Anesthesia management for tracheoesophageal fistula closed with a new gastrointestinal occluder device: a case report

Patients with TEF usually have severe pulmonary infection, malnutrition and other conditions, and primary or recurrent TEF is an important challenge for airway management. At present, minimally invasive thoracoscopic approaches or thoracostomy are important methods for treating TEF, but some patients cannot tolerate surgical stress. With the development of endoscopic repair technology, minimally invasive treatment of TEF has achieved great progress. In the past ten years, cases of congenital heart disease closure devices for the treatment of TEF have been reported. Compared with the congenital heart disease closure device, the new gastrointestinal occluder device (designed by Zhang et al. [8]) is made of laminated nitinol mesh with two self-expanding discs connected by a thin waist (Additional file 1: Fig. S1A, B). The occluder device has a lighter weight on both sides of the umbrella disc, which can reduce the pressure on the fistula tissue to reduce the risk of necrosis, bleeding, displacement, shedding, and even suffocation.

At present, there is no unified standard anesthesia management for the repair of TEF under endoscopy. The monitored anesthesia care without intubation requires a relatively small dose of anesthetic; however, the depth of anesthesia may not meet the requirements of the endoscopy operation, and the risks of hypoxemia and aspiration resulting from esophageal reflux are significantly increased intraoperatively. Most TEF patients are complicated with long-term pneumonia, which increases the difficulty of extubation after general anesthesia, but the establishment of an artificial airway can ensure the stability of intraoperative oxygenation. After a preoperative multidisciplinary consultation, endotracheal intubation to control ventilation was relatively safe for this patient.

Previous studies have demonstrated that positioning the endotracheal tube with its end lying distal to the fistula is essential for avoiding gastric distension [9]. However, the fiberoptic bronchoscope could not observe the tracheal side of the fistula when entering from the endotracheal tube. In this case, implantation of the new gastrointestinal occluder device requires the guidance of gastroscopy combined with tracheoscopy. To observe the tracheal side of the TEF, the fiberoptic bronchoscope should enter the trachea from outside the endotracheal tube. Therefore, the endotracheal tube needs to be carefully evaluated for an appropriate inner diameter to ensure that the fiberoptic bronchoscope and the endotracheal tube can be placed in the trachea in parallel.

The choice of endotracheal tube diameter in the endoscopic treatment of TEF has no unified standard to date. Tracheal anatomy shows that the normal diameter of the trachea is 1.2–1.5 cm for males and 1.0–1.2 cm for females. Considering that the fiberoptic bronchoscope diameter was approximately 0.5–0.6 cm, an endotracheal tube with an inner diameter of 5.5 mm was selected to ensure there was adequate space for the fiberoptic bronchoscope to observe the tracheal side of the TEF from outside the endotracheal tube and to guide the accurate implantation of the occluder device.

In conclusion, the implantation of a new gastrointestinal occluder device under gastroscopy combined with tracheoscopy could be a promising option for TEF repair. This case may provide a kind of airway management for implantation of the new gastrointestinal occluder device; however, the efficacy and safety of this protocol needs to be verified in more cases.

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