Written by: Olubukola Toyobo and Mary Beth McAlevy, MD
Reviewed by: Sonia Vaida, MD

A 72-year-old man, weighing 91 kg and with ASA class III physical status, presented to the endoscopy suite for endoscopic retrograde cholangiopancreatography (ERCP) for choledocholithiasis.

His medical history was significant for hypertension treated with lisinopril and metoprolol, poorly controlled gastroesophageal reflux disease, type 2 diabetes mellitus and mild aortic stenosis. Two years prior, he had undergone a total thyroidectomy due to papillary thyroid cancer complicated by permanent unilateral vocal cord paralysis.

The patient’s daughter was an anesthesiologist at another institution and kindly requested avoiding endotracheal intubation for her father’s procedure, if possible. The care team proceeded with general anesthesia and used a Laryngeal Mask Airway (LMA) Gastro (Teleflex) for airway protection and to facilitate the ERCP procedure.

After the placement of standard monitors, general anesthesia was induced with 50 mg of IV fentanyl, 60 mg of lidocaine and 250 mg of propofol. With the patient in the supine position, an LMA Gastro size 5 with the cuff fully deflated was placed at the first insertion attempt. The cuff was inflated with 60 mL of air to reach a green mark on the built-in, color-coded pressure gauge. Correct placement was confirmed by bilateral lung auscultation and end-tidal carbon dioxide. The device was secured with a strap, and the patient was positioned prone with his head in the right lateral position.

image

The ERCP scope was passed through the dedicated endoscopy channel without difficulty. Anesthesia was maintained with a propofol infusion at a rate of 100 mcg/kg per minute, and the patient was allowed to breathe spontaneously with manual ventilation assistance when necessary. Oxygenation and ventilation were adequately maintained throughout the procedure. The ERCP procedure was successfully performed and lasted 50 minutes. Bloodstains were observed on the LMA Gastro as it was removed. The patient was discharged home one hour after the procedure. The next day he complained of a mild sore throat, which resolved spontaneously after 48 hours.

Discussion

Non–operating room anesthesia in the gastroenterology suite for advanced endoscopic procedures is increasingly necessary. The anesthetic techniques for endoscopic procedures vary largely from moderate or deep sedation assisted by low- or high-flow oxygen to general anesthesia with an endotracheal tube. The choice of the anesthetic technique differs from institution to institution, and it is based on multiple factors such as the complexity and expected length of the procedure, the risk for aspiration, etc.1 Airway protection can be achieved with an endotracheal tube or supraglottic airway device such as the LMA.2 Using a supraglottic airway device offers the advantage of airway protection while avoiding endotracheal intubation.

The LMA Gastro is a novel modification of the LMA developed by Marcus Skinner, MBBS.3 It is a dual-channel, second-generation supraglottic airway device, separating the gastric and airway access. It is designed to enable simultaneous ventilation of the lungs through an airway channel and upper gastrointestinal access through a 16-mm internal diameter endoscopy channel. In addition, the LMA Gastro is equipped with a bite block and cuff pilot technology for monitoring intracuff pressure. It is available in three sizes (3, 4 and 5). An adjustable strap helps to stabilize the device during endoscopic manipulation.

Several studies have reported the effectiveness and safety of the LMA Gastro for a variety of endoscopic procedures.3-6 In 2018, Terblanche et al published a prospective observational study with very encouraging results regarding airway effectiveness and endoscopy success when using the LMA Gastro with a standardized device insertion and endoscopic technique.3 The study involved 292 nonobese (mean body mass index, 28 kg/m2), ASA class I and II patients with low pulmonary aspiration risk. The overall LMA Gastro insertion success rate was 99%, with a first-attempt insertion success rate of 82%.

Esophagogastroduodenoscopy procedures in the lateral position were successfully performed in 99% of patients. Postoperative sore throat was reported in 37% of patients, with one patient requiring readmission because of the inability to tolerate oral intake.

The LMA Gastro has been successfully used to perform more complex endoscopic procedures such as ERCP and percutaneous endoscopic gastrostomy.4-6 In a retrospective analysis conducted by Tran et al, 64 ERCP procedures conducted in 59 patients had a success rate of 93%.6 The patients were positioned in the lateral or semi-prone position with a mean duration of anesthesia of 57 minutes.

The LMA Gastro also has been used to facilitate transesophageal echocardiography through the dedicated endoscopic channel.7

The Gastro-Laryngeal Tube (VBM Medizintechnik GmbH), a modification of the Laryngeal Tube (King LT), is a similar device to the LMA Gastro and was released before the LMA Gastro. In 2010, Gaitini et al reported the effectiveness and safety of the Gastro-Laryngeal Tube in 30 patients undergoing diagnostic and therapeutic ERCPs. The authors found that the incidences of bloodstains on the device after removal, sore throat, dysphagia and dysphonia were similar to those of the King LT.8

Uysal et al published a comparison of the LMA Gastro Airway and Gastro-Laryngeal Tube in 100 patients undergoing ERCPs.9 The first-attempt insertion rate was significantly higher with the LMA Gastro (96%) than the Gastro-Laryngeal Tube (72%). The oropharyngeal leak pressure was superior with the LMA Gastro (32 cm H2O) versus the Gastro-Laryngeal Tube (26 cm H2O). Sore throat incidence and severity were higher with the Gastro-Laryngeal Tube.

Conclusion

The LMA Gastro may be used as a primary airway device to allow safe and effective airway management. It has the advantage of offering airway protection while avoiding endotracheal intubation. It can also be used to perform a variety of endoscopic procedures, including ERCP.

Toyobo is a medical student at Penn State College of Medicine, in Hershey, Pa.

McAlevy is an assistant professor of anesthesiology and perioperative medicine at Penn State Health Milton S. Hershey Medical Center, in Hershey, Pa.

Vaida is a professor of anesthesiology and obstetrics and gynecology, the vice chair for research, and the director of obstetric anesthesia, Department of Anesthesiology and Perioperative Medicine, at Penn State Health Milton S. Hershey Medical Center.

The author and reviewer reported no relevant financial disclosures. References are available online at AnesthesiologyNews.com.

References

  1. Smith ZL, Mullady DK, Lang GD, et al. A randomized controlled trial evaluating general endotracheal anesthesia versus monitored anesthesia care and the incidence of sedation-related adverse events during ERCP in high-risk patients. Gastrointest Endosc. 2019;89(4):855-862.
  2. Osborn IP, Cohen J, Soper RJ, et al. Laryngeal mask airway—a novel method of airway protection during ERCP: comparison with endotracheal intubation. Gastrointest Endosc. 2002;56(1):122-128.
  3. Terblanche NCS, Middleton C, Choi-Lundberg DL, et al. Efficacy of a new dual channel laryngeal mask airway, the LMA® Gastro? Airway, for upper gastrointestinal endoscopy: a prospective observational study. Br J Anaesth. 2018;120(2):353-360.
  4. Hagan KB, Carlson R, Arnold B, et al. Safety of the LMA® Gastro? for endoscopic retrograde cholangiopancreatography. Anesth Analg. 2020;131(5):1566-1572.
  5. Schmutz A, Loeffler T, Schmidt A, et al. LMA Gastro? airway is feasible during upper gastrointestinal interventional endoscopic procedures in high risk patients: a single-center observational study. BMC Anesthesiol. 2020;20(1):40.
  6. Tran A, Thiruvenkatarajan V, Wahba M, et al. LMA® Gastro? Airway for endoscopic retrograde cholangiopancreatography: a retrospective observational analysis. BMC Anesthesiol. 2020;20(1):113.
  7. Saxena S, Aminian A, Nahrwold DA, et al. LMA Gastro airway seen through the eyes of a cardiac anesthesiologist. J Cardiothorac Vasc Anesth. 2019;33(8):2365-2366.
  8. Gaitini LA, Lavi A, Stermer E, et al. Gastro-Laryngeal Tube for endoscopic retrograde cholangiopancreatography: a preliminary report. Anaesthesia. 2010;65(11):1114-1118.
  9. Uysal H, Senturk H, Calim M, et al. Comparison of LMA® Gastro Airway and Gastro-Laryngeal Tube in endoscopic retrograde cholangiopancreatography: a prospective randomized observational trial. Minerva Anestesiol. 2021;87(9):987-996.