The intraoperative diagnosis of a tracheoesophageal fistula in an adult.

A 61-yr-old woman (weight, 121 kg) presented to the operating room for closure of an abdominal wound. Her history was notable for morbid obesity and restrictive lung disease, necessitating numerous therapeutic bronchoscopies for correction of atelectasis. The patient did not have symptoms of recurrent aspiration. She was not specifically questioned about coughing associated with food intake. Approximately 6 months before the current procedure, she underwent a complex revision of a previously failed gastric bypass. She had a difficult postoperative course complicated by infarction of her gastric remnant, the development of multiple enteroenteroand enterocutaneous fistulae, and several episodes of sepsis. She was in the hospital with a nasogastric tube in place for several months. Approximately 3 months before the current procedure, she underwent a 9-h operation, during which multiple fistulae were taken down and intestinal continuity was restored. Anesthetic during this surgery was notable for a leak around the endotracheal tube (ETT) after placement of a 7.0 cuffed tube. This leak disappeared after reintubation with an 8.0 cuffed ETT. The current case began with an uneventful intravenous induction of anesthesia with fentanyl, propofol, and succinylcholine. A 7.0 ETT was placed via direct laryngoscopy without difficulty. The ETT cuff was inflated and bilateral breath sounds were confirmed. The tube was taped in place, an esophageal stethoscope was inserted, and mechanical ventilation was started, using 50% nitrous oxide (N2O) and desflurane in oxygen. After 5–10 min, as the effects of succinylcholine wore off, a gurgling sound was noted around her airway at end-inspiration with each respiratory cycle. Assuming a poor seal by the ETT, 2 ml air was added to the cuff; however, the leak persisted. Repeat laryngoscopy confirmed that the ETT cuff was entirely below the vocal cords. Particularly notable was the finding that removal of the esophageal stethoscope before repeat laryngoscopy resulted in an increase in the intensity of the gurgling sound. A presumptive diagnosis of TEF was made. A brief fiberoptic evaluation of the patient’s airway (through the ETT) failed to reveal any defects in the tracheal wall. A gastroenterologist was not available to endoscopically examine the patient’s esophagus during the anesthetic. Postoperatively, an esophagram showed a tracheoesophageal fistula at the level of the carina. Esophagoscopy and bronchoscopy revealed this lesion to taper from an approximately 0.6-cm lesion in the anterolateral esophagus to a pinhole defect in the tracheal wall.