We report the case of a 60 year old male who underwent a laryngeal endoscopy under general anesthesia.
Eleven months ago, this patient underwent an oesophagectomy according to the Lewis-Santy technique for oesophageal cancer. During the lymphadenectomy procedure , the right laryngeal recurrent nerve was cut. In the immediate post-operative period, the patient experienced breathing difficulties and bronchial hypersecretion . The nasofibroscopic exam showed a right vocal cord paralysis, a reduction in left vocal cord movements and bilateral arytenoid oedema. Oxygen, physiotherapy and an antibiotic regimen were started. Unfortunately, the patient’s condition worsened, culminating into cardiac arrest, that was quickly and succesfully ressuscitated. He was transferred to the ICU where he made good progress with good neurologic recovery. The main issue during the ICU stay was recurrent aspiration pneumonias. A tracheotomy was performed to secure the airways, and the patient was spontaneously ventilating with an inflated cuff cannula.
Weaning proved difficult with several unsuccessful weaning trials from the tracheostomy cannula. The patient was dyspneic and seemingly had a poor laryngeal mobility recovery, despite speech therapy. Nasofibroscopic exams revealed a subglottic tracheal stenosis suspiscion due to long cuff inflated intubation.
Accordingly, the patient was planned for a complete airway exam under general anesthesia.
Patients who have undergone oesophagectomy with a new gastric pouch in the thorax are at very high risk of aspiration. General anesthesia is a challenge and the anesthetic teams are prone to manage these patients very cautiously. An airway exam under general anesthesia presents a further challenge, because the patient must be deeply sedated for a short time interval, while keeping the airway open because of the necessity to see through the larynx.
This patient was therefore scheduled in the ENT ambulatory departement. He routinely takes proton pump inhibitor medication. We asked the patient to eat lightly the evening before the surgery and later nil by mouth for 12 hours. When he arrived at 7:00 am the day of the surgery, a naso-gastric tube was inserted (40 cm at the patient’s nostrils) and an IV cannula was placed. Thirty minutes before the surgery, he was given 250 mg IV erythromycin to optimize gastric emptying.
In the operating room, the patient breathed spontaneously . After a long pre-oxygenation throught the tracheotomy cannula. Suction was placed on the naso-gastric tube. We choose to do a local adaptation of the standard rapid induction sequence protocol, using remifentanil, propofol and suxamethonium. When the patient was deeply sedated and paralyzed, we put a tracheal tube in his upper oesophagus so that any gastric secretion whould be drained through this tube and not enter the oropharynx. Then, we removed his tracheal cannula to insert a classic 6.5 endotracheal tube through his tracheostomy and inflate the cuff. In this setting, the surgeon was able to perform uneventfully the airway exam. We were even able to temporally remove the tracheal tube, in order to make a complete endoscopic tracheal exam. Because the oesophagus tube was still in place, we felt confident that the airways were secured against aspiration.
We would like to report this case for two reasons. First, patients with a thoracic gastric pouch are at very high risk of aspiration when they undergo general anesthesia. So we would like to make several recommendations to manage these patients :
- a long nil per mouth period is mandatory
- preoperative IV erythromycine can help clear the stomach from its residual content
- empty the stomach with a gastric tube inserted to around 40 cm at the nostrils
- make sure that everyone in the operating room is aware of the aspiration risk and is prepared for it
Then, we also think that a large tracheal tube intentionally put in the upper oesophagus is a good way to shunt gastric secretions out of the patient mouth.
Finally, we suggest that short-acting opioid drugs like remifentanil could take part in a rapid sequence induction protocol. They help to blunt the hemodynamic response to intubation and have proved safe in difficult or emergency intubation.