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Year : 2021  |  Volume : 4  |  Issue : 2  |  Page : 128-131

Airway manoeuvres during anaesthetic management of adult acquired tracheo-oesophageal fistula

Department of Anaesthesiology and Critical Care, Smt Kashibai Navale Medical College and General Hospital, Pune, Maharashtra, India

Date of Submission24-May-2021
Date of Acceptance29-Jun-2021
Date of Web Publication10-Aug-2021

Correspondence Address:
Dr. Kavita Udaykumar Adate
102, Radhanagri Phase II, Wadgaon Bk, Sinhagad Road, Pune - 411 041, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/arwy.arwy_29_21

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Regardless of aetiology, acquired tracheo-oesophageal fistula (TEF) is a life-threatening condition due to the risk of pulmonary soiling and sepsis. Distorted airway anatomy below the glottis makes airway management challenging. We present the anaesthetic management for TEF repair in an adult male who developed fistula following organophosphorus poisoning. Maintaining optimum position of the endotracheal tube (ETT) during cross-field ventilation and ETT repositioning is crucial. For better understanding of the anaesthetic management for this relatively rare surgery, we have described airway management sequentially to coincide with different phases of surgical interventions.

Keywords: Acquired tracheo-oesophageal fistula, cross-field intubation, fibreoptic bronchoscope

How to cite this article:
Adate KU, Kale J, Dongare D, Patil K, Yalgudkar H. Airway manoeuvres during anaesthetic management of adult acquired tracheo-oesophageal fistula. Airway 2021;4:128-31

How to cite this URL:
Adate KU, Kale J, Dongare D, Patil K, Yalgudkar H. Airway manoeuvres during anaesthetic management of adult acquired tracheo-oesophageal fistula. Airway [serial online] 2021 [cited 2022 May 20];4:128-31. Available from: https://www.arwy.org/text.asp?2021/4/2/128/323574

  Introduction Top

Tracheo-oesophageal fistula (TEF) can be congenital or acquired. Acquired TEF is a rare but serious condition due to the risk of aspiration and sepsis.[1] Nowadays, 50% of acquired TEF are secondary to mediastinal malignancy while non-malignant TEF could be traumatic or iatrogenic in origin.[2],[3] Anaesthetic management for repair of TEF always throws up challenges in securing the optimum position of the endotracheal tube (ETT) and intraoperative ventilation strategies.

  Case Report Top

A 45-year-old male presented with a 6-month history of regurgitation after each meal through an already present tracheostomy. He gave a history of organophosphorus poisoning 9 months prior for which he was on mechanical ventilation. He was discharged with a Portex tracheostomy tube (TT) and nasogastric tube (NGT). Due to the COVID pandemic and subsequent lockdown, the patient could not approach any tertiary care centre for weaning off the tracheostomy. He repeatedly attended a nearby health centre for changing his TT and NGT. The patient was clinically diagnosed to have a TEF confirmed by positive Ono's sign (cough following deglutition). High-resolution computerised tomography of the thorax showed a large defect (22 mm × 44 mm) extending from T1 to T3 vertebra. Oesophago-gastro-duodenoscopy revealed a wide opening between the trachea and oesophagus extending 5 cm distally from the cricopharynx.

Preoperative optimisation was done to minimise pulmonary aspiration and sepsis. Percutaneous endoscopic gastrostomy tube was positioned and enteral nutrition initiated. A propped-up position was maintained, and proton pump inhibitors and antibiotic therapy were started. The Portex TT was exchanged for a metal TT.

The patient was accepted as ASA II for primary repair of TEF. A difficult airway cart and a crash cart were kept ready. In view of the large TEF, fibreoptic bronchoscopy (FOB) guided awake nasotracheal intubation was planned that would bypass the fistula. Preinduction monitors included electrocardiogram, noninvasive blood pressure and pulse oximetry. The right radial artery was cannulated after induction of anaesthesia for invasive blood pressure monitoring and to facilitate frequent blood sampling for arterial blood gas analysis.

Airway preparation was done with lignocaine nebulisation (2%) and spray (10%). The metal TT was removed. The patient was premedicated with intravenous glycopyrrolate (0.2 mg), midazolam (1 mg) and ondansetron (4 mg). A 7.0-mm ID flexometallic tube (FMT) was preloaded over an FOB introduced through the right nostril. Accessing the trachea below the vocal cords was difficult as the tube was repeatedly entering a common passage due to a large fistula. A similar problem was encountered while working through the opposite nostril. With maximum flexion of the tip of the FOB against the anterior tracheal wall, we could reach well above the carina. The FMT was railroaded over the FOB so that the cuff went beyond the fistula and the tip of the tube was above the carina [Figure 1]a. Bilateral equal air entry was confirmed. Anaesthesia was induced with propofol 2 mg/kg and vecuronium 0.08 mg/kg and maintained with controlled ventilation with sevoflurane in 50% air-oxygen mixture. Dexmedetomidine infusion was started at 0.5 μg/kg/h to provide analgesia and also maintain the depth of anaesthesia keeping in mind loss of tidal volume through the large fistula.
Figure 1: Schematic representation of position of endotracheal tube during various stages of surgery (a) nasotracheal tube positioned such that the tip is above carina and tracheo-oesophageal fistula is by-passed (b) cross-field ventilation and (c) epidural catheter-guided orotracheal intubation

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A transverse incision along the skin crease was made at the level of the tracheostomy. Primary dissection, mucosal separation of trachea and oesophagus and strap muscle mobilisation were done. Cross-field ventilation was provided before primary anastomosis. The proximal FMT was withdrawn up to the cricopharynx after deflating the cuff and secured in position by passing an epidural catheter through it, and a mosquito clamp was applied at both ends. A sterile 7.0-mm ID FMT was passed through the distal end of the tracheal incision [Figure 1]b. Its optimum position was assessed by auscultation for bilateral equal air entry. The tube was fixed to the anterior chest wall with stay sutures to avoid accidental extubation. Anaesthesia was continued through a sterile circuit. After achieving cross-field ventilation, anastomosis of the anterior and posterior oesophageal walls and repair of posterior tracheal wall was completed. Strap muscle was buttressed between the trachea and oesophagus to strengthen the anastomotic site.

Before repairing the anterior tracheal wall, the surgeon requested for oral intubation with a smaller size ETT to maintain postoperative neck flexion. The proximal FMT was therefore withdrawn, and a 6.5-mm ID FMT was railroaded over the orally withdrawn epidural catheter. The tip of the FMT was advanced to a point just above the carina through the distal tracheal incision after removing the FMT that was being used for cross-field ventilation [Figure 1]c. Anastomosis of the anterior tracheal wall was completed.

Postoperatively, the neck was maintained in flexion with a stout stay suture, and the patient was sedated and paralysed for 48 h. The patient was extubated uneventfully in the operation theatre after a positive cuff leak test. Tracheostomy and FOB were ready at hand. Dye swallow test done after 24 h was negative. A happy and satisfied patient was discharged on the 12th postoperative day.

  Discussion Top

Benign acquired TEF in adults can be of traumatic or iatrogenic aetiology. Traumatic causes include previous surgery of trachea and oesophagus, corrosive poisoning or damage caused by small battery ingestion. Iatrogenic TEF could be due to oesophageal stenting, oesophageal or tracheal endoscopy, transo-oesophageal echocardiography and tracheal intubation.[4],[5],[6] The pathology behind TEF is ischaemia, pressure necrosis and tissue damage which further leads to local ulceration and formation of a fistula. There is spillage of oesophageal contents into the trachea which may lead to frequent lung infection.

There were several anaesthetic challenges which we encountered during TEF repair. The first was a difficult airway. As the airway was compromised below the vocal cords due to distorted anatomy, mask ventilation was not opted for as tidal volume leakage through the fistula could lead to further gastric distension and increase the risk of aspiration. The airway was therefore secured in the awake state.

As a conventional technique of intubation does not permit visualisation of the lower airway, this may predispose to incorrect ETT placement through a false lumen leading to undetected, catastrophic loss of the airway. Hence, we planned awake FOB-aided intubation to precisely evaluate the preexisting TEF and to facilitate optimum ETT position beyond the level of the fistula. FOB-guided awake tracheal intubation has been cited as the gold standard in airway management for anticipated difficult intubation due to its high success rate and low-risk profile.[7],[8] Although the oral route could have been chosen, we opted for nasal FOB as it is a common practice for us and the patient cooperation is better with avoidance of gag reflex. Marked difficulty was encountered in negotiating the FOB distal to the fistula. Our alternative Plan B was always ready due to the presence of tracheostomy stoma. The metal TT was removed to achieve a clean surgical field and to avoid excessive manipulation of the tube during dissection.

Inadequate anaesthetic depth may give rise to haemodynamic instability along with tension on suture lines and anastomotic leak. Anaesthetic depth was maintained with TIVA along with controlled ventilation considering the loss of tidal volume through the fistula and during FMT repositioning. Yazıcıoğlu et al. managed this challenge by intraoperative EEG monitoring.[9] BIS monitoring could be another option.

Meticulous sharing of the airway and repositioning of ETT according to the stage of surgery proved challenging. Cross-field ventilation through the open tracheal incision was practically easy but to confirm and maintain optimum position of ETT was difficult. Literature supports the use of a 'hook or hockey-stick shaped' reinforced tube with a short distal tip for cross-field intubation through the distal segment of the trachea.[9],[10] Use of the epidural catheter to secure the proximal FMT during cross-field ventilation and to railroad an orotracheal FMT later was a novel technique used by us. Intermittent apnoea was managed by ventilation with 100% oxygen 3 min before ETT repositioning. This helped to maintain haemodynamic stability and better oxygen saturation without producing hypercarbia.

Perioperative analgesia was achieved by 1 g paracetamol given intravenously. Thoracic epidural and superficial cervical plexus block are viable alternatives. Hybrid techniques of extubation such as the use of an Aintree exchange catheter, supraglottic airway device or FOB could have been used in our case. However, these could have placed an undue stress on the suture lines. To avoid that, surgeons were prepared to do a low tracheostomy. Hence, extubation was conducted in operation theatre after confirming a positive cuff leak test.

  Conclusion Top

Effective usage of FOB to secure airway must be carefully planned to avoid potentially disastrous situations during TEF repair. Maintaining depth of anaesthesia and establishing 100% oxygenation before ETT repositioning give haemodynamic stability. Continuous capnography and pulse oximetry are mandatory. Last but not least, extremely good understanding and communication with surgeons are necessary while sharing the airway.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the forms, the patient has given his consent for images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Diddee R, Shaw IH. Acquired tracheo-oesophageal fistula in adults. Continuing education in anaesthesia. Critical Care Pain 2006;6:105-8.  Back to cited text no. 1
Bibas BJ, Guerreiro Cardoso PF, Minamoto H, Eloy-Pereira LP, Tamagno MF, Terra RM, et al. Surgical management of benign acquired tracheoesophageal fistulas: A ten-year experience. Ann Thorac Surg 2016;102:1081-7.  Back to cited text no. 2
Smith HM, Bacon DR, Sprung J. Difficulty assessing endotracheal tube placement in a patient with undiagnosed iatrogenic tracheoesophageal fistula. J Cardiothorac Vasc Anesth 2006;20:223-4.  Back to cited text no. 3
Priya V, Riaz R, Goyal P, Singh S. Acquired tracheoesophageal fistula with undiagnosed tracheal stenosis: A simple innovation to avoid tracheostomy! Indian J Anaesth 2016;60:869-70.  Back to cited text no. 4
Paraschiv M. Tracheoesophageal fistula--A complication of prolonged tracheal intubation. J Med Life 2014;7:516-21.  Back to cited text no. 5
Kaur D, Anand S, Sharma P, Kumar A. Early presentation of postintubation tracheoesophageal fistula: Perioperative anesthetic management. J Anaesthesiol Clin Pharmacol 2012;28:114-6.  Back to cited text no. 6
[PUBMED]  [Full text]  
Ahmad I, El-Boghdadly K, Bhagrath R, Hodzovic I, McNarry AF, Mir F, et al. Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults. Anaesthesia 2020;75:509-28.  Back to cited text no. 7
Shwetapriya R, Shenoy A, Nittala A. Tracheo-oesophageal fistula-A disastrous complication of endotracheal intubation. Ind J Resp Care 2013;2:238-40.  Back to cited text no. 8
Yazıcıoğlu H, Özler B, Tezcan B, Subaşı M, Yekeler E. A challenging anesthetic management of acquired tracheo-esophageal fistula operation. Int J Case Rep Images 2018;9:100932Z01HY2018.  Back to cited text no. 9
Joshi S, Kulkarni A, Holkunde RS. A rare case of adult acquired tracheo-oesophageal fistula with sub-glottic stenosis for corrective surgery-An anesthetic challenge. J Clin Diagn Res 2014;8:D01-3.  Back to cited text no. 10


  [Figure 1]

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