Anesthesia for feeding jejunostomy in a case of difficult airway: A novel approach.

Sir,

Securing airway in advanced head and neck cancer patient has always been a challenge for anesthesiologist. Feeding jejunostomy is a palliative surgery performed in such patients to ensure adequate enteral nutrition[1] Being an upper abdominal intraperitoneal surgery, it requires controlled ventilation under general anesthesia. However, in advanced cancer of hypopharynx extending into oropharynx and involving multiple neck nodes, intubation as well as tracheostomy for airway control is difficult; different techniques may need to be combined to avoid untoward consequences of loss of airway control. We have herein shared our experience of anesthetic management of one such case.

The patient was a 65-year-old elderly female patient, diagnosed as advanced metastatic carcinoma of hypopharynx involving oropharynx, prevertebral muscles, jugular, retropharyngeal, paratracheal, and mediastinal nodes with multiple vertebral metastasis. In view of advanced stage of disease, she had received palliative chemotherapy and was planned for feeding jejunostomy. On airway examination, mouth opening was adequate, but MP grade 4 and neck movement was restricted. Her records revealed that endoscopic jejunostomy failed because of oropharyngeal mass. Since general anesthesia was required and airway was difficult, it was planned to do awake fibreoptic bronchoscopy (FOB) and proceed further, but laryngeal opening could not be visualized. Because of multiple neck nodes, elective tracheostomy was also difficult. Therefore, after discussing it with the surgical team, it was planned that the patient should be provided dexmedetomidine infusion with bilateral transversus abdominis plane (TAP) block.

After securing intravenous line, monitors were attached and infusion of dexmedetomidine was started. After loading dose of 1 μg/kg over 10 min, maintenance dose of 0.4 μg/kg/h was continued. Humidified oxygen supplementation with face mask was done. Ultrasound-guided bilateral TAP blocks with 23 gauze spinal needle were given; 15 ml of 0.25% plain bupivacaine was injected on each side. After confirming the sensory level, surgery was started. The surgery lasted for 45 min and was completed without any complication.

TAP block is commonly used for postoperative analgesia in anterior wall abdominal surgery. In recent times, ultrasound-guided TAP block increased the success rate with reduction in complications.[23] Intraperitoneal surgery under TAP block always carries a risk of pain and pouting out of gut while handling it. Supplementation with opioid analgesics will reduce the visceral pain sensation, but may cause respiratory depression that will be lethal in our case. That is the reason we avoided opioid-based analgesics and used dexmedetomidine. Subarachnoid block was not feasible in our case because of multiple vertebral metastases. Thus, combining Dexmedetomidine with TAP block obviates the need for opioids by providing supplemental analgesia with sedation.

In summary, anterior abdominal wall surgery in patients with difficult airway can be done under regional (TAP) blocks with analgesic supplementation without handling airway. It also provides postoperative analgesia and reduces analgesic requirement.