Monitored anesthesia care combined with thoracic paravertebral block for percutaneous endoscopic gastrostomy: A case report

Abstract

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) in patients with concurrent esophageal and tracheal stents presents significant anesthetic challenges due to the risk of stent displacement during airway manipulation. The combination of monitored anesthesia care (MAC) and thoracic paravertebral block (TPVB) has been used in various surgical settings, but its application in this specific high-risk population remains rarely reported.

CASE SUMMARY

This case report describes the successful use of MAC combined with TPVB in a high-risk patient with both esophageal and tracheal stents undergoing PEG. Bilateral TPVB at T6 and T8 Levels using 0.33% ropivacaine (10 ml per injection point) was performed, followed by propofol and remifentanil titrated to maintain optimal sedation under Bispectral index monitoring. Spontaneous ventilation was maintained via a nasopharyngeal airway with capnography. The procedure was completed with stable hemodynamics and minimal pain, avoiding endotracheal intubation entirely.

CONCLUSION

This case demonstrates MAC combined with TPVB may be a safe anesthetic option for PEG in patients with dual stents.

Key Words: Percutaneous endoscopic gastrostomy; Monitored anesthesia care; Thoracic paravertebral block; Anesthesia management; Ropivacaine; Case report

Core Tip: This case is the first to describe the use of monitored anesthesia care combined with thoracic paravertebral block for percutaneous endoscopic gastrostomy in a patient with concurrent esophageal and tracheal stents. The technique avoided endotracheal intubation, minimized stent displacement risk, and provided adequate anesthesia with stable hemodynamics and fast recovery.

INTRODUCTION

Percutaneous endoscopic gastrostomy (PEG) is a minimally invasive procedure used to establish long-term enteral access in patients with impaired swallowing. Under endoscopic guidance, a feeding tube is inserted through the abdominal wall into the stomach[1].

Esophageal and tracheal stents are commonly used to maintain luminal patency in patients with advanced esophageal cancer complicated by tracheoesophageal fistula. However, these stents pose significant challenges for anesthesia management, particularly during airway manipulation, due to the risk of displacement[2].

Monitored anesthesia care (MAC) involves the administration of sedatives and analgesics under physiological and consciousness monitoring by an anesthesiologist, while preserving spontaneous ventilation[3]. Thoracic paravertebral block (TPVB) entails the injection of local anesthetic into the paravertebral space, producing unilateral somatic and sympathetic blockade. It is effective for anesthesia and analgesia in thoracic and abdominal surgeries. MAC combined with TPVB has been shown to reduce anesthetic requirements and associated complications in certain studies, such as in gastrectomy and breast cancer surgeries[4,5].

We report the successful application of MAC combined with TPVB in a high-risk patient with both esophageal and tracheal stents undergoing elective PEG. The concurrent presence of stents introduced specific challenges, including potential migration of the esophageal stent during PEG insertion and dislodgement of the tracheal stent during endotracheal intubation. This case illustrates the potential efficacy and safety of MAC combined with TPVB in such complex clinical scenarios.

CASE PRESENTATION

Chief complaints

A 42-year-old female presented with productive cough and exertional dyspnea for one year, which had worsened over the past month. She also reported progressive weight loss and difficulty in oral intake.

History of present illness

The patient (height 160 cm, weight 48 kg, body mass index 18.76 kg/m²) was diagnosed with esophageal carcinoma two years ago and had been receiving chemoradiotherapy. One year prior to admission, a tracheal stent was placed due to tumor-related bronchial stenosis. One month before admission, an esophageal stent was inserted because of a tracheoesophageal fistula. Due to progressive malnutrition and inadequate oral intake, PEG was planned for enteral nutrition support.

History of past illness

The patient had a two-year history of esophageal carcinoma without surgical resection, with tracheal stenting and esophageal stenting. She also had a history of carbapenem-resistant Pseudomonas aeruginosa pneumonia with left lung atelectasis. No hypertension, diabetes, or cardiac disorders were reported.

Personal and family history

The patient denied smoking or alcohol consumption. No family history of malignancies or other genetic disorders was reported.

Physical examination

The patient was frail but conscious, with vital signs: Blood pressure 119/70 mmHg, heart rate 73 bpm, respiratory rate 18/minute, and SpO₂ 98% on room air. Lung auscultation revealed decreased breath sounds in the left lower lobe, with no wheezing or crackles. Cardiac and abdominal examinations were unremarkable. American Society of Anesthesiologists physical status was III.

Laboratory examinations

Complete blood count and coagulation profile were normal. Liver and renal function tests were normal. Serum albumin was 29 g/L, reflecting poor nutrition.

Imaging examinations

Chest computed tomography confirmed the esophageal cancer lesion and appropriate positioning of both stents (Figure 1A). Left lung atelectasis with inflammatory changes was also noted. No stent migration or displacement was observed.

Figure 1 Computed tomography and ultrasound images. A: Showed dual stents and the esophageal cancer lesion orange arrow shows the tracheal stent; blue arrow shows the esophageal stent; B: Downward of the pleura after thoracic paravertebral block orange arrow shows the pleura; blue arrow shows the paravertebral space. TP: Transverse process.

MULTIDISCIPLINARY EXPERT CONSULTATION

A multidisciplinary team, including anesthesiologists, gastroenterologists, thoracic surgeons, and nutritionists, concluded that general anesthesia with endotracheal intubation carried a high risk of tracheal stent dislodgement, while esophageal stent migration could occur during PEG insertion. MAC combined with TPVB was selected as the primary anesthetic strategy, with endotracheal intubation reserved for emergency.

FINAL DIAGNOSIS

Esophageal carcinoma with tracheoesophageal fistula, tracheal and esophageal stent placement, carbapenem-resistant Pseudomonas aeruginosa pneumonia with left lung atelectasis, and progressive malnutrition.

TREATMENT

Anesthetic management

The procedure was performed in the supine position. Standard monitoring including non-invasive blood pressure, pulse oximetry, electrocardiography, and Bispectral index (BIS) monitoring were applied. Anesthesia was induced with intravenous sufentanil 10 ug and midazolam 1 mg. Under ultrasound guidance, bilateral TPVB was performed at T6 and T8 levels using 0.33% ropivacaine (10 mL per injection point). A convex ultrasound probe was used to visualize the transverse process and paravertebral space, and downward displacement of the pleura was observed after local anesthetic injection (Figure 1B). Sensory blockade was confirmed from T4 to T10. Sedation was maintained with propofol (3-4 mg/kg/hour) and remifentanil (0.05-0.1 μg/kg/minute), titrated to maintain BIS 60-80. A filtered nasopharyngeal airway (MEDIS, ID 7.0 mm) was inserted to facilitate supraglottic oxygen delivery and capnography monitoring (Figure 2). An endotracheal tube was kept available for emergency airway management.

Figure 2  The filtered nasopharyngeal airway during monitored anesthesia care combined with thoracic paravertebral block orange arrow shows the oxygen delivery tube, black arrow shows the capnography tube.

PEG insertion

Under endoscopic guidance, the PEG tube was advanced through the abdominal wall into the stomach. The procedure was completed successfully.

OUTCOME AND FOLLOW-UP

The procedure lasted 62 minutes with stable hemodynamics. Capnography confirmed adequate spontaneous ventilation throughout. PEG placement was successful and well-tolerated. An additional 5 μg of sufentanil was administered before completion. The patient awakened within 10 minutes with excellent pain control Visual Analogue Scale (VAS) 1. PEG feeding started on postoperative day 1. She was discharged after 23 days without any anesthesia-related complications. At nine-month follow-up, her nutritional status had improved with body mass index increased to 19.65 kg/m².

DISCUSSION

This case demonstrates the successful use of MAC combined with TPVB in a high-risk patient with dual esophageal and tracheal stents undergoing PEG. The anesthetic challenges included the risk of esophageal stent migration during the procedure and the contraindication to conventional endotracheal intubation due to the tracheal stent. Supine positioning further increased the risk of tongue obstruction compared to lateral decubitus position. MAC combined with TPVB minimized airway manipulation, reduced opioid requirements, and provided sufficient sedation and analgesia. Multidisciplinary coordination was essential. The surgeon carefully advanced the PEG tube to avoid stent displacement, while the anesthesiologist maintained an appropriate depth of sedation to prevent patient movement.

Advantages of MAC combined with TPVB

MAC has been shown to be safer than general endotracheal anesthesia for procedures such as endoscopic retrograde cholangiopancreatography (ERCP). A meta-analysis indicated reduced pulmonary complications during ERCP. PEG shares similarities with ERCP as both involve endoscopic manipulation within esophagus and stomach[6]. While general anesthesia can suppress pharyngeal and epiglottic reflexes, excessive sedation may lead to respiratory or neurological depression. Inadequate analgesia may need other analgesic regimens to compensate.

TPVB has well-established benefits in various surgical settings. In thoracic surgery, it provides superior analgesia compared to erector spinae plane block[7]. In elderly patients undergoing gastrectomy, bilateral T8 TPVB with 0.375% ropivacaine (20 mL per injection point) before incision reduced general anesthetic requirements and improved postoperative recovery[5]. Similarly, in thoracoscopic lobectomy, 0.33% ropivacaine was shown to lower VAS scores and facilitate postoperative rehabilitation[8]. In this case, bilateral TPVB at T6 and T8 with 0.33% ropivacaine was selected for several reasons. The concentration of 0.33% was chosen based on the number of injection points and the benefits demonstrated in previous studies. PEG-related nociceptive stimuli are primarily transmitted via the celiac plexus and sympathetic trunk to spinal segments T6-T10[9,10]. A bilateral approach was adopted due to the uncertainty in preoperative localization of the PEG site.

Compared to conventional general anesthesia for PEG, MAC combined with TPVB reduced anesthetic requirements (1% propofol 4 μg/mL and remifentanil 0.3 μg/kg/minute vs propofol 3-4 mg/kg/hour, remifentanil 0.05-0.1 μg/kg/minute)[11]. In breast cancer surgery, MAC combined with TPVB has been associated with stable hemodynamics and faster recovery[4]. These advantages are likely applicable to PEG, which is less invasive. The patient’s favorable outcomes support this approach, including minimal pain and no discomfort.

Anesthetics selection

Short-acting agents such as propofol and remifentanil were appropriately selected for this frail patient with reduced physiological reserve. Frail patients are more susceptible to the effects of general anesthesia, requiring vigilant monitoring even at reduced doses[12]. In addition to TPVB, BIS monitoring helped tailor sedation depth and reduced the risk of respiratory or neurological depression. No complications occurred with this carefully managed approach.

Airway management

Airway management was challenging due to the patient’s underlying risks. Early detection of respiratory depression is critical to preventing complications[13]. A filtered nasopharyngeal airway was used to enable oxygen supplementation and continuous capnography. Emergency intubation equipment was available but not required. Avoiding endotracheal intubation was crucial to prevent tracheal stent dislodgement and worsening of preexisting pneumonia.

CONCLUSION

This case highlights the importance of interdisciplinary collaboration and meticulous anesthetic planning in high-risk procedures. MAC combined with TPVB provided adequate conditions with reduced anesthetic requirements, avoided airway instrumentation, and maintained patient comfort and safety. This approach may be particularly beneficial for patients with dual stents or other complex airway issues undergoing upper gastrointestinal endoscopic procedures. Future studies with larger sample size are needed to confirm the efficacy of MAC combined with TPVB for PEG.