Radical esophagectomy for esophageal cancer with a bronchial occluder placed within a tracheotomy trocar: a case report

Radical esophagectomy for esophageal cancer with a bronchial occluder placed within a tracheotomy trocar: a case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF registered-report Radical esophagectomy for esophageal cancer with a bronchial occluder placed within a tracheotomy trocar: a case report Zhen-Hua Xu, Kai Cao, Ren Sun, Zhi-Hong Zhang, Qiu-Lan Li, Hai-Long Zhang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6493687/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Radical surgery for esophageal cancer frequently necessitates the use of pulmonary isolation techniques during general anesthesia. However, the airway management of patients with esophageal cancer who undergo this procedure with a combined tracheotomy is undoubtedly challenging and difficult for anesthesiologists. In this case report, we describe the case of a patient who was retained with a tracheotomy metal cannula in place following radical surgery for tongue root cancer. The anesthetic management strategy used for this patient provides a new concept for anesthesiologists to implement lung isolation techniques when encountering this type of patient to improve airway management. Case Presentation: The patient was a 68-year-old male who had experienced a choking sensation for over a month without any discernible triggers. Two years previously, he underwent a radical surgical procedure and tracheotomy for cancer of the tongue root; this was followed by postoperative radiotherapy and the insertion of a tracheotomy metal cannula. Gastroscopy revealed an irregular neoplasm located 38 cm from the central incisor, and a biopsy indicated squamous cell carcinoma. Based on these findings, the patient was diagnosed with esophageal malignancy. Radical surgery for esophageal cancer was planned under general anesthesia. Following the surgical procedure, the patient demonstrated a favorable recovery trajectory following a series of adjuvant therapies. The patient was subsequently discharged from the Department of Medical Oncology following the completion of related treatments. Conclusion: The placement of a bronchial occluder into the tracheotomy tube represents a simple, effective, and less invasive method of airway management when performing pulmonary isolation techniques for tracheotomized patients under general anesthesia. However, the safety and standardization of this method still require validation through further clinical practice. Esophageal cancer Tracheotomy Bronchial occluder One-lung ventilation Figures Figure 1 Figure 2 Background Esophageal cancer is a common malignant tumor of the digestive tract that can be treated effectively in most cases by radical surgery [ 1 ]. As a complex form of thoracic surgery, airway management during anesthesia for radical esophageal cancer surgery is a crucial link in ensuring patient safety and improving the surgical success rate [ 2 ]. One-lung ventilation (OLV) is a commonly employed anesthetic technique for airway management during this procedure; the object of this technique is to ensure a clear surgical field and reduce intraoperative contamination. For patients who have undergone a tracheotomy and require OLV for procedures such as lung or esophagus surgery, the management of this complex situation becomes far more challenging [ 3 ]. The selection of appropriate airway management methods can help to minimize complications during OLV after tracheotomy [ 4 , 5 ]. In this report, we present the case of a postoperative patient who underwent a radical esophagectomy for carcinoma of the root of the tongue and experienced general anesthesia with a bronchial occluder placed through his retained tracheotomy trocar. This strategy resulted in a smooth and safe radical esophagectomy for carcinoma of the root of the esophagus. Herein, we discuss the anesthetic management of this patient, focusing particularly on the OLV strategy. Case Presentation The patient was a 68-year-old male who presented to our hospital with a choking sensation while eating. The patient weighed 64 kg and was 165 cm in height. The patient had been diagnosed with cancer of the tongue root 2 years ago, following the development of tongue pain on the right side and ulcers on the floor of the mouth. He underwent a double neck clearance procedure, involving removal of the collar and neck of the floor of the mouth, in addition to a left anterolateral femoral flap repair and tracheotomy. Pathological analysis indicated that the squamous cell carcinoma of the mucous membrane of the floor of the mouth was of grade I-II, with the tumor invading the nerves. Post-surgery, he was subsequently treated with 30 cycles of local radiotherapy. However, the patient's choking symptoms had exacerbated and he was only able to consume a minimal amount of fluid. A positron emission tomography-computed tomography (PET-CT) scan revealed that the local wall of the lower part of the esophagus was irregularly thickened with local narrowing of the lumen; in addition, there was a marked elevation in the uptake of fluorodeoxyglucose (FDG). Gastroscopy revealed an irregular neoplasm that was located 38 cm from the central incisors, which exhibited brittleness and was prone to bleeding. Pathological analysis of biopsy specimens indicated the presence of squamous cell carcinoma. The patient's cardiopulmonary function was satisfactory, and a two-incision radical esophagectomy for esophageal cancer was planned under general anesthesia. The patient was placed in a tracheotomy state and was retained with a metal cannula (size 7) in place (Figure 1A); airway patency was normal. Routine airway care was provided on the ward, and no yellow sputum or fever was observed. A reconstruction of the patient's chest CT (sagittal) was performed to confirm the absence of variations in the right main bronchial opening in the right upper lobe. In addition, the length of the right main bronchus was measured to ensure the suitability of the bronchial occluder. Once the patient was admitted to the operating room, various vital signs were monitored, including electrocardiography, pulse oximetry, and non-invasive blood pressure monitoring. Peripheral venous access was established, and 64 µg of dextromethorphan was injected intravenously over a 10-minute period (concentration: 4 µg/ml). Following sedation, the patient was suctioned, the airway was cleared, and the tracheotomy metal trocar was replaced with a tracheotomy plastic trocar to match the anesthesia machine. Prior to the administration of anesthesia, an outdated and discarded tracheotomy plastic cannula and bronchial sealer were utilized for demonstration and initial testing. Following the induction of anesthesia, we proceeded to cannulate the right radial artery for the purpose of monitoring arterial blood pressure and blood gas analysis. In addition, we performed ultrasound-guided cannulation of the right subclavian vein in order to establish central venous access. Prior to the induction of anesthesia, a paravertebral nerve block was performed at the T5-T6 gap level under ultrasound guidance, and 20 ml of 0.3% ropivacaine was injected to provide analgesia [6]. The induction of general anesthesia involved the intravenous administration of midazolam (0.04 mg/kg), 1% isoproterenol (20 mg/kg), sufentanil (0.3 µg/kg), and rocuronium bromide (0.6 mg/kg). As the patient's respiration gradually declined, the respiratory circuit of the anesthesia machine was connected and the mode of ventilation was transitioned from assisted to controlled. The bronchial blocker was then placed from the opening of the airway catheter to the opening of the right main trachea under the guidance of a visual fiberoptic bronchoscope; this was then fixed in place. Once the fiberoptic bronchoscope had been removed, a stethoscope was used once more to auscultate both lungs in order to confirm the location of the bronchial occluder and its sealing effect. Intraoperatively, the bispectral index (BIS) and nasopharyngeal temperature were monitored. The intraoperative mechanical ventilation protocol was derived from the Expert Consensus on Lung Protective Ventilation in Surgical Patients, published in the British Journal of Anesthesiology in 2019 [7]. The mechanical ventilation parameters employed during two-lung ventilation were as follows: a tidal volume (TV) of 8 ml/kg (predicted body weight), a positive end-expiratory pressure (PEEP) of 5 cm H₂O, an oxygenation index (FiO₂) of 0.5–0.8, and an inspiratory-to-expiratory ratio of 1:2; in addition, the respiratory rate was adjusted to maintain an end-expiratory partial pressure of carbon dioxide (ETCO₂) between 35–45 mmHg. The parameters used during one-lung ventilation were as follows: a tidal volume of 4–6 ml/kg; a PEEP of 5 cm H 2 O, an FiO 2 of 0.4–0.5, an inspiratory-expiratory ratio of 1:2, and the respiratory rate was adjusted to maintain the ETCO 2 between 235–45 mmHg. Intraoperative manipulative lung resuscitation was performed, with 15–20 seconds of lung resuscitation under a continuous positive airway pressure of 30 cm H₂O (two-lung ventilation) or 20 cm H₂O (OLV). Anesthesia was maintained by the intravenous infusion of propofol (0.03–0.05 µg/kg/min) and remifentanil (0.1–0.2 µg/kg/min), with the intermittent administration of rocuronium bromide (0.15 mg/kg) to maintain muscle relaxation. Intraoperative warming was achieved by the use of heating blankets and infusion fluids, which helped to maintain the patient's body temperature. Postoperative analgesia was achieved by the administration of a patient-controlled intravenous analgesia regimen comprising a drug formulation of sufentanil (100 µg), dextromethorphan (100 µg) and azasetron hydrochloride (40mg) diluted to 100ml of saline and infused continuously at 2ml/h for 48 hours. The operation lasted for a total of 250 minutes, and was successfully completed. Throughout the operation, the patient's vital signs remained stable. Following the removal of the bronchial blocker, the tracheotomy catheter was retained and the patient was transferred to the ICU for transitional treatment off the ventilator. Following the surgical procedure, the patient was transferred to the medical oncology department for further chemotherapy. The patient was monitored for 3 years without significant adverse effects. During this period, he was hospitalized for heel fracture surgery. This case report was published with the patient's written and informed consent. Discussion and Conclusion The management of anesthesia is a crucial aspect of radical esophageal cancer surgery. One-lung ventilation (OLV) represents a pivotal technique in anesthetic airway management, offering the surgeon enhanced surgical vision and operating space. In light of the specific circumstances and surgical requirements of each patient, an anesthesiologist may find it necessary to adapt the OLV strategy. A comprehensive preoperative airway assessment enables the development of an individualized anesthesia plan, which ensures the patient's ventilation and oxygenation during surgery [8]. It is the responsibility of anesthesiologists to anticipate and manage any potential airway issues in order to enhance patient safety and surgical success, as well as to provide a wider range of tools and options for clinical practice [9, 10]. Through systematic evaluation and rational management, the risks associated with airway management can be significantly reduced, thereby improving the overall prognosis of the patient [11, 12]. The human esophagus and airway structures are in close proximity to one another, and in certain instances, such as when esophageal tumors result in airway obstruction, tracheal stenting may be indicated [13]. The patient described herein presented with a unique preoperative condition of tracheotomy; this posed a specific challenge for the anesthetic team. The medical team was required to make a joint decision regarding the implementation of anesthesia in light of these special airway conditions. Consequently, prior to the administration of anesthesia, a suitable OLV plan should be selected, and a range of airway management devices that may be required should be prepared in order to minimize the risk of airway injury and inadequate ventilation [14]. Furthermore, the incompatibility between the metal tracheal tube and the threaded tube interface on the anesthetic machine necessitates the replacement of patients with metal tracheal tubes with a tracheal tube that matches the anesthesia machine prior to anesthesia surgery. When replacing the tracheal tube, it is imperative to ensure that the airway and tube are free of secretions to prevent choking and obstruction. Appropriate sedation can be administered during the operation to ensure patient comfort. In clinical practice, the double-lumen bronchial catheter is the most commonly used tool for OLV. However, the hard material and thicker outer diameter of this particular catheter are prone to cause damage to the vocal cords and airway mucosa during intubation and extubation, thus leading to complications such as sore throat and hoarseness [15]. Another technique used for OLV is the use of a bronchial blocker with a single-lumen tracheal tube. This has the advantage of a thinner diameter, thus making it easier to intubate, with a lower probability of mucosal injury to the vocal cords and airway than the double-lumen bronchial catheter. However, this thinner catheter is associated with a slower rate of intraoperative lung collapse and is less convenient for airway suction [16]. In the field of anesthesia, single-lumen catheters are also employed for OLV [17]. However, due to anatomical considerations, the angle between the lower edge of the right main bronchus and the longitudinal axis of the trachea is smaller, thus increasing the probability of gaining access to the right main bronchus [18]. However, this method is not without its drawbacks. One such drawback is the inconvenience of aspiration, which can be avoided by using a double-lumen catheter. Furthermore, the transition between one-lung and two-lung ventilation is more difficult with this method, thus necessitating a return to the main bronchus. In our case, the postoperative status of the patient following radical surgery for tongue root cancer, the retention of a tracheotomy catheter, and tracheal intubation through the mouth, presented significant risks and challenges. The placement of a double-lumen bronchial catheter via tracheotomy is a more traumatic and stressful procedure, and the depth of tracheal intubation is not easily controlled. Another alternative is the placement of a single-lumen catheter through the tracheotomy. However, the depth of a single-lumen catheter must be repeatedly adjusted during the transition between OLV and two-lung ventilation, which can also cause damage to the tracheotomy. In addition, dual-modal high-frequency superimposed jet ventilation equipment represents an effective and feasible alternative, although its major complications, including pneumatic pressure injuries, carbon dioxide retention, and inadequate humidification, should be considered [19]. It is also important for hospitals to consider the cost of expensive equipment when implementing new procedures. Following a comprehensive evaluation, we selected the bronchial occluder with tracheotomy catheter protocol. Prior to the surgical procedure, it was necessary to measure the dimensions of the trachea in order to gain a comprehensive understanding of the airway situation. This included the length of the trachea (from the level of the clavicle to the tracheal bifurcation), the cross-sectional area of the trachea (measured 5 cm above the rongeur), the cross-sectional area of the left and right main bronchi (measured 1 cm distal to the rongeur), and the lengths of the right and left main bronchi (measured from the opening to the first bifurcation). The lengths of the right and left main bronchus (measured from the opening to the first bifurcation), right and left subcrestal angle (defined as the angle between the tracheal axis and the lower outer edge of the proximal left and right main bronchus), and the subcrestal angle (the angle of the bifurcation of the trachea measured directly from the inferior aspect) were also recorded. Furthermore, it was necessary to ascertain the degree of right upper lobe variance in the patient; this is also important in determining the suitability of the bronchial blocker. A computed tomography (CT) scan of our patient revealed an angle of approximately 20.4° between the lower edge of the right main bronchus and the longitudinal axis of the trachea. In addition, the opening of the right upper lobe was 1.62 cm from the beginning of the right main bronchus (Figure 1B). These findings indicated that the bronchial blocker was suitable for this patient. Furthermore, the distance between the tracheotomy site and the beginning of the right main bronchus was measured by CT imaging, thus providing a reference for the depth required for placement of the bronchial occluder. Given that the bronchial occluder was positioned through the tracheotomy opening, its exposed portion was relatively long. It is of paramount importance to ensure that the catheter was adequately fixed during the procedure to prevent dislodgement due to positional changes. The bronchial occluder utilized in this case was a Coopdech occluder with a lumen situated in its center. A slight improvement was made to the design (Figure 2A) to enhance the efficacy of non-ventilated lung collapse and continuous positive air pressure (CPAP), which can mitigate the complications associated with lung collapse. Lung collapse is normally achieved by applying low-pressure suction (20 cm H₂O) through the suction lumen until the non-ventilated lung is sufficiently atrophied [20]. In our case, the implementation of CPAP was optimized, thus resulting in stable intraoperative oxygenation without desaturation (Figure 2B). During the surgical procedure, the removal of the tumor and the traction on the esophagus frequently resulted in alterations to the position of the bronchial blocker, thus necessitating readjustment facilitated by fiberoptic bronchoscopy. It is of particular importance to monitor the airway pressure and the partial pressure of end-tidal carbon dioxide (PETCO 2 ) intraoperatively, to not only reflect the change in the position of the bronchial occluder, but also the carbon dioxide retention. Intraoperatively, we monitored our patient's oxygen saturation (SpO 2 ) and performed arterial blood gas analysis to assess oxygenation status [21]. Given the propensity of intrathoracic surgery and the prolonged operation times to induce perioperative hypothermia, we employed nasopharyngeal temperature monitoring to track our patient's body temperature and utilized an air heating blanket and infusion thermometer to mitigate the temperature fluctuations associated with the surgical procedure. Given the propensity for hypotension during esophageal operations involving compression of the inferior vena cava (to reduce venous return), other large intrathoracic vessels, or cardiac recipients, it is crucial to maintain normovolemia. Furthermore, it is essential to have vasopressor/positive inotropic agents available to restore arterial blood pressure in the corpus cavernosum and blood flow to the esophageal anastomosis [22]. In light of the more traumatic and stressful nature of this type of surgery, we considered it prudent to transfer the patient to the ICU for further observation following surgery. We did this to prevent postoperative agitation and dramatic hemodynamic fluctuations. Although there is no clear and unified definition for early extubation after esophageal cancer surgery, and considering that our patient was post-tracheotomy, there were risks of pneumatic pressure injury, nosocomial acquired pneumonia, and reduced respiratory self-clearance. Therefore, the patient was extubated as early as possible after he recovered spontaneous respiration in the first hour postoperatively. The patient was followed up and returned to the ICU for further observation. The patient was followed-up for a total period of 3 consecutive years. During this time, he was admitted to the hospital for surgery to repair an accidental ankle fracture but did not experience any other related complications. Here, we presented the case of a post-tracheotomy patient undergoing anesthesia for radical surgery for esophageal cancer. Our intention was to describe a simple and effective airway management protocol via a bronchial occluder for patients undergoing OLV for associated surgery. Further case studies are now required to refine this protocol and provide a foundation for the clinical implementation of this protocol on a wider scale. Declarations Author Contribution Author ContributionsZ-H.X., K.C., R.S., Z-H.Z., Q-L.L. performed experiments, analyzed data, prepared figures, and wrote the manuscript. H-L.Z. edited the manuscript. Z-H.X. and H-L.Z. designed the study, supervised the work, and finalized the paper. All the authors have read and approved the paper. Acknowledgement The authors wish to thank all study participants, researchers, technicians, administrative staff, editors and reviewers who contributed to this study. References van der Wilk BJ, Eyck BM, Hofstetter WL, Ajani JA, Piessen G, Castoro C, Alfieri R, Kim JH, Kim SB, Furlong H et al : Chemoradiotherapy Followed by Active Surveillance Versus Standard Esophagectomy for Esophageal Cancer: A Systematic Review and Individual Patient Data Meta-analysis . Ann Surg 2022, 275 (3):467-476. Park M, Yoon S, Nam JS, Ahn HJ, Kim H, Kim HJ, Choi H, Kim HK, Blank RS, Yun SC et al : Driving pressure-guided ventilation and postoperative pulmonary complications in thoracic surgery: a multicentre randomised clinical trial . Br J Anaesth 2023, 130 (1):e106-e118. Jia H, Tan WF, Ma H, Cui Y: A novel method using a single lumen tube and extraluminal bronchial blocker for one-lung ventilation in severe tracheal stenosis: a case report . Ann Palliat Med 2021, 10 (1):749-753. Joe YE, Lee CY, Kim N, Lee K, Kang SJ, Oh YJ: Effect of permissive hypercarbia on lung oxygenation during one-lung ventilation and postoperative pulmonary complications in patients undergoing thoracic surgery: A prospective randomised controlled trial . Eur J Anaesthesiol 2023, 40 (9):691-698. Szamos K, Balla B, Paloczi B, Enyedi A, Sessler DI, Fulesdi B, Vegh T: One-lung ventilation with fixed and variable tidal volumes on oxygenation and pulmonary outcomes: A randomized trial . J Clin Anesth 2024, 95 :111465. Zhang S, Liu H, Cai H: Efficacy and Safety of Continuous Paravertebral Block after Minimally Invasive Radical Esophagectomy for Esophageal Cancer . Pain Res Manag 2020, 2020 :3105874. Young CC, Harris EM, Vacchiano C, Bodnar S, Bukowy B, Elliott RRD, Migliarese J, Ragains C, Trethewey B, Woodward A et al : Lung-protective ventilation for the surgical patient: international expert panel-based consensus recommendations . Br J Anaesth 2019, 123 (6):898-913. Spaeth J, Ott M, Karzai W, Grimm A, Wirth S, Schumann S, Loop T: Double-lumen tubes and auto-PEEP during one-lung ventilation . Br J Anaesth 2016, 116 (1):122-130. Edelman DA, Perkins EJ, Brewster DJ: Difficult airway management algorithms: a directed review . Anaesthesia 2019, 74 (9):1175-1185. Pedersen TH, Ueltschi F, Hornshaw T, Greif R, Theiler L, Huber M, Kleine-Brueggeney M: Optimisation of airway management strategies: a prospective before-and-after study on events related to airway management . Br J Anaesth 2021, 127 (5):798-806. Cumberworth A, Lewith H, Sud A, Jefferson H, Athanassoglou V, Pandit JJ: Major complications of airway management: a prospective multicentre observational study . Anaesthesia 2022, 77 (6):640-648. Roth D, Pace NL, Lee A, Hovhannisyan K, Warenits AM, Arrich J, Herkner H: Airway physical examination tests for detection of difficult airway management in apparently normal adult patients . Cochrane Database Syst Rev 2018, 5 (5):CD008874. Kim HS, Khemasuwan D, Diaz-Mendoza J, Mehta AC: Management of tracheo-oesophageal fistula in adults . Eur Respir Rev 2020, 29 (158). Apfelbaum JL, Hagberg CA, Connis RT, Abdelmalak BB, Agarkar M, Dutton RP, Fiadjoe JE, Greif R, Klock PA, Mercier D et al : 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway . Anesthesiology 2022, 136 (1):31-81. Chen Z, Jin Y, Lu G, Jin Y, Feng C, Zhao X: Preoperative Ultrasound-Guided Internal Branch Block of Superior Laryngeal Nerve Reduces Postoperative Sore Throat Caused by Double Lumen Endotracheal Intubation: A Randomized Trial . Anesth Analg 2023, 137 (6):1270-1278. Clayton-Smith A, Bennett K, Alston RP, Adams G, Brown G, Hawthorne T, Hu M, Sinclair A, Tan J: A Comparison of the Efficacy and Adverse Effects of Double-Lumen Endobronchial Tubes and Bronchial Blockers in Thoracic Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials . J Cardiothorac Vasc Anesth 2015, 29 (4):955-966. Campos JH: Lung isolation techniques for patients with difficult airway . Curr Opin Anaesthesiol 2010, 23 (1):12-17. Bussieres JS, Gingras M, Perron L, Somma J, Frenette M, Couture EJ, Moreault O, Lacasse Y: Right upper lobe anatomy revisited: a computed tomography scan study . Can J Anaesth 2019, 66 (7):813-819. Salim A, Martin M: High-frequency percussive ventilation . Crit Care Med 2005, 33 (3 Suppl):S241-245. Narayanaswamy M, McRae K, Slinger P, Dugas G, Kanellakos GW, Roscoe A, Lacroix M: Choosing a lung isolation device for thoracic surgery: a randomized trial of three bronchial blockers versus double-lumen tubes . Anesth Analg 2009, 108 (4):1097-1101. Shu J, Zhang K, Chen Y, Zhang H, Zou J, Tang Y, Dong J, Du Y: Using the capnogram to assess pulmonary perfusion during a lobectomy: case studies . J Clin Monit Comput 2019, 33 (6):1061-1064. Ishii K, Tsubosa Y, Mayanagi S, Inoue M, Haneda R: Tissue Oxygen Saturation during Gastric Tube Reconstruction with Cervical Anastomosis for Esophagectomy: A Case Series . J Invest Surg 2022, 35 (4):809-813. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6493687","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"registered-report","associatedPublications":[],"authors":[{"id":447185739,"identity":"73c0acca-b637-4f3c-94c5-653377f9f4a6","order_by":0,"name":"Zhen-Hua Xu","email":"","orcid":"","institution":"Affiliated Zhangjiagang Hospital of Soochow University","correspondingAuthor":false,"prefix":"","firstName":"Zhen-Hua","middleName":"","lastName":"Xu","suffix":""},{"id":447185740,"identity":"8aa13626-32c5-4a86-b45a-9851c87aaa9d","order_by":1,"name":"Kai Cao","email":"","orcid":"","institution":"Affiliated Zhangjiagang Hospital of Soochow University","correspondingAuthor":false,"prefix":"","firstName":"Kai","middleName":"","lastName":"Cao","suffix":""},{"id":447185741,"identity":"0caef971-80ab-4d7d-85a6-2893576993ac","order_by":2,"name":"Ren Sun","email":"","orcid":"","institution":"Affiliated Zhangjiagang Hospital of Soochow University","correspondingAuthor":false,"prefix":"","firstName":"Ren","middleName":"","lastName":"Sun","suffix":""},{"id":447185742,"identity":"4582e186-a800-4d53-b2b3-9d0855feaa58","order_by":3,"name":"Zhi-Hong Zhang","email":"","orcid":"","institution":"Affiliated Zhangjiagang Hospital of Soochow University","correspondingAuthor":false,"prefix":"","firstName":"Zhi-Hong","middleName":"","lastName":"Zhang","suffix":""},{"id":447185743,"identity":"729c364b-2b90-4563-8d8e-40adadb0c34e","order_by":4,"name":"Qiu-Lan Li","email":"","orcid":"","institution":"Affiliated Zhangjiagang Hospital of Soochow University","correspondingAuthor":false,"prefix":"","firstName":"Qiu-Lan","middleName":"","lastName":"Li","suffix":""},{"id":447185744,"identity":"879bd4ec-a621-4c7b-b85b-f564582e18f7","order_by":5,"name":"Hai-Long Zhang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8UlEQVRIiWNgGAWjYBACA3YGNhBd38/ewMDAA2IeIKSFGaKFcWbPAVK1bJiRQKQWc2b2Zw9+7qhlNpB8/kziTQ2DHN+NBMbPBXi0WDYzpBv2njnOZi6dYyY55xiDseSNBGbpGfgcdpjhmARv2zEey9k5bNI8bAyJG24ksDHz4NXC2Cb5t+2YhMHN48+kef4x1BOhhZlNmretxsDgBoMZkMGQYEBYCxubtGzbgQTJnhxjy7l9EoYzzzxslsar5Xj7M8m3bXUJ/OzHH954881Gnu948sHP+LRAwWEYQwKIGRsIa2BgqCNG0SgYBaNgFIxUAAACEUmTe+/NwwAAAABJRU5ErkJggg==","orcid":"","institution":"The Fourth Affiliated Hospital of Soochow University","correspondingAuthor":true,"prefix":"","firstName":"Hai-Long","middleName":"","lastName":"Zhang","suffix":""}],"badges":[],"createdAt":"2025-04-21 07:53:05","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6493687/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6493687/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":81963449,"identity":"b7ef0ceb-dd06-4552-a36a-9f479594f78a","added_by":"auto","created_at":"2025-05-05 11:18:59","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":3070130,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA\u003c/strong\u003e Computed tomography (CT) scan showing the patient's metal tracheostomy tube.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eB \u003c/strong\u003eSagittal reconstruction of the patient's lung CT.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6493687/v1/915fe60c46e3360a9fe26a93.png"},{"id":81963451,"identity":"f9ad0e34-35b4-49f7-8d31-cd107ae5f6fd","added_by":"auto","created_at":"2025-05-05 11:18:59","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":13396000,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA\u003c/strong\u003e Lung ventilation and assisted lung collapse device connected to a three-way valve at the end of a bronchial blocker. One side channel was connected to a negative pressure suction device, while the other was connected to a ventilation device.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e The bronchial blocker was successfully disposed of through the patient's tracheotomy.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6493687/v1/42de4025e7aca1ef9f334ae7.png"},{"id":81964625,"identity":"7ffc9df2-a9d1-4459-902c-b41140eaf979","added_by":"auto","created_at":"2025-05-05 11:27:05","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":17530072,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6493687/v1/7ded9567-8f78-4d07-8fac-98a10823d9ae.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Radical esophagectomy for esophageal cancer with a bronchial occluder placed within a tracheotomy trocar: a case report","fulltext":[{"header":"Background","content":"\u003cp\u003eEsophageal cancer is a common malignant tumor of the digestive tract that can be treated effectively in most cases by radical surgery [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. As a complex form of thoracic surgery, airway management during anesthesia for radical esophageal cancer surgery is a crucial link in ensuring patient safety and improving the surgical success rate [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. One-lung ventilation (OLV) is a commonly employed anesthetic technique for airway management during this procedure; the object of this technique is to ensure a clear surgical field and reduce intraoperative contamination. For patients who have undergone a tracheotomy and require OLV for procedures such as lung or esophagus surgery, the management of this complex situation becomes far more challenging [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The selection of appropriate airway management methods can help to minimize complications during OLV after tracheotomy [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In this report, we present the case of a postoperative patient who underwent a radical esophagectomy for carcinoma of the root of the tongue and experienced general anesthesia with a bronchial occluder placed through his retained tracheotomy trocar. This strategy resulted in a smooth and safe radical esophagectomy for carcinoma of the root of the esophagus. Herein, we discuss the anesthetic management of this patient, focusing particularly on the OLV strategy.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eThe patient was a 68-year-old male who presented to our hospital with a choking sensation while eating. The patient weighed 64 kg and was 165 cm in height. The patient had been diagnosed with cancer of the tongue root 2 years ago, following the development of tongue pain on the right side and ulcers on the floor of the mouth. He underwent a double neck clearance procedure, involving removal of the collar and neck of the floor of the mouth, in addition to a left anterolateral femoral flap repair and tracheotomy. Pathological analysis indicated that the squamous cell carcinoma of the mucous membrane of the floor of the mouth was of grade I-II, with the tumor invading the nerves. Post-surgery, he was subsequently treated with 30 cycles of local radiotherapy. However, the patient's choking symptoms had exacerbated and he was only able to consume a minimal amount of fluid. A positron emission tomography-computed tomography (PET-CT) scan revealed that the local wall of the lower part of the esophagus was irregularly thickened with local narrowing of the lumen; in addition, there was a marked elevation in the uptake of fluorodeoxyglucose (FDG). Gastroscopy revealed an irregular neoplasm that was located 38 cm from the central incisors, which exhibited brittleness and was prone to bleeding. Pathological analysis of biopsy specimens indicated the presence of squamous cell carcinoma. The patient's cardiopulmonary function was satisfactory, and a two-incision radical esophagectomy for esophageal cancer was planned under general anesthesia.\u003c/p\u003e\n\u003cp\u003eThe patient was placed in a tracheotomy state and was retained with a metal cannula (size 7) in place (Figure 1A); airway patency was normal. Routine airway care was provided on the ward, and no yellow sputum or fever was observed. A reconstruction of the patient's chest CT (sagittal) was performed to confirm the absence of variations in the right main bronchial opening in the right upper lobe. In addition, the length of the right main bronchus was measured to ensure the suitability of the bronchial occluder.\u003c/p\u003e\n\u003cp\u003eOnce the patient was admitted to the operating room, various vital signs were monitored, including electrocardiography, pulse oximetry, and non-invasive blood pressure monitoring. Peripheral venous access was established, and 64 µg of dextromethorphan was injected intravenously over a 10-minute period (concentration: 4 µg/ml). Following sedation, the patient was suctioned, the airway was cleared, and the tracheotomy metal trocar was replaced with a tracheotomy plastic trocar to match the anesthesia machine. Prior to the administration of anesthesia, an outdated and discarded tracheotomy plastic cannula and bronchial sealer were utilized for demonstration and initial testing. Following the induction of anesthesia, we proceeded to cannulate the right radial artery for the purpose of monitoring arterial blood pressure and blood gas analysis. In addition, we performed ultrasound-guided cannulation of the right subclavian vein in order to establish central venous access. Prior to the induction of anesthesia, a paravertebral nerve block was performed at the T5-T6 gap level under ultrasound guidance, and 20 ml of 0.3% ropivacaine was injected to provide analgesia [6]. The induction of general anesthesia involved the intravenous administration of midazolam (0.04 mg/kg), 1% isoproterenol (20 mg/kg), sufentanil (0.3 µg/kg), and rocuronium bromide (0.6 mg/kg). As the patient's respiration gradually declined, the respiratory circuit of the anesthesia machine was connected and the mode of ventilation was transitioned from assisted to controlled. The bronchial blocker was then placed from the opening of the airway catheter to the opening of the right main trachea under the guidance of a visual fiberoptic bronchoscope; this was then fixed in place. Once the fiberoptic bronchoscope had been removed, a stethoscope was used once more to auscultate both lungs in order to confirm the location of the bronchial occluder and its sealing effect. Intraoperatively, the bispectral index (BIS) and nasopharyngeal temperature were monitored.\u003c/p\u003e\n\u003cp\u003eThe intraoperative mechanical ventilation protocol was derived from the Expert Consensus on Lung Protective Ventilation in Surgical Patients, published in the British Journal of Anesthesiology in 2019 [7]. The mechanical ventilation parameters employed during two-lung ventilation were as follows: a tidal volume (TV) of 8 ml/kg (predicted body weight), a positive end-expiratory pressure (PEEP) of 5 cm H₂O, an oxygenation index (FiO₂) of 0.5–0.8, and an inspiratory-to-expiratory ratio of 1:2; in addition, the respiratory rate was adjusted to maintain an end-expiratory partial pressure of carbon dioxide (ETCO₂) between 35–45 mmHg. The parameters used during one-lung ventilation were as follows: a tidal volume of 4–6 ml/kg; a PEEP of 5 cm H\u003csub\u003e2\u003c/sub\u003eO, an FiO\u003csub\u003e2\u003c/sub\u003e of 0.4–0.5, an inspiratory-expiratory ratio of 1:2, and the respiratory rate was adjusted to maintain the ETCO\u003csub\u003e2\u003c/sub\u003e between 235–45 mmHg. Intraoperative manipulative lung resuscitation was performed, with 15–20 seconds of lung resuscitation under a continuous positive airway pressure of 30 cm H₂O (two-lung ventilation) or 20 cm H₂O (OLV). Anesthesia was maintained by the intravenous infusion of propofol (0.03–0.05 µg/kg/min) and remifentanil (0.1–0.2 µg/kg/min), with the intermittent administration of rocuronium bromide (0.15 mg/kg) to maintain muscle relaxation. Intraoperative warming was achieved by the use of heating blankets and infusion fluids, which helped to maintain the patient's body temperature. Postoperative analgesia was achieved by the administration of a patient-controlled intravenous analgesia regimen comprising a drug formulation of sufentanil (100 µg), dextromethorphan (100 µg) and azasetron hydrochloride (40mg) diluted to 100ml of saline and infused continuously at 2ml/h for 48 hours.\u003c/p\u003e\n\u003cp\u003eThe operation lasted for a total of 250 minutes, and was successfully completed. Throughout the operation, the patient's vital signs remained stable. Following the removal of the bronchial blocker, the tracheotomy catheter was retained and the patient was transferred to the ICU for transitional treatment off the ventilator. Following the surgical procedure, the patient was transferred to the medical oncology department for further chemotherapy. The patient was monitored for 3 years without significant adverse effects. During this period, he was hospitalized for heel fracture surgery. This case report was published with the patient's written and informed consent.\u003c/p\u003e"},{"header":"Discussion and Conclusion ","content":"\u003cp\u003eThe management of anesthesia is a crucial aspect of radical esophageal cancer surgery. One-lung ventilation (OLV) represents a pivotal technique in anesthetic airway management, offering the surgeon enhanced surgical vision and operating space. In light of the specific circumstances and surgical requirements of each patient, an anesthesiologist may find it necessary to adapt the OLV strategy. A comprehensive preoperative airway assessment enables the development of an individualized anesthesia plan, which ensures the patient's ventilation and oxygenation during surgery [8].\u003c/p\u003e\n\u003cp\u003eIt is the responsibility of anesthesiologists to anticipate and manage any potential airway issues in order to enhance patient safety and surgical success, as well as to provide a wider range of tools and options for clinical practice [9, 10]. Through systematic evaluation and rational management, the risks associated with airway management can be significantly reduced, thereby improving the overall prognosis of the patient [11, 12].\u003c/p\u003e\n\u003cp\u003eThe human esophagus and airway structures are in close proximity to one another, and in certain instances, such as when esophageal tumors result in airway obstruction, tracheal stenting may be indicated [13]. The patient described herein presented with a unique preoperative condition of tracheotomy; this posed a specific challenge for the anesthetic team. The medical team was required to make a joint decision regarding the implementation of anesthesia in light of these special airway conditions. Consequently, prior to the administration of anesthesia, a suitable OLV plan should be selected, and a range of airway management devices that may be required should be prepared in order to minimize the risk of airway injury and inadequate ventilation [14]. Furthermore, the incompatibility between the metal tracheal tube and the threaded tube interface on the anesthetic machine necessitates the replacement of patients with metal tracheal tubes with a tracheal tube that matches the anesthesia machine prior to anesthesia surgery. When replacing the tracheal tube, it is imperative to ensure that the airway and tube are free of secretions to prevent choking and obstruction. Appropriate sedation can be administered during the operation to ensure patient comfort.\u003c/p\u003e\n\u003cp\u003eIn clinical practice, the double-lumen bronchial catheter is the most commonly used tool for OLV. However, the hard material and thicker outer diameter of this particular catheter are prone to cause damage to the vocal cords and airway mucosa during intubation and extubation, thus leading to complications such as sore throat and hoarseness [15]. Another technique used for OLV is the use of a bronchial blocker with a single-lumen tracheal tube. This has the advantage of a thinner diameter, thus making it easier to intubate, with a lower probability of mucosal injury to the vocal cords and airway than the double-lumen bronchial catheter. However, this thinner catheter is associated with a slower rate of intraoperative lung collapse and is less convenient for airway suction [16]. In the field of anesthesia, single-lumen catheters are also employed for OLV [17]. However, due to anatomical considerations, the angle between the lower edge of the right main bronchus and the longitudinal axis of the trachea is smaller, thus increasing the probability of gaining access to the right main bronchus [18]. However, this method is not without its drawbacks. One such drawback is the inconvenience of aspiration, which can be avoided by using a double-lumen catheter. Furthermore, the transition between one-lung and two-lung ventilation is more difficult with this method, thus necessitating a return to the main bronchus.\u003c/p\u003e\n\u003cp\u003eIn our case, the postoperative status of the patient following radical surgery for tongue root cancer, the retention of a tracheotomy catheter, and tracheal intubation through the mouth, presented significant risks and challenges. The placement of a double-lumen bronchial catheter via tracheotomy is a more traumatic and stressful procedure, and the depth of tracheal intubation is not easily controlled. Another alternative is the placement of a single-lumen catheter through the tracheotomy. However, the depth of a single-lumen catheter must be repeatedly adjusted during the transition between OLV and two-lung ventilation, which can also cause damage to the tracheotomy. In addition, dual-modal high-frequency superimposed jet ventilation equipment represents an effective and feasible alternative, although its major complications, including pneumatic pressure injuries, carbon dioxide retention, and inadequate humidification, should be considered [19]. It is also important for hospitals to consider the cost of expensive equipment when implementing new procedures.\u003c/p\u003e\n\u003cp\u003eFollowing a comprehensive evaluation, we selected the bronchial occluder with tracheotomy catheter protocol. Prior to the surgical procedure, it was necessary to measure the dimensions of the trachea in order to gain a comprehensive understanding of the airway situation. This included the length of the trachea (from the level of the clavicle to the tracheal bifurcation), the cross-sectional area of the trachea (measured 5 cm above the rongeur), the cross-sectional area of the left and right main bronchi (measured 1 cm distal to the rongeur), and the lengths of the right and left main bronchi (measured from the opening to the first bifurcation). The lengths of the right and left main bronchus (measured from the opening to the first bifurcation), right and left subcrestal angle (defined as the angle between the tracheal axis and the lower outer edge of the proximal left and right main bronchus), and the subcrestal angle (the angle of the bifurcation of the trachea measured directly from the inferior aspect) were also recorded. Furthermore, it was necessary to ascertain the degree of right upper lobe variance in the patient; this is also important in determining the suitability of the bronchial blocker. A computed tomography (CT) scan of our patient revealed an angle of approximately 20.4° between the lower edge of the right main bronchus and the longitudinal axis of the trachea. In addition, the opening of the right upper lobe was 1.62 cm from the beginning of the right main bronchus (Figure 1B). These findings indicated that the bronchial blocker was suitable for this patient. Furthermore, the distance between the tracheotomy site and the beginning of the right main bronchus was measured by CT imaging, thus providing a reference for the depth required for placement of the bronchial occluder.\u003c/p\u003e\n\u003cp\u003eGiven that the bronchial occluder was positioned through the tracheotomy opening, its exposed portion was relatively long. It is of paramount importance to ensure that the catheter was adequately fixed during the procedure to prevent dislodgement due to positional changes. The bronchial occluder utilized in this case was a Coopdech occluder with a lumen situated in its center. A slight improvement was made to the design (Figure 2A) to enhance the efficacy of non-ventilated lung collapse and continuous positive air pressure (CPAP), which can mitigate the complications associated with lung collapse. Lung collapse is normally achieved by applying low-pressure suction (20 cm H₂O) through the suction lumen until the non-ventilated lung is sufficiently atrophied [20]. In our case, the implementation of CPAP was optimized, thus resulting in stable intraoperative oxygenation without desaturation (Figure 2B).\u003c/p\u003e\n\u003cp\u003eDuring the surgical procedure, the removal of the tumor and the traction on the esophagus frequently resulted in alterations to the position of the bronchial blocker, thus necessitating readjustment facilitated by fiberoptic bronchoscopy. It is of particular importance to monitor the airway pressure and the partial pressure of end-tidal carbon dioxide (PETCO\u003csub\u003e2\u003c/sub\u003e) intraoperatively, to not only reflect the change in the position of the bronchial occluder, but also the carbon dioxide retention. Intraoperatively, we monitored our patient's oxygen saturation (SpO\u003csub\u003e2\u003c/sub\u003e) and performed arterial blood gas analysis to assess oxygenation status [21]. Given the propensity of intrathoracic surgery and the prolonged operation times to induce perioperative hypothermia, we employed nasopharyngeal temperature monitoring to track our patient's body temperature and utilized an air heating blanket and infusion thermometer to mitigate the temperature fluctuations associated with the surgical procedure. Given the propensity for hypotension during esophageal operations involving compression of the inferior vena cava (to reduce venous return), other large intrathoracic vessels, or cardiac recipients, it is crucial to maintain normovolemia. Furthermore, it is essential to have vasopressor/positive inotropic agents available to restore arterial blood pressure in the corpus cavernosum and blood flow to the esophageal anastomosis [22].\u003c/p\u003e\n\u003cp\u003eIn light of the more traumatic and stressful nature of this type of surgery, we considered it prudent to transfer the patient to the ICU for further observation following surgery. We did this to prevent postoperative agitation and dramatic hemodynamic fluctuations. Although there is no clear and unified definition for early extubation after esophageal cancer surgery, and considering that our patient was post-tracheotomy, there were risks of pneumatic pressure injury, nosocomial acquired pneumonia, and reduced respiratory self-clearance. Therefore, the patient was extubated as early as possible after he recovered spontaneous respiration in the first hour postoperatively. The patient was followed up and returned to the ICU for further observation. The patient was followed-up for a total period of 3 consecutive years. During this time, he was admitted to the hospital for surgery to repair an accidental ankle fracture but did not experience any other related complications.\u003c/p\u003e\n\u003cp\u003eHere, we presented the case of a post-tracheotomy patient undergoing anesthesia for radical surgery for esophageal cancer. Our intention was to describe a simple and effective airway management protocol via a bronchial occluder for patients undergoing OLV for associated surgery. Further case studies are now required to refine this protocol and provide a foundation for the clinical implementation of this protocol on a wider scale.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAuthor ContributionsZ-H.X., K.C., R.S., Z-H.Z., Q-L.L. performed experiments, analyzed data, prepared figures, and wrote the manuscript. H-L.Z. edited the manuscript. Z-H.X. and H-L.Z. designed the study, supervised the work, and finalized the paper. All the authors have read and approved the paper.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors wish to thank all study participants, researchers, technicians, administrative staff, editors and reviewers who contributed to this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003evan der Wilk BJ, Eyck BM, Hofstetter WL, Ajani JA, Piessen G, Castoro C, Alfieri R, Kim JH, Kim SB, Furlong H\u003cem\u003e\u0026nbsp;et al\u003c/em\u003e: \u003cstrong\u003eChemoradiotherapy Followed by Active Surveillance Versus Standard Esophagectomy for Esophageal Cancer: A Systematic Review and Individual Patient Data Meta-analysis\u003c/strong\u003e. \u003cem\u003eAnn Surg\u0026nbsp;\u003c/em\u003e2022, \u003cstrong\u003e275\u003c/strong\u003e(3):467-476.\u003c/li\u003e\n \u003cli\u003ePark M, Yoon S, Nam JS, Ahn HJ, Kim H, Kim HJ, Choi H, Kim HK, Blank RS, Yun SC\u003cem\u003e\u0026nbsp;et al\u003c/em\u003e: \u003cstrong\u003eDriving pressure-guided ventilation and postoperative pulmonary complications in thoracic surgery: a multicentre randomised clinical trial\u003c/strong\u003e. \u003cem\u003eBr J Anaesth\u0026nbsp;\u003c/em\u003e2023, \u003cstrong\u003e130\u003c/strong\u003e(1):e106-e118.\u003c/li\u003e\n \u003cli\u003eJia H, Tan WF, Ma H, Cui Y: \u003cstrong\u003eA novel method using a single lumen tube and extraluminal bronchial blocker for one-lung ventilation in severe tracheal stenosis: a case report\u003c/strong\u003e. \u003cem\u003eAnn Palliat Med\u0026nbsp;\u003c/em\u003e2021, \u003cstrong\u003e10\u003c/strong\u003e(1):749-753.\u003c/li\u003e\n \u003cli\u003eJoe YE, Lee CY, Kim N, Lee K, Kang SJ, Oh YJ: \u003cstrong\u003eEffect of permissive hypercarbia on lung oxygenation during one-lung ventilation and postoperative pulmonary complications in patients undergoing thoracic surgery: A prospective randomised controlled trial\u003c/strong\u003e. \u003cem\u003eEur J Anaesthesiol\u0026nbsp;\u003c/em\u003e2023, \u003cstrong\u003e40\u003c/strong\u003e(9):691-698.\u003c/li\u003e\n \u003cli\u003eSzamos K, Balla B, Paloczi B, Enyedi A, Sessler DI, Fulesdi B, Vegh T: \u003cstrong\u003eOne-lung ventilation with fixed and variable tidal volumes on oxygenation and pulmonary outcomes: A randomized trial\u003c/strong\u003e. \u003cem\u003eJ Clin Anesth\u0026nbsp;\u003c/em\u003e2024, \u003cstrong\u003e95\u003c/strong\u003e:111465.\u003c/li\u003e\n \u003cli\u003eZhang S, Liu H, Cai H: \u003cstrong\u003eEfficacy and Safety of Continuous Paravertebral Block after Minimally Invasive Radical Esophagectomy for Esophageal Cancer\u003c/strong\u003e. \u003cem\u003ePain Res Manag\u0026nbsp;\u003c/em\u003e2020, \u003cstrong\u003e2020\u003c/strong\u003e:3105874.\u003c/li\u003e\n \u003cli\u003eYoung CC, Harris EM, Vacchiano C, Bodnar S, Bukowy B, Elliott RRD, Migliarese J, Ragains C, Trethewey B, Woodward A\u003cem\u003e\u0026nbsp;et al\u003c/em\u003e: \u003cstrong\u003eLung-protective ventilation for the surgical patient: international expert panel-based consensus recommendations\u003c/strong\u003e. \u003cem\u003eBr J Anaesth\u0026nbsp;\u003c/em\u003e2019, \u003cstrong\u003e123\u003c/strong\u003e(6):898-913.\u003c/li\u003e\n \u003cli\u003eSpaeth J, Ott M, Karzai W, Grimm A, Wirth S, Schumann S, Loop T: \u003cstrong\u003eDouble-lumen tubes and auto-PEEP during one-lung ventilation\u003c/strong\u003e. \u003cem\u003eBr J Anaesth\u0026nbsp;\u003c/em\u003e2016, \u003cstrong\u003e116\u003c/strong\u003e(1):122-130.\u003c/li\u003e\n \u003cli\u003eEdelman DA, Perkins EJ, Brewster DJ: \u003cstrong\u003eDifficult airway management algorithms: a directed review\u003c/strong\u003e. \u003cem\u003eAnaesthesia\u0026nbsp;\u003c/em\u003e2019, \u003cstrong\u003e74\u003c/strong\u003e(9):1175-1185.\u003c/li\u003e\n \u003cli\u003ePedersen TH, Ueltschi F, Hornshaw T, Greif R, Theiler L, Huber M, Kleine-Brueggeney M: \u003cstrong\u003eOptimisation of airway management strategies: a prospective before-and-after study on events related to airway management\u003c/strong\u003e. \u003cem\u003eBr J Anaesth\u0026nbsp;\u003c/em\u003e2021, \u003cstrong\u003e127\u003c/strong\u003e(5):798-806.\u003c/li\u003e\n \u003cli\u003eCumberworth A, Lewith H, Sud A, Jefferson H, Athanassoglou V, Pandit JJ: \u003cstrong\u003eMajor complications of airway management: a prospective multicentre observational study\u003c/strong\u003e. \u003cem\u003eAnaesthesia\u0026nbsp;\u003c/em\u003e2022, \u003cstrong\u003e77\u003c/strong\u003e(6):640-648.\u003c/li\u003e\n \u003cli\u003eRoth D, Pace NL, Lee A, Hovhannisyan K, Warenits AM, Arrich J, Herkner H: \u003cstrong\u003eAirway physical examination tests for detection of difficult airway management in apparently normal adult patients\u003c/strong\u003e. \u003cem\u003eCochrane Database Syst Rev\u0026nbsp;\u003c/em\u003e2018, \u003cstrong\u003e5\u003c/strong\u003e(5):CD008874.\u003c/li\u003e\n \u003cli\u003eKim HS, Khemasuwan D, Diaz-Mendoza J, Mehta AC: \u003cstrong\u003eManagement of tracheo-oesophageal fistula in adults\u003c/strong\u003e. \u003cem\u003eEur Respir Rev\u0026nbsp;\u003c/em\u003e2020, \u003cstrong\u003e29\u003c/strong\u003e(158).\u003c/li\u003e\n \u003cli\u003eApfelbaum JL, Hagberg CA, Connis RT, Abdelmalak BB, Agarkar M, Dutton RP, Fiadjoe JE, Greif R, Klock PA, Mercier D\u003cem\u003e\u0026nbsp;et al\u003c/em\u003e: \u003cstrong\u003e2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway\u003c/strong\u003e. \u003cem\u003eAnesthesiology\u0026nbsp;\u003c/em\u003e2022, \u003cstrong\u003e136\u003c/strong\u003e(1):31-81.\u003c/li\u003e\n \u003cli\u003eChen Z, Jin Y, Lu G, Jin Y, Feng C, Zhao X: \u003cstrong\u003ePreoperative Ultrasound-Guided Internal Branch Block of Superior Laryngeal Nerve Reduces Postoperative Sore Throat Caused by Double Lumen Endotracheal Intubation: A Randomized Trial\u003c/strong\u003e. \u003cem\u003eAnesth Analg\u0026nbsp;\u003c/em\u003e2023, \u003cstrong\u003e137\u003c/strong\u003e(6):1270-1278.\u003c/li\u003e\n \u003cli\u003eClayton-Smith A, Bennett K, Alston RP, Adams G, Brown G, Hawthorne T, Hu M, Sinclair A, Tan J: \u003cstrong\u003eA Comparison of the Efficacy and Adverse Effects of Double-Lumen Endobronchial Tubes and Bronchial Blockers in Thoracic Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials\u003c/strong\u003e. \u003cem\u003eJ Cardiothorac Vasc Anesth\u0026nbsp;\u003c/em\u003e2015, \u003cstrong\u003e29\u003c/strong\u003e(4):955-966.\u003c/li\u003e\n \u003cli\u003eCampos JH: \u003cstrong\u003eLung isolation techniques for patients with difficult airway\u003c/strong\u003e. \u003cem\u003eCurr Opin Anaesthesiol\u0026nbsp;\u003c/em\u003e2010, \u003cstrong\u003e23\u003c/strong\u003e(1):12-17.\u003c/li\u003e\n \u003cli\u003eBussieres JS, Gingras M, Perron L, Somma J, Frenette M, Couture EJ, Moreault O, Lacasse Y: \u003cstrong\u003eRight upper lobe anatomy revisited: a computed tomography scan study\u003c/strong\u003e. \u003cem\u003eCan J Anaesth\u0026nbsp;\u003c/em\u003e2019, \u003cstrong\u003e66\u003c/strong\u003e(7):813-819.\u003c/li\u003e\n \u003cli\u003eSalim A, Martin M: \u003cstrong\u003eHigh-frequency percussive ventilation\u003c/strong\u003e. \u003cem\u003eCrit Care Med\u0026nbsp;\u003c/em\u003e2005, \u003cstrong\u003e33\u003c/strong\u003e(3 Suppl):S241-245.\u003c/li\u003e\n \u003cli\u003eNarayanaswamy M, McRae K, Slinger P, Dugas G, Kanellakos GW, Roscoe A, Lacroix M: \u003cstrong\u003eChoosing a lung isolation device for thoracic surgery: a randomized trial of three bronchial blockers versus double-lumen tubes\u003c/strong\u003e. \u003cem\u003eAnesth Analg\u0026nbsp;\u003c/em\u003e2009, \u003cstrong\u003e108\u003c/strong\u003e(4):1097-1101.\u003c/li\u003e\n \u003cli\u003eShu J, Zhang K, Chen Y, Zhang H, Zou J, Tang Y, Dong J, Du Y: \u003cstrong\u003eUsing the capnogram to assess pulmonary perfusion during a lobectomy: case studies\u003c/strong\u003e. \u003cem\u003eJ Clin Monit Comput\u0026nbsp;\u003c/em\u003e2019, \u003cstrong\u003e33\u003c/strong\u003e(6):1061-1064.\u003c/li\u003e\n \u003cli\u003eIshii K, Tsubosa Y, Mayanagi S, Inoue M, Haneda R: \u003cstrong\u003eTissue Oxygen Saturation during Gastric Tube Reconstruction with Cervical Anastomosis for Esophagectomy: A Case Series\u003c/strong\u003e. \u003cem\u003eJ Invest Surg\u0026nbsp;\u003c/em\u003e2022, \u003cstrong\u003e35\u003c/strong\u003e(4):809-813.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Esophageal cancer, Tracheotomy, Bronchial occluder, One-lung ventilation","lastPublishedDoi":"10.21203/rs.3.rs-6493687/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6493687/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Radical surgery for esophageal cancer frequently necessitates the use of pulmonary isolation techniques during general anesthesia. However, the airway management of patients with esophageal cancer who undergo this procedure with a combined tracheotomy is undoubtedly challenging and difficult for anesthesiologists. In this case report, we describe the case of a patient who was retained with a tracheotomy metal cannula in place following radical surgery for tongue root cancer. The anesthetic management strategy used for this patient provides a new concept for anesthesiologists to implement lung isolation techniques when encountering this type of patient to improve airway management.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase Presentation:\u003c/strong\u003e The patient was a 68-year-old male who had experienced a choking sensation for over a month without any discernible triggers. Two years previously, he underwent a radical surgical procedure and tracheotomy for cancer of the tongue root; this was followed by postoperative radiotherapy and the insertion of a tracheotomy metal cannula. Gastroscopy revealed an irregular neoplasm located 38 cm from the central incisor, and a biopsy indicated squamous cell carcinoma. Based on these findings, the patient was diagnosed with esophageal malignancy. Radical surgery for esophageal cancer was planned under general anesthesia. Following the surgical procedure, the patient demonstrated a favorable recovery trajectory following a series of adjuvant therapies. The patient was subsequently discharged from the Department of Medical Oncology following the completion of related treatments.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e The placement of a bronchial occluder into the tracheotomy tube represents a simple, effective, and less invasive method of airway management when performing pulmonary isolation techniques for tracheotomized patients under general anesthesia. However, the safety and standardization of this method still require validation through further clinical practice.\u003c/p\u003e","manuscriptTitle":"Radical esophagectomy for esophageal cancer with a bronchial occluder placed within a tracheotomy trocar: a case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-05 11:18:54","doi":"10.21203/rs.3.rs-6493687/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d8956044-54b7-4a4f-bba4-5a2f571fe9d8","owner":[],"postedDate":"May 5th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-05-29T13:08:15+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-05 11:18:54","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6493687","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6493687","identity":"rs-6493687","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}