1. Department of Anesthesiology, University of Arizona Health Science Center, Tucson, AZ Airway Management in a Patient with Incidental, Intraoperative Finding of a TE Fistula Iftequar A. Siddiqui, Pharm.D, MD, David Lucas, MD Introduction: Malignancy is the most common cause of TE fistulas in adults; esophageal cancer being the most common type of malignancy. TE fistulas secondary to malignancies can connect to any part of the respiratory tract. 1 This presentation describes a case where the patient was found to have previously unknown TE fistula requiring change in surgical and anesthetic plan. Patient Case: Patient is a 66-year-old female with esophageal SCC (T3N1M0) s/p neoadjuvant chemoradiation, esophageal stent and PEG placement, scheduled for Ivor Lewis Esophagectomy. PMH: Hypothyroidism, HTN, restrictive lung disease. In the OR, She was intubated easily with a 35 Fr double lumen ETT, but ventilation was found to be difficult. On withdrawing the ETT by a few centimeters, ventilation became possible. Bronchoscopy was then performed and the esophageal stent was seen in the trachea (picture 1). TE fistula was suspected and DL ETT was exchanged for a single lumen to ease in performing EGD and bronchoscopy which were then performed intraoperatively. A large TE fistula was found through which the stent had migrated with visible aspiration of secretions. The initial difficulty in ventilation was suspected to be due to inadvertent intubation of the TE fistula. The ETT was then advanced beyond the fistula to ventilate the lungs and not the esophagus. The surgery was cancelled as the tumor was deemed unresectable and the patient was transferred to ICU intubated due to the thick secretions and aspiration. The plan going forward was to place stents in the esophagus and trachea overriding the fistula to restore patency and integrity of both. Patient underwent bronchoscopy on POD #1 and the TE fistula (Type E) was noted to be mid tracheal in location. In the ICU, the patient developed septic shock from aspiration pneumonia, but had to return to the OR urgently secondary to difficult ventilation on POD#2 while still intubated for stenting. On return the OR, air leak around the ETT was appreciated and patient was placed on pressure support while continuing her ICU fentanyl and propofol drips, and she was ventilating well. At this point, we extubated her and easily placed a #4 LMA, and pulmonologist placed a tracheal stent overriding the TE fistula. The LMA was then exchanged with ETT #7 easily using DL, to allow the GI service to place an esophageal stent. In ICU, patient was extubated on POD#4 and eventually discharged on Day 12 of hospitalization to an inpatient rehab facility after appropriate evaluation by PT/OT and was tolerating tube feeds. Discussion: The challenges in this patient included previously undiagnosed TE fistula, inability to ventilate, suspected difficult intubation once the ETT in place was removed with concern for airway edema. Patient’s hemodynamic instability also raised concerns regarding limited time for intubation attempts. The cuff leak test and patient demonstrating ability to support her own ventilation prior to extubation were reassuring factors, and the procedure went uneventfully. Airway management is one of the key aspects of Anesthesia care which requires anticipation of potential difficulties in intubation and/or ventilation and warrants adequate pre-procedure evaluation and preparation as practically possible. Acquired TE fistula bypasses laryngeal protection and leads to repeated aspiration. 2 Appropriate preoperative supportive therapy, minimization of aspiration and aggressive management of respiratory infections lead to better outcomes. 3 Inability to ventilate due to intubation of the TE fistula is a major concern. References: 1. Miller, RD et al. "Anesthesia for Thoracic Surgery." Miller's anesthesia. 7th ed. 2010: 1863. 2. Diddee R, Shaw IH. Acquired tracheo-oesophageal fistula in adults. Contin Educ Anaesth Crit Care Pain (2006) 6 (3): 105-108. 3. Kaur D, Anand S, Sharma P, Kumar A. Early presentation of postintubation tracheoesophageal fistula: Perioperative anesthetic management. J Anesthesiology Clin Pharmacol. 2012 Jan-Mar; 28(1): 114-116. Pic. 2 pertaining to “3” on figure above Pic. 1 pertaining to “6” on figure below