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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 3  |  Issue : 1  |  Page : 45-48

An alternative method for tracheal stent deployment in malignant tracheo-oesophageal fistula


1 Department of Onco-Anaesthesia and Palliative Medicine, Dr BRAIRCH, All India Institute of Medical Sciences, New Delhi, India
2 Department of Pulmonary Medicine and Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India

Date of Submission12-Feb-2020
Date of Acceptance10-Apr-2020
Date of Web Publication30-May-2020

Correspondence Address:
Dr. Rakesh Garg
Room No. 139, First Floor, Department of Onco.Anaesthesia and Palliative Medicine, Dr. BRAIRCH, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ARWY.ARWY_4_20

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  Abstract 


Malignant tracheo-oesophageal fistula, a troublesome complication of oesophageal cancer, often requires placement of airway self-expanding metallic stent (SEMS) for palliation. Devices such as SEMS can be deployed by flexible or rigid bronchoscopy under sedation or general anaesthesia. General anaesthesia is preferred as it not only provides better operating conditions to the pulmonologist but also avoids unnecessary patient movement and coughing during stent deployment which could result in stent displacement. However, general anaesthesia can be complicated by the presence of comorbidities, poor general condition and deranged blood gases. A comprehensive perioperative anaesthetic plan with a team approach can reduce complications. Stent deployment can be difficult in a few cases using conventional techniques such as with a rigid bronchoscope. We describe the anaesthetic management of tracheobronchial stent placement by flexible bronchoscopy which is one of the alternate techniques of stent placement.

Keywords: Direct laryngoscopy, i-gel, self-expanding metallic stent, total intravenous anaesthesia, tracheo-oesophageal fistula


How to cite this article:
Dattatri R, Garg R, Madan K, Hadda V, Mohan A. An alternative method for tracheal stent deployment in malignant tracheo-oesophageal fistula. Airway 2020;3:45-8

How to cite this URL:
Dattatri R, Garg R, Madan K, Hadda V, Mohan A. An alternative method for tracheal stent deployment in malignant tracheo-oesophageal fistula. Airway [serial online] 2020 [cited 2020 Jul 5];3:45-8. Available from: http://www.arwy.org/text.asp?2020/3/1/45/285431




  Introduction Top


Malignant tracheo-oesophageal fistula (TOF), a common sequel of oesophageal cancer, is a distressing condition occurring in 5%–10% of patients.[1] If untreated, TOF may lead to aspiration, pneumonia, sepsis and death.[2] Being an incurable condition, it is only amenable for palliative treatment in the form of stent placement. We describe the anaesthetic management for the placement of a tracheobronchial Y-stent under flexible bronchoscopic guidance with the help of a direct laryngoscope.


  Case Report Top


A 60-year-old male, a known case of oesophageal cancer with self-expanding tracheal stent in situ placed 8 months prior for mid-tracheal fistula, developed progressively increasing breathlessness along with cough on food intake. He had received five sessions of radiotherapy 6 months earlier. Complete haemogram, liver function tests, renal function tests and electrocardiogram (ECG) were normal. Chest X-ray showed hyperinflated lung fields with prominent bronchovascular markings. Pulmonary function tests were suggestive of a severe obstructive respiratory pattern. The patient was posted for rigid bronchoscopic evaluation and further management.

In the pulmonary intervention suite, peripheral intravenous access was secured after attaching standard monitors such as ECG, noninvasive blood pressure and pulse oximetry. Bispectral index (BIS) was used to monitor the depth of anaesthesia. Preoxygenation was performed with 100% oxygen until end-tidal oxygen was >90%. Intravenous dexamethasone 8 mg was administered. Anaesthesia was induced with intravenous fentanyl 2 μg/kg and target-controlled infusion of propofol (Marsh model). After ensuring bag-mask ventilation, intravenous atracurium 0.4 mg/kg was administered. A size 11 ventilating trachea-bronchoscope was passed into the trachea. Maintenance of anaesthesia was done using 100% oxygen and target-controlled infusion with propofol (targeting a concentration of 2 μg/mL and a BIS value of 40–60). Bronchoscopic evaluation revealed a bulge and granulation tissue in the trachea causing non-critical tracheal narrowing at around the mid-tracheal level. A TOF was seen distal to tracheal self-expanding metallic stent (SEMS), just at the carina, along with granulation tissue without significant luminal narrowing of proximal bronchi. The size of the SEMS required to cover the lesion was also assessed.

Following a bronchoscopic evaluation, a tracheobronchial Y-stent placement was planned. The rigid bronchoscope was removed and # 3 i-gel was placed to secure the airway and facilitate stent placement. A Y-SEMS deployer and flexible bronchoscope were introduced through the i-gel [Figure 1]. However, both could not be simultaneously negotiated through the i-gel. Hence, the i-gel was removed. Direct laryngoscopy was performed immediately using Macintosh blade #3, and a guidewire was placed in the trachea once the vocal cords were visualised [Figure 2]. The guidewire was inserted through the left limb of the Y-SEMS following which the SEMS deployer was advanced through the glottis under direct laryngoscopy. Further advancement of the stent deployer was made under direct flexible bronchoscopic vision. The guidewire was advanced into the left main bronchus under flexible bronchoscopic guidance by the pulmonologist. Once the deployer was appropriately positioned, SEMS was deployed. Post-SEMS deployment, bronchoscopy showed Y-SEMS covering the proximal trachea and the distal TOF. Tracheobronchial toileting was done. The procedure lasted for 15 min during which period oxygenation was maintained using high-flow apnoeic oxygenation technique. The entire procedure was uneventful. At the end of the procedure, a # 3 i-gel was positioned. Residual neuromuscular blockade was reversed with neostigmine and glycopyrrolate, and the i-gel was removed once adequate respiratory efforts were established.
Figure 1: Attempt to place stent deployer through i-gel

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Figure 2: Placement of stent deployer under direct laryngoscopy

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  Discussion Top


Patients with malignant TOF may require airway/oesophageal stent placement. SEMS, which are metal stents, may be used and are placed in trachea using a stent deployer. SEMS placement requires flexible or rigid bronchoscopy.[3],[4] SEMS can be deployed under local anaesthesia, sedation or general anaesthesia. Each of these techniques has been described in literature with various limitations. General anaesthesia is preferred as it provides maximum comfort to the patient and better operating conditions to the pulmonologist. General anaesthesia also avoids unnecessary patient movement and coughing during stent deployment which can result in stent displacement.[4] Airway blocks could be alternate options but do not provide complete anaesthesia during insertion of a rigid bronchoscope. Absence of muscle relaxation causes more risk of airway injury and thus general anaesthesia remains the technique of choice. However, anaesthetic management of tracheobronchial stent placement in TOF can be challenging due to a multitude of factors such as shared airway, presence of comorbidities, aspiration risk, gastric insufflation, hypoxaemia, hypercarbia and failure to place the stent due to pressure limitations in narrowed airways.[3],[5] In addition to these, our patient already had a tracheal SEMS in situ, and any inadvertent airway manipulation could have been catastrophic.

A thorough preanaesthetic history should be obtained including the initial need for stent placement, type of stent used, its position, whether secured or not, presence of stridor and orthopnoea. Covered stents pose a higher risk of airway obstruction if displaced, whereas uncovered stents may have granulation tissue overgrowth contributing to difficult ventilation and laryngoscopy.[6] Concomitant chemoradiotherapy can also increase the risk of difficult laryngoscopy.

The airway can be secured either by endotracheal tube or supraglottic airway device. Laryngeal mask airways have been successfully used for the placement of SEMS in obstructive tracheobronchial lesions and also obviate airway manipulation.[7],[8] In our patient, we avoided tracheal intubation and used i-gel, but the flexible bronchoscope could not be negotiated along with a stent deployer through the i-gel. Although a large-lumen rigid bronchoscope is ideal for the placement of a Y-SEMS in the trachea, the presence of a preexisting tracheal SEMS does not allow the negotiation of a size 14 rigid bronchoscope. Therefore, an alternative stent deployment strategy was warranted in our patient. Flexible bronchoscopic visualisation was essential to avoid incorrect airway manipulation and blind stent placement as our patient already had a stent in situ. The i-gel also helped in the smooth return of spontaneous ventilation while avoiding coughing, thereby avoiding stent displacement. If an endotracheal tube is to be placed, flexible fibreoptic-guided intubation is preferred. Performing direct laryngoscopy helped to avoid injury to the vocal cords and to place the guidewire in the trachea and subsequently aided placement of stent deployer through the glottis. We also used total intravenous anaesthesia (TIVA) for maintenance of anaesthesia as volatile anaesthetic delivery can be interrupted due to manipulation of bronchoscope, leading to inconsistent delivery of agents. TIVA helps to maintain better anaesthetic depth which was monitored by BIS.

In conclusion, we believe that constant vigilance, good communication with the pulmonologist and adoption of strategies to optimise oxygenation and ventilation are all vital to the successful management of airway stenting. In addition, using a multitude of airway gadgets alone or in combination aids in better placement of SEMS in the difficult airway due to malignant fistulas.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given consent for his 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

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Tomaselli F, Maier A, Sankin O, Woltsche M, Pinter H, Smolle-Jüttner FM. Successful endoscopical sealing of malignant esophageotracheal fistulae by using a covered self-expandable stenting system. Eur J Cardiothorac Surg 2001;20:734-8.  Back to cited text no. 1
    
2.
Smith JL, Michaletz PA, Tabibian N, Schwartz JT, Graham DY. Improved palliation of a respiratory-esophageal fistula with a cuffed esophageal prosthesis. Am J Gastroenterol 1987;82:1175-6.  Back to cited text no. 2
    
3.
Galway U, Zura A, Khanna S, Wang M, Turan A, Ruetzler K. Anesthetic considerations for bronchoscopic procedures: A narrative review based on the Cleveland Clinic experience. J Thorac Dis 2019;11:3156-70.  Back to cited text no. 3
    
4.
McGrath EE, Warriner D, Anderson P. The insertion of self expanding metal stents with flexible bronchoscopy under sedation for malignant tracheobronchial stenosis: A single-center retrospective analysis. Arch Bronconeumol 2012;48:43-8.  Back to cited text no. 4
    
5.
Dolan AM, Moore MF. Anaesthesia for tracheobronchial stent insertion using an laryngeal mask airway and high-frequency jet ventilation. Case Rep Med 2013;2013:950437.  Back to cited text no. 5
    
6.
Davis N, Madden BP, Sheth A, Crerar-Gilbert AJ. Airway management of patients with tracheobronchial stents. Br J Anaesth 2006;96:132-5.  Back to cited text no. 6
    
7.
Okada S, Ishimori S, Yamagata S, Satoh S, Yaegashi S, Tanaba Y. Placement of self-expandable metallic stents with a laryngeal mask and a fiberoptic flexible bronchoscope for obstructive tracheobronchial lesions. J Thorac Cardiovasc Surg 2002;124:1032-4.  Back to cited text no. 7
    
8.
Obeidat S, Badin S, Khawaja I. A new technique of deploying dynamic y stent using flexible bronchoscope, video laryngoscope, and laryngeal mask airway. J Bronchology Interv Pulmonol 2010;17:171-3.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2]



 

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