial artery for monitoring of arterial blood pressure. An 18-Fr S-B tube (TSB tube, MD-47018A, Sumitomo Bakelite CO Ltd., Tokyo, Japan) was inserted through the left naris into the esophagus after an IV injection of 50 µg of fentanyl. The optimal position of the S-B tube for sealing the tracheoesophageal fistula was confirmed by both fiberoptic bronchoscopy and inflation of the balloon with a contrast agent under radiographic monitoring. Thereafter, we confirmed that spontaneous ventilation via a facemask could be performed effectively without distension of the stomach. Anesthesia was then induced with IV injections of atropine 0.25 mg, fentanyl 50 µg, and propofol 30 mg, and the patient’s trachea was intubated without use of muscle relaxant. We also confirmed that sufficient ventilation was obtained manually through an endotracheal tube without distension of the stomach. Anesthesia was maintained with fentanyl 100 µg and vecuronium 7 mg and with 0.5%–1.5% sevoflurane in oxygen (Fio2 = 1.0). The patient was placed in the neck extended position for insertion of a rigid bronchoscope, and the endotracheal tube was removed from his trachea.
During placement of the Dumon long Y stent using the rigid bronchoscope, the balloon of the S-B tube was inflated with diluted povidone iodine solution and its optimal position for sealing the fistula was maintained effectively. The patient’s lungs were ventilated manually through the ventilation port of the rigid bronchoscope without distention of the stomach due to leakage of the gas. The Dumon stent was successfully placed in the trachea and adjusted, so that its position was optimal for sealing the fistula tightly using an alligator forceps. The patient’s vital signs, including arterial blood pressure, heart rate, and oxygen saturation in the peripheral artery, were stable and were maintained within their normal limits throughout the procedure. The rigid bronchoscope was then removed and manual ventilation via a facemask was restarted after successful placement of the Dumon stent. Muscle relaxation was reversed with neostigmine 2 mg after the recovery of spontaneous respiration was confirmed. The S-B tube was removed after respiration became stable and sufficient under inhalation of sevoflurane at an end-tidal concentration of 0.3%. Emergence from anesthesia was smooth and the postoperative course was uneventful.
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DISCUSSION
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Malignancies such as esophageal cancer can cause combined tracheoesophageal fistula. Once these problems develop, the patient’s general condition deteriorates rapidly and survival is threatened.2,3
In the present case, we induced general anesthesia for insertion of a Dumon stent to seal a large tracheoesophageal fistula. Since placement of the stent requires insertion of a rigid bronchoscope with its tip located between the tracheal bifurcation and the fistula, controlled ventilation through the bronchoscope was expected to be inadequate because oxygen would be diverted through the fistula into the stomach from the trachea, rather than into the lung. This difficulty was successfully overcome by sealing the fistula from the esophageal side with the S-B tube.
This method of sealing the fistula resembles previously reported methods in which a Fogarty balloon catheter and an original hand-made device were used, respectively.1,4 In the first case, a Fogarty catheter was used in an infant for temporary occlusion of the distal esophagus to prevent entry of air from the trachea into the stomach. However, the balloon of a Fogarty catheter was too small to occlude the fistula in our patient. In the second case, an original hand-made device was used in an adult patient. We considered that such a device would not always be available, and there were some concerns about its accuracy and safety for this purpose. Another approach is the use of a percutaneous cardiopulmonary support system.5 However, the equipment is expensive and the method is excessively invasive.
Our method for placement of a Dumon stent by sealing a large tracheoesophageal fistula with a S-B tube was performed successfully, and seems to be simple but effective for this purpose in adult patients, requiring little time.
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Footnotes
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Accepted for publication December 21, 2007.
Supported, in part, by the research fund of the Aichi Cancer Center.
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REFERENCES
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- Inada T, Umemoto M, Ohshima T, Sawada O, Nakamura Y. Anesthesia for insertion of a Dumon stent in a patient with a large tracheo-esophageal fistula. Can J Anaesth 1999;46:372–5[Web of Science][Medline]
- Burt M, Diehl W, Martini N, Bains MS, Ginsberg RJ, McCormack PM, Rusch VW. Malignant esophagorespiratory fistula: management options and survival. Ann Thorac Surg 52:1222–8, 1991; discussion 1228–9
- Yamamoto R, Tada H, Kishi A, Tojo T, Asada H. Double stent for malignant combined esophago-airway lesions. Jpn J Thorac Cardiovasc Surg 2002;50:1–5[Medline]
- Filston HC, Chitwood WR Jr, Schkolne B, Blackmon LR. The Fogarty balloon catheter as an aid to management of the infant with esophageal atresia and tracheoesophageal fistula complicated by severe RDS or pneumonia. J Pediatr Surg 1982;17:149–51[Web of Science][Medline]
- Niwa H, Masaoka A, Yamakawa Y, Fukai I, Kiriyama M, Shindou J. Esophageal tracheobronchoplasty for membranous laceration caused by insertion of a Dumon stent; maintenance of oxygenation by percutaneous cardiopulmonary support. Eur J Cardiothorac Surg 1995;9:213–5[Abstract]
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Abstract
Introduction
