Anesthetic Management of Patient with an Oesotracheal Fistula (Case Report)

Case Report

Austin J Anesthesia and Analgesia. 2023; 11(2): 1118.

Anesthetic Management of Patient with an Oesotracheal Fistula (Case Report)

Hicham Hammadi¹*; Mouad Amraoui²; Youssef Halhoul¹; Achraf Jeddab¹; Ahmed Fakri¹; Hamza Kassimi¹; Abdelhamid Jaafari¹; Omar Slaoui¹; Abderrahman El Wali¹; Mohammed Meziane¹; Mohamed Rabi Andaloussi¹; Massine Elhamoumi²; Elhassan Kabiri²; Hicham Balkhi¹; Mustapha Bensghir¹

1Department of Anesthesiology and Critical Care, Military Teaching Hospital Mohammed V, Faculty of Medicine and Pharmacy of Rabat, Mohammed V University of Rabat, Rabat, Morocco

2Thoracic Surgery Department, Military Teaching Hospital Mohammed V, Faculty of Medicine and Pharmacy of Rabat, Mohammed V University of Rabat, Rabat, Morocco

*Corresponding author: Hicham Hammadi Department of Anesthesiology and Critical Care, Military Teaching Hospital Mohammed V, Faculty of Medicine and Pharmacy of Rabat, Mohammed V University of Rabat, Rabat, Morocco. Email: hichamhammadi418@gmail.com

Received: November 20, 2023 Accepted: December 23, 2023 Published: December 30, 2023

Abstract

Oesotracheal Fistulas (OTF) are rare, but their etiologies are manifold. Their severity is due to the passage of digestive tract contents into the trachea, bronchi and lungs, and the resulting infections. These infections, combined with undernutrition, contribute to the deterioration of the patient’s general condition, and the prognosis can be life-threatening [3].Currently, around 50% of acquired OTFs are benign [1]; in the literature, over 75% result from trauma to the endotracheal cuff in patients on prolonged mechanical ventilation [1]. The two main objectives of anesthetic management are to manage the airway preoperatively and intraoperatively, and to enable spontaneous ventilation as soon as possible postoperatively [4]. Determining the duration of surgery is a crucial step in the successful management of OTF, and immediate extubation is the goal [4]. Postoperatively, all cases of OTF repair should have a nasogastric tube or percutaneous endoscopic gastrostomy for at least 9 days[4].

Introduction

Acquired benign Oesotracheal Fistula (OTF) is a rare but serious pathology. It is a potentially fatal affection due to pulmonary complications, about 50% of acquired OTFs are benign [1].There are many variable causes that have a significant role in such a complication. Tracheal intubation with cuff-related lesions is the most common cause [2]. The proximity of the esophagus, trachea, upper mediastinal structures and large blood vessels can further complicate anesthesia and surgical procedures[1]. We report an observation of a 20-year-old autistic patient with a post-tracheostomy esotrachealfistula.

Observation

Patient aged 20; programmed for Oserotracheal Fistula (OTF) diagnosed by cervico-thoracic (CT) scan and esophageal fibroscopy with antecedent autism since childhood and cellulitis treated for 3 months for which he was operated with placement of a tracheotomy for 40 days complicated by an OTF; Pre-anaesthetic evaluation: patient weight 70 kg, height 1.70 m (BMI 24); respiratory status: patient reported false routes with chronic cough and whitish sputum; respiratory rate 20 cycles/min, SpO2: 100% on ambient air, respiratory auscultation was normal; chest x-ray was normal, chest CT showed lung parenchyma without abnormality and absence of tracheal stenosis, fistula was 2 cm from vocal cords; blood pressure was normal with heart rate at 90 beats/min, no murmur on cardiac auscultation; neurologically: difficult contact with agitation; no sensitivo-motor deficit, pupils equal and reactive. Airway assessment: presence of difficult ventilation and intubation criteria: limited mouth opening, retrognatism and a thyromental distance <65 cm (fig. 1, 2,3). The rest of the examination was without particularity. Preoperative laboratory results: haemoglobin 12 g/dl; platelet count 450000 /mm3 ; urea 0.17 g/l; creatinine 6 mg/l; kalaemia 3.7 mmol; Na+ 136 mmol; CRP 5; procalcitonin negative; ABO RH grouping :A+.

After consultation with the surgeons: the procedure will be performed via an anterior cervical approach, and the anesthetic protocol consists of sedation with sevoflurane; then airway management via nasotracheal intubation with fibroscopy in spontaneous ventilation; then, as soon as the fistula is located, the patient is reintubated by the surgeons via a montandon tube; at the end of the procedure, the patient is reintubated orotracheally via a simple tube using videolaryngoscopy.