Airway Management in Patients with Tracheoesophageal Fistula and Prior Stent Placement Undergoing Subsequent Surgery: A Case Series

When the body's internal plumbing develops a leak between the windpipe and the food pipe, the consequences are immediate and severe. This connection, known as a tracheoesophageal fistula, allows food, drink, and stomach acid to spill directly into the lungs. The result is a relentless cycle of choking, infection, and starvation that can be fatal within days if not addressed. For decades, doctors have relied on placing stents—small, mesh-like tubes—to plug these holes from the inside, offering a lifeline to patients who might otherwise have no options. However, these stents are often a temporary measure. They can shift, erode, or fail to seal the leak completely, eventually requiring a surgeon to open the chest and repair the damage directly. This creates a unique and dangerous puzzle for the anesthesiologist: how do you put a patient to sleep and secure their airway when a metal or silicone tube is already sitting inside their windpipe, blocking the path and altering the shape of the very passage you need to use?

A team of researchers at the First Affiliated Hospital of Guangdong Pharmaceutical University recently tackled this specific challenge by looking back at the care of fifteen patients who faced exactly this situation. These individuals had previously received stents to manage their fistulas but later required major surgery to fix the underlying problem. The researchers reviewed the medical records of these patients, who underwent a total of nineteen surgical procedures between 2023 and 2026. Their goal was not to test a new drug or a new machine, but to map out the safest way to manage the airway when a stent is already in place. They focused on how to insert breathing tubes without causing further injury, how to keep the lungs from collapsing during surgery, and how to ensure the patient could breathe safely once the operation was over.

The process began long before the patient entered the operating room. In every case, the medical team used a flexible camera, passed through the nose or mouth, to get a clear view of the fistula and the stent. This allowed them to see exactly where the leak was, what kind of tube was currently sitting in the windpipe, and how tightly it was pressed against the walls. This visual map was critical because the presence of a stent changes the anatomy of the airway, making standard intubation techniques risky or impossible. The team found that they could not rely on a single method for everyone. Instead, they had to tailor their approach to the specific shape and location of the stent. For some patients, they used a double-lumen tube, which is a special breathing tube with two channels that allows one lung to be ventilated while the other is collapsed, giving the surgeon a clear view. For others, particularly those with stents that blocked the path for a double-lumen tube, they used a bronchial blocker. This is a small balloon-tipped device that can be threaded through a standard breathing tube to seal off one side of the airway, effectively isolating the lung that needs to be worked on.

In all fifteen cases, the team successfully placed the breathing tubes under the direct guidance of the flexible camera. This visual confirmation ensured that the tube was positioned correctly without damaging the stent or the delicate tissue around the fistula. The success rate was perfect; every intubation was completed without failure. The surgeons reported that the lung isolation techniques worked well, providing the clear, dry field they needed to perform the repairs. In twelve of the procedures, isolating one lung was necessary, and the team achieved this using a combination of double-lumen tubes in four cases and bronchial blockers in seven cases. In one particularly difficult case where an esophageal stent had eroded into the windpipe and caused a severe narrowing, the team used a custom-made, extra-long breathing tube that could be guided alongside the obstruction into the left lung.

The study also highlighted the importance of how the patients were put to sleep. The researchers used two main strategies depending on the condition of the airway. For patients with stents that were well-placed and sealed the leak effectively, the team used a rapid sequence induction, a method that quickly renders the patient unconscious and paralyzed to secure the airway. However, for patients with poorly fitting stents, incomplete seals, or severe narrowing, the team chose a safer, slower approach. They kept the patient breathing on their own while gently sedating them and numbing the airway with local anesthetic. This allowed them to confirm that the breathing tube created a tight seal before fully paralyzing the patient, significantly reducing the risk of stomach contents being sucked into the lungs. This distinction proved vital; in the four cases where the slower, spontaneous breathing method was used, there were no complications related to aspiration or oxygen levels.

The outcomes of these surgeries were encouraging, though the path to recovery was often long. Two patients did not survive, succumbing to severe infections that developed after their operations, a risk inherent to such complex procedures. Of the thirteen survivors, most were able to resume eating by mouth, and eleven of them were still alive more than six months after their surgery. The median time spent in the hospital was twenty-nine days, reflecting the complexity of the recovery. The researchers noted that the type of stent originally placed mattered significantly. Metal stents tended to fit tightly against the airway walls but often caused tissue overgrowth that made suctioning secretions difficult. Silicone stents, while less likely to cause tissue overgrowth, were more prone to shifting or not sealing the leak completely, which sometimes required extra care when threading new tubes through them.

The authors conclude that there is no single "best" way to manage the airway in these patients. Instead, the key to safety lies in a personalized plan built on a detailed preoperative assessment. By using a flexible camera to understand the specific geometry of the stent and the fistula, the medical team can choose the right tool for the job, whether that is a specialized double-lumen tube, a bronchial blocker, or a custom-length tube. The study suggests that this individualized approach, combined with the option to keep the patient breathing on their own during the initial tube placement, effectively ensures airway safety and meets the demanding requirements of the surgery. While the sample size was small, the consistent success in these difficult cases provides a clear roadmap for other teams facing similar challenges, emphasizing that careful preparation and visual guidance are the most reliable tools in the operating room.