A Leak Between Two Worlds: Anesthetic Management of an Acquired Adult Tracheoesophageal Fistula

ABSTRACT: Tracheoesophageal fistula (TEF) in adults is an uncommon but clinically significant condition that poses considerable challenges in anesthetic management. Most acquired cases are associated with prolonged mechanical ventilation, trauma, malignancy, or corrosive injury, with postintubation injury being a well-recognized etiology. We report a 29-year-old male who developed TEF following prolonged ventilatory support for traumatic brain injury. He presented with dysphagia, regurgitation, and intermittent vomiting. Chest computed tomography revealed chronic bronchitis, emphysema, and bilateral pneumonic changes with partial right lung consolidation. Pulmonary function testing showed moderate-to-severe restrictive ventilatory dysfunction. Esophagography confirmed a fistulous communication at the T4 level, with contrast entering the right bronchus. In view of the risk of gas leak through the fistula associated with pneumoperitoneum during laparoscopic surgery, an open surgical approach was planned. Anesthesia was induced with propofol and succinylcholine. To achieve one-lung ventilation and bypass the right-sided defect, a left-sided double-lumen tube was inserted under videolaryngoscopic guidance, and its position was confirmed using fiber-optic bronchoscopy. Anesthesia was maintained with sevoflurane, with strategies aimed at minimizing positive pressure-related complications. The intraoperative course remained stable without significant events. The patient was monitored postoperatively in the intensive care unit, and recovery was uneventful following confirmation of repair integrity. This case highlights the importance of meticulous airway and ventilation planning in TEF, emphasizing that fistula characteristics and underlying pulmonary status are critical determinants of anesthetic strategy.