Spontaneous ventilation as rescue after failed one-lung ventilation in a patient with a destroyed lung and a TEF: a case report

Introduction

A tracheoesophageal fistula (TEF) in patients with advanced cancer is a devastating complication, often leading to recurrent aspiration pneumonia, nutritional depletion, and interruption of life-prolonging antitumor therapy. Prognosis remains dismal, with historical median survival of approximately 1 month (1). While esophageal or airway stenting offers palliative relief (2), surgical reconstruction may be considered in selected patients with responsive tumors and preserved organ function, aiming to restore gastrointestinal continuity and enable continued targeted therapy (3). However, the presence of a destroyed lung, distorted airway anatomy, and active infection imposes extreme anesthetic risks, particularly regarding airway management and ventilation. We present a case of successful TEF repair using a spontaneous-ventilation general anesthetic strategy after failure of the intended single-lung isolation, emphasizing perioperative decision-making and airway management lessons.

Case report

Patient history and presentation

A 48-year-old female patient (height 156 cm, weight 44 kg) had undergone surgery for left submandibular gland basal cell carcinoma 14 years prior, with a second resection for local recurrence 3 years later, followed by postoperative radiotherapy and chemotherapy. One year ago, chest CT revealed right bronchial occlusion with right lung destruction and a soft-tissue mass in the left upper lobe. She underwent argon plasma coagulation ablation of a left main bronchus neoplasm and bronchial stent placement; postoperative pathology confirmed metastatic basal cell carcinoma, leading to a diagnosis of left submandibular gland basal cell carcinoma (rTxN3M1, stage IV). Subsequent chemotherapy and targeted therapy (with regular CT follow-up) showed tumor shrinkage, but the bronchial stent was later found to have migrated and was removed.

Eighteen days prior to admission to our hospital, the patient developed a severe cough, vomiting, and choking during swallowing. A TEF was diagnosed at another institution, where it was clinically attributed to local tumor invasion and/or chemoradiotherapy-induced tissue damage. She was subsequently transferred to our hospital for further management.

Admission evaluation

Admission CT scans demonstrated rightward tracheal deviation with a fistulous communication between the posterior wall of the trachea at the level of the carina and the esophagus, with an opening measuring approximately 6 mm × 7 mm. The fistula was in close proximity to the right main bronchus; the right thoracic cage was collapsed, and the right lung was destroyed. An irregular soft tissue mass measuring 40 mm × 30 mm × 20 mm with internal cavitation was found in the anterior segment of the left upper lobe, accompanied by interstitial pneumonitis of the left lung (Figure 1a). Fiberoptic bronchoscopy (FOB) demonstrated a widened and deformed carina, marked hyperemia and edema of the left bronchial tree mucosa, and white necrotic debris in the carinal and right main bronchial regions. The right main bronchus opening showed substantial mucosal erosion and a 6-mm-long TEF located on its posterior wall. Electrocardiogram (ECG) and other laboratory findings were essentially within normal limits. A multidisciplinary team (MDT) discussion concluded that, despite the advanced malignancy, the patient's tumor remained responsive to targeted therapy, and no major organ dysfunction was present. Taking into consideration the potential for curative-intent surgery, the unfavorable anatomy of the fistula for safe stenting, and the patient's history of failed previous stenting, the team planned a laparoscopy-assisted gastric transposition to reconstruct the gastrointestinal tract—aiming to restore enteral feeding, enable timely resumption of targeted therapy, and improve quality of life. The surgical plan, along with its risks and benefits, was thoroughly discussed with the patient and her family, and informed consent was obtained. The initial anesthetic plan was FOB-guided left main bronchus intubation with general anesthesia and extracorporeal membrane oxygenation (ECMO) on standby, which would be deployed by the ICU-ECMO team if needed; no prophylactic cannulation was performed.

On the morning of surgery, the patient received nebulized beclomethasone and ipratropium bromide on the ward. In the operating room, she was positioned in a 45° head-up semirecumbent position. Monitoring included ECG, non-invasive blood pressure, oxygen saturation (SpO₂), and bispectral index (BIS). A left radial arterial line was placed under local anesthesia for direct pressure and arterial blood gas (ABG) sampling. Baseline vital signs were BP 123/65 mmHg, HR 81 bpm, and SpO₂ 99%. ABG values are shown in Table 1. Peripheral venous access was secured. Premedication included intravenous dexamethasone 5 mg and penehyclidine 0.5 mg. A loading dose of dexmedetomidine at 1 μg·kg⁻¹ was infused over 10 min. Topical airway anesthesia was achieved with 2% lidocaine spray to the oropharynx and a transtracheal injection via cricothyroid membrane puncture. The patient breathed 100% oxygen via a face mask. Anesthesia was induced with intravenous etomidate 6 mg and sufentanil 3 μg, followed by propofol infusion at 3.5 mg·kg⁻¹·h⁻¹ and remifentanil at 0.004 mg·kg⁻¹·h⁻¹. After loss of consciousness, an extended cuffed endotracheal tube (ID 6.5) was inserted orally and connected to the ventilator in the spontaneous breathing mode. FOB via the tube revealed a markedly widened and deformed carina (Figure 1b), erosion of the right main bronchus opening covered with yellowish secretions and granulation tissue (Figure 1c), and a stenotic, edematous left main bronchus forming a nearly 90° angle with the trachea.

Table 1. Arterial blood gas analysis during the perioperative period.

Following suctioning of secretions, FOB was advanced into the left main bronchus. Under deepened anesthesia, attempts to advance the endotracheal tube over the bronchoscope into the left main bronchus failed repeatedly, as the widened carina prevented tube passage despite rotation and changes in head/body position. To avoid repeated instrumentation that could worsen airway edema and/or bleeding or lead to catastrophic ventilatory failure, we immediately consulted the attending anesthesiologist and surgical team. The anesthetic plan was revised to: (1) general anesthesia with a retained endotracheal tube (tip positioned in the midtrachea) and preserved spontaneous ventilation, combined with lower thoracic epidural blockade; and (2) conversion from laparoscopic to open laparotomy. After obtaining renewed informed consent, a T9–10 epidural catheter was placed, and 0.375% ropivacaine was administered in divided doses. Anesthesia was maintained with continuous intravenous infusions of propofol, remifentanil, and dexmedetomidine, with BIS monitoring to maintain the values between 50 and 60 (4). After the decision to convert to spontaneous-ventilation anesthesia was made, the endotracheal tube, which had been successfully placed prior to the attempted left main bronchus intubation, remained in situ and was connected to the anesthesia circuit. The patient’s spontaneous respiratory rate and tidal volume were continuously monitored, and the depth of anesthesia was titrated accordingly. During the procedure, spontaneous tidal volume was maintained at 300–350 mL, respiratory rate above 10 breaths/min, and end-tidal CO₂ between 35 and 55 mmHg under 100% oxygen, with SpO₂ consistently at 99%. The ABG results before induction, at 1 h, 3 h, and 30 min postsurgery are shown in Table 1.

The surgical procedure (open gastroplasty with gastric transposition, cervical esophagogastrostomy, thoracic esophageal exclusion with drainage, and feeding jejunostomy) lasted 3.5 h, with stable hemodynamics throughout. During the entire procedure, the surgeons did not observe any gastric insufflation or distension, consistent with the absence of positive-pressure ventilation.

Postoperative outcome

At the end of surgery, the patient was awake but tachypneic. Given the destroyed contralateral lung and preexisting pulmonary inflammation, we elected to keep her intubated and transfer her to the ICU for controlled airway suctioning, anti-infective therapy, and nutritional support. The subsequent postoperative course was uneventful (timeline summarized in Table 2). Oral intake was initiated after a contrast study confirmed anastomotic integrity, and she tolerated feeding without choking or regurgitation. Notably, although the fistula remained present anatomically, the patient's cough and sputum production improved markedly, with reduced pulmonary inflammation and diminished secretions around the fistula tract. She was discharged in good condition and resumed antitumor therapy 1 week later. At 6-month follow-up, she remained in good general condition with stable oral intake.

Table 2. Timeline of key clinical events from admission to discharge.

Discussion

For patients requiring surgical repair of TEF, conventional airway management strategies are not directly applicable. The majority of previous reports have focused on congenital TEF in pediatric populations, with an emphasis on avoiding positive-pressure ventilation through the fistula to minimize gastric distension (5). In adults with acquired TEF, anesthetic management has been described primarily in case reports and interventional settings, and no unified airway management protocol is currently available (6). In interventional pulmonology, airway management for TEF remains challenging due to the shared airway and ventilation difficulties. The majority of procedures are performed under spontaneous-ventilation anesthesia with flexible bronchoscopy via the supraglottic airway, while rigid bronchoscopy is typically supported by jet ventilation to maintain oxygenation (7). However, jet ventilation carries a substantial risk of gastric insufflation, which could severely compromise surgical exposure and manipulation. This was particularly so in our case, where gastric transposition and esophagogastrostomy were performed. Therefore, we opted for spontaneous ventilation throughout the entire procedure, which effectively avoided gastric distension while maintaining adequate oxygenation and stable hemodynamics. Of note, while gastric transposition is one of the established surgical options for certain subtypes of congenital tracheoesophageal fistula—particularly long-gap TEF in pediatric populations where primary anastomosis is not feasible (8)—its application in adults with malignant TEFs remains exceedingly rare, with only isolated case reports available in the literature. At our institution, we have successfully performed this procedure in several adult patients with malignant TEFs, demonstrating its feasibility in carefully selected cases.

To our knowledge, this is the first report to describe the successful use of spontaneous-ventilation anesthesia as a rescue strategy during gastric transposition in an adult patient with a destroyed lung and a malignant TEF. Given the rarity of this clinical scenario and the lack of established guidelines, we reflect here on the key advantages, potential pitfalls, and lessons learned from this case to inform future practice.

First, preoperative airway assessment has inherent limitations in the setting of severely deformed anatomy. Although we reviewed both CT and FOB findings to select the endotracheal tube size and plan a left main bronchial intubation, the actual three-dimensional spatial distortion—including tracheal and mediastinal rightward shift, carinal widening and elevation, and an acute angle between the trachea and the left main bronchus—was underestimated. On preoperative CT, the left main bronchus appeared artifactually “widened” due to oblique sectioning, while FOB, although demonstrating the anatomical changes, could easily pass through angulated airways owing to its greater flexibility and smaller caliber, failing to predict the rigid tube's impingement on the carina. We suggest that preoperative three-dimensional CT airway reconstruction may provide more intuitive anatomical guidance in such cases. Furthermore, direct participation of the attending anesthesiologist in the diagnostic FOB could facilitate a more accurate prediction of tube passage difficulty and improve perioperative planning.

Second, meticulous topical airway anesthesia was crucial to patient tolerance. In this case, the patient remained calm and hemodynamically stable throughout 30 min of repeated FOB and intubation attempts. The combination of lidocaine spray, transtracheal injection, and dexmedetomidine sedation effectively suppressed coughing while preserving spontaneous breathing, allowing time for intraoperative decision-making without resorting to neuromuscular blockade.

Third, the revision to a spontaneous ventilation strategy with epidural analgesia was a case-specific rescue measure rather than a preferred approach. The main strength of this approach lies in its avoidance of positive-pressure ventilation in a patient with an open TEF and a destroyed contralateral lung, thereby minimizing the risks of gastric insufflation and air trapping in the non-functional lung. However, the anesthetic regimen—combining propofol, remifentanil, dexmedetomidine, and thoracic epidural ropivacaine—carried inherent risks of respiratory depression. We managed this by using stage-adjusted anesthetic depth: during the abdominal phase, adequate epidural blockade allowed for minimal intravenous anesthetics; during the thoracic and cervical phases, we proactively adjusted drug infusions guided by BIS and respiratory parameters to prevent awareness and body movement while preserving a safe tidal volume and respiratory rate. The transient hypercapnia (PaCO₂ up to 60.4 mmHg at 3 h) was tolerated in this otherwise healthy contralateral lung with adequate oxygenation, but this underscores the need for vigilant monitoring.

Fourth, our experience is limited to a single case, and the generalizability of this strategy awaits further validation in a larger series. The availability of standby ECMO provided a critical safety net, ensuring that rescue mechanical ventilation or oxygenation could be instituted if spontaneous ventilation failed. For centers without such expertise or resources, proceeding with a high-risk TEF repair under spontaneous ventilation would be inadvisable. Nonetheless, this case demonstrates that when one-lung ventilation fails in this specific high-risk population, spontaneous-ventilation anesthesia can serve as a viable rescue strategy. The patient expressed strong satisfaction with the overall perioperative care, particularly regarding the successful restoration of oral intake and the timely resumption of antitumor therapy.

In conclusion, this case illustrates that in highly selected patients with advanced TEFs and impossible single-lung isolation, a carefully executed spontaneous-ventilation general anesthetic strategy combined with epidural blockade can enable successful surgical repair. However, thorough multidisciplinary planning, three-dimensional airway evaluation, real-time intraoperative adaptability, and a contingency plan (including ECMO backup) are indispensable prerequisites.

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Footnotes

Edited by: Mert Şentürk, Istanbul University, Türkiye

Reviewed by: Aby Pynadath, University of Illinois Campus of Medicine Peoria, United States

Ozlem Yagiz Agayarov, Izmir Tepecik Training and Research Hospital, Türkiye