Challenges in positioning linear echoendoscopes via LMA®GastroTM airway: A report of two cases

Carmine Cavallo 1, Federica Fimiano 2, Carmela Abbatiello 3, Mario Gagliardi 4,
Michele Fusco 5, Claudio Zulli 6, Giuseppe Terracciano 7, Mariano Sica 8
Authors affiliations:
  1. Carmine Cavallo, AOU San Giovanni e Ruggi D’Aragona , Department of Anesthesia e Intensive Care, Salerno, Italy- drcarminecavallo@gmail.com; {0000-0002-9704-5074}
  2. Federica Fimiano, Digestive Endoscopy unit, Gaetano Fucito hospital, AOU San Giovanni e Ruggi D’Aragona , Mercato San Severino, Salerno, Italy: Email: federicafimiano@gmail.com; {orcid.org/0000-0002-9560-6915}
  3. Carmela Abbatiello, Digestive Endoscopy unit, Gaetano Fucito hospital, AOU San Giovanni e Ruggi D’Aragona , Mercato San Severino, Salerno, Italy: Email: carmela.abbatiello@sangiovannieruggi.it; {orcid.org/0000-0001-8793-4583}
  4. Mario Gagliardi, Digestive Endoscopy unit, Gaetano Fucito hospital, AOU San Giovanni e Ruggi D’Aragona , Mercato San Severino, Salerno, Italy: Email: mario.gagliardi@sangiovannieruggi.it; {orcid.org/0000-0002-5213-3193}
  5. Michele Fusco, Digestive Endoscopy unit, Gaetano Fucito hospital, AOU San Giovanni e Ruggi D’Aragona , Mercato San Severino, Salerno, Italy: Email: michele.fusco@sangiovannieruggi.it; {orcid.org/0000-0002-6964-8951}
  6. Claudio Zulli, Digestive Endoscopy unit, Gaetano Fucito hospital, AOU San Giovanni e Ruggi D’Aragona , Mercato San Severino, Salerno, Italy: Email: claudio.zulli@sangiovannieruggi.it; {orcid.org/0000-0002-2141-1701}
  7. Giuseppe Terracciano, AOU San Giovanni e Ruggi D’Aragona , Department of Anesthesia e Intensive Care, Mercato San Severino, Salerno, Italy; Email: giuseppe.terracciano@sangiovannieruggi.it; {orcid.org/0009-0008-3735-3092}
  8. Mariano Sica, Digestive Endoscopy unit, Gaetano Fucito hospital, AOU San Giovanni e Ruggi D’Aragona , Mercato San Severino, Salerno, Italy: Email: mariano.sica@sangiovannieruggi.it; {orcid.org/0000-0002-3033-2052}
Correspondence: Federica Fimiano, MD, Email: federicafimiano@gmail.com, ORCID: orcid.org/0000-0002-9560-6915, Phone: +393385901348

 

ABSTRACT

 

Endotracheal intubation was perhaps the gretest invention in the field of anesthesia, as well as intensive care. It made the life of the clinicians much easier, but soon the associated drawbacks and complications made many to frown. The most compelling factor was the need of deep anesthesia and/or the need of muscle relaxants for successful insertion into the glottis. Laryngeal Mask Airway (LMA) revolutionized the science of airway management, as it could be used without relaxation and was less traumatic. Since the earliest versions, many new varients have been introduced. The LMA GastroTM is one of these. The authors present two case report of use of this device for positioning linear echo endoscopes and the related challenges.

Keywords: Airway; Echo endoscopy; Endotracheal intubation, Laryngeal Mask Airway; LMA Gastro

Citation: Cavallo C, Fimiano F, Abbatiello C, Gagliardi M, Fusco M, Zulli C, Terracciano G, Sica M. Challenges in positioning linear echo endoscopes via LMA®GastroTM airway: A report of two cases. Anaesth. pain intensive care 2025;29(3):708-710. DOI: 10.35975/apic.v29i3.2645
Received: January 14, 2025; Revised: February 05, 2025; Accepted: March 20, 2025

 

1. BACKGROUND

 

The LMA GastroTM Airway by Teleflex Medical, Ireland, is a cuffed peri-laryngeal supra-glottic airway (SGA) with an endoscopic channel compatible with all standard endoscopes. We reported two cases of failed attempts to position a linear echoendoscope through the  LMA®GastroTM channel in patiens with difficult airways management during conversion to endotracheal intubation.

 

2. INTRODUCTION

 

The use of deep sedation or general anesthesia (GA) during minimally invasive upper gastrointestinal (GI) endoscopy has increased significantly due to the rising complexity and duration of such procedures.1 Consequently, ensuring airway safety while maintaining unobstructed endoscopic access has become crucial. Risks associated with sedation during esophagogastroduodenoscopy (EGD) include the potential for deep sedation to progress to general anesthesia, especially with propofol administration,2 prone positioning during the procedure, and patient-related factors such as obesity.

The LMA Gastro™ Airway (Teleflex Medical, Ireland) is a cuffed peri-laryngeal supra-glottic airway (SGA) designed with an endoscopic channel compatible with standard endoscopes. It features separate channels for esophageal and pulmonary access, a built-in bite block, and an indicator for cuff pressure. Available in three sizes—#3 (30–50 kg), #4 (50–70 kg), and #5 (70–100 kg)—it has demonstrated promising results in previous studies. In a recent observational study,3 Terblanche et al. reported a 99% success rate for airway insertion and a 93% first-attempt success rate for endoscopy among 292 low-risk patients.Here, we describe two cases of failed attempts to position a linear echoendoscope (Fujifilm EG-530UT2, tip diameter: 13.9 mm) through the  LMA®GastroTM channel.

 

3. CASE 1

 

The first patient was a 48-year-old female (weight: 67 kg, BMI: 23) with a reduced mouth opening (30 mm), thyromental distance of 4 cm, and Mallampati score of 2. The procedure was conducted with the LMA®GastroTM Airway in a supine position. Adequate placement of the LMA was confirmed by evaluating parameters such as inspired and expired tidal volume difference, seal pressure, and a square-wave capnogram. General anesthesia was induced using fentanyl (100 µg), propofol (2.5 mg/kg), and sevoflurane (MAC 0.8%).

Despite ensuring optimal anesthesia depth, the expert endoscopist encountered significant resistance when attempting to insert the lubricated linear echoendoscope through the LMA®GastroTM  channel. Repeated attempts failed to position the endoscope in the esophagus. The procedure was converted to endotracheal intubation. A 7 mm endotracheal tube was placed using a stylet under direct laryngoscopy, with a Cormack-Lehane grade of 2E.

 

4. CASE 2

 

The second patient was a 65-year-old female (weight: 55 kg, BMI: 22.5) with a reduced mouth opening (<30 mm), a thyromental distance of 3.4 cm, and a Mallampati score of 3. Multiple failed attempts to position the echoendoscope through the LMA®GastroTM  channel, led to the decision to convert to endotracheal intubation. In this case, intubation was performed using a Glidescope videolaryngoscope due to a challenging airway (Cormack-Lehane grade 3E).

 

5. DISCUSSION

 

General anesthesia is the best choice for endoscopic procedures. Although the insertion of LMA®GastroTM guarantees very high rate of successful placement for airways under general anesthesia, this study reports the inability to insert the endoscope  Fujifilm EG-530UT2  Tip diameter, 13.9 mm  via LMA®GastroTM into esophagus. Different patients have varied anatomical structures, which can complicate the positioning of the endoscope. Factors such as obesity, sleep apnea, and previous surgeries can alter normal anatomy and make navigation difficult. We attribute the failed attempts to reduced hypopharyngeal space, likely associated with difficult airway management parameters, including a short thyromental distance and high-grade Cormack-Lehane scores during intubation.

Only a few studies have documented failed endoscopic device insertion using LMA GastroTM.4 Other studies have identified challenges in introducing duodenoscopes into the esophagus, which may be linked to thick cricopharyngeus muscles or anterior cervical osteophytes, particularly in elderly patients.5 In the single-center observational study of  Schmutz and Coll.,6 27 patients were managed successfully using the LMA Gastro while in four of them placement or ventilation with LMA Gastro™ was not possible and conversion to an oral tracheal tube was required for four patients only, three of them with a history of major oral cancer and radiation therapy. We attribute the failed attempts to reduced hypopharyngeal space, likely associated with difficult airway management parameters, including reduced mouth opening and a short thyromental distance. In our cases, ventilation was perfectly perfomed in each of patiens. We converted in endotracheal intubation only for impossibility of positioning  Echoendoscopic probe.

During endotracheal intubation, expert anesthesiologist reported high-grade Cormack-Lehane scores during intubations. To our knowledge, this study is the first to report a mismatch between anesthetist and endoscopist comfort levels. While patients were optimally ventilated using the LMA®GastroTM, endoscopists were unable to introduce the probe. Difficult airway management emerged during the conversion to endotracheal intubation.We hypothesize a correlation bwtween failed echoendoscopic probe positioning via LMA®GastroTM  and difficult aiways management during conversion in endotracheal intubation.

 

6. CONCLUSION

 

To our knowledge, this is one of the first reports documenting failed positioning of a linear echoendoscope through the LMA®GastroTM channel. Our cases highlight the potential association between challenging airway management and unsuccessful  endoscopic device placement through LMA. Further studies are needed to confirm this correlation and identify predictors for failed endoscopic device insertion in patients with difficult airways.

7. Note
LMA®GastroTM  is a registered trademark of The Laryngeal Mask Company Ltd., an affiliate of Teleflex Incorporated.

8. Conflict of interest
All authors declare that there was no conflict of interest.

9. Consent for publication
Not applicable.

10. Authors’ contribution
All authors took part in the lierature search, conduct of the cases and drafting the manuscript.

 

11. REFERENCES

 
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  2. Coté GA, Hovis RM, Ansstas MA, Waldbaum L, Azar RR, Early DS, et al. Incidence of sedation related complications with propofol use during advanced endoscopic procedures. Clin Gastroenterol Hepatol. 2000;8(2):137–42. PubMed DOI: 1016/j.cgh.2009.07.008
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  5. Tran A, Thiruvenkatarajan V, Wahba M, Currie J, Rajbhoj A, van Wijk R, et al. LMA Gastro airway for endoscopic retrograde cholangiopancreatography: a retrospective observational analysis. BMC Anesthesiol. 2020;20:113. PubMed DOI: 1186/s12871-020-01019-5
  6. Schmutz A, Loeffler T, Schmidt A, Ulrich G. LMA Gastro airway is feasible during upper gastrointestinal interventional endoscopic procedures in high risk patients: a single-center observational study. BMC Anesthesiol. 2020;20:40. PubMed DOI: 1186/s12871-020-0938-9