{'fraction_non_alphanumeric': 0.020305781175346392, 'fraction_numerical': 0.00692785475394171, 'mean_word_length': 5.239940387481371, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Acute airway obstruction and tracheal laceration during gastrostomy placement in an infant with tracheoesophageal fistula.

This case report describes an unusual case of iatrogenic airway obstruction and tracheal laceration after placement of a gastrostomy catheter in an infant with esophageal atresia. A 2410-g male infant was delivered vaginally at 37 weeks’ gestation. When a feeding tube was to be passed, the tube was unable to be placed into the stomach through the esophagus. Esophageal atresia (Gross type C) was diagnosed, and on radiography, the tube was seen to be coiled in the upper esophagus in association with air in the intestine distal to the stomach. The day-old infant was scheduled for tracheoesophageal fistula repair. General anesthesia was induced with sevoflurane and oxygen, and the trachea was easily intubated. Fentanyl was administered for perioperative anesthesia. A gastrostomy catheter was inserted into the stomach to a depth of 25 cm through the abdominal and gastric walls. The guidewire was removed, and the balloon was inflated to anchor the tube. Shortly thereafter, no end-tidal CO2 was detected, the O2 saturation decreased to less than 70%, and he became bradycardiac. Cardiopulmonary resuscitation was initiated, and atropine and epinephrine were intravenously administered. Auscultation revealed absent breath sounds. Possibilities included displacement or obstruction of the endotracheal tube (ETT), pneumothorax, and equipment failure; each of these was eliminated as a cause. Mask ventilation was ineffective. A new ETT was tried, but it could not pass into the distal portion of the trachea. Pneumothorax was suspected, and the gastrostomy balloon was deflated, which facilitated ventilation and allowed the trachea to be intubated. The conclusion was that the catheter had been passed through the tracheoesophageal fistula, and asphyxia was caused by airway obstruction after inflation of the balloon in the trachea. The period of cardiopulmonary resuscitation was 13 minutes and was associated with bradycardia without asystole. When he was hemodynamically stable, the infant was placed on pressure-controlled ventilation. Hypoxia and hypercarbia were not seen on arterial blood gas analysis. He was positioned for a right thoracotomy. Bronchoscopy was performed through the 3.0-mm ETT. Insertion of the 2.2-mm-outerdiameter flexible bronchoscope revealed a small amount of clot in the trachea. Packing this area with absorbent gauze reduced air leakage. The gastrostomy balloon caused an airway obstruction and a tracheal laceration, which was in the membranous portion of the trachea 10 mm above the carina and was about 10 mm in length. It was successfully closed with sutures. The fistula, which communicated between the distal esophagus and right main bronchus, was repaired. The postoperative chest x-ray showed no subcutaneous emphysema or pneumomediastinum. Positive-pressure ventilation was well tolerated, and no air leak from the repaired laceration was seen. An anastomotic leak of the esophagus on postoperative day (POD) 3 caused tension pneumothorax that required bilateral chest tube placement. These tubes were removed at the bedside on POD 9. The infant was successfully extubated on POD 11. An esophagram on POD 26 revealed a severe esophageal cicatricial stricture and an underdeveloped angle of His. This underdeveloped angle might have contributed to the passage of the gastrostomy catheter into the trachea. Several operations were performed to balloon-dilate the esophageal stricture with no perioperative complications. The baby was discharged from the hospital with an intact neurologic status. The situation in this infant suggests that some procedure should be followed to ensure correct placement of the gastrostomy catheter. However, the 2 possibilities would be to use fluoroscopy or bronchoscopy, both of which carry disadvantages in young infants. Therefore, the awareness of the possibility of airway obstruction is the most important aspect in preventing this complication. Knowledge of the possibility of this iatrogenic injury should lead to prompt diagnosis and successful treatment of the problem.