Unusually difficult intraesophageal bougie insertion in an intubated pediatric patient.

A 7-month-old male weighing 6.8 kg was scheduled for elective laparoscopic hiatal repair due to repetitive regurgitation. The patient had no past history of recent upper respiratory tract infection or deglutition difficulty. On physical examination, the patient had no anatomical throat variants other than malnutrition. Laboratory values were normal and an upper gastrointestinal contrast revealed the diagnosis of hiatal hernia (Fig. 1). Anesthesia was induced with atropine 0.5 mg, midazolam 0.5 mg, propofol 15 mg and remifentanil 5μg. After intravenous administration of cisatracurium, the patient was uneventfully intubated with an uncuffed armored tracheal tube (ID: 4.0 mm). Her direct laryngoscopic view was grade 1 according to the Cormack and Lehane classification with no pharynx and throat deformity. Anesthesia was maintained with sevoflurane and remifentanil. The patient received pressure-controlled ventilation with a peak inspiratory pressure of 20 cmH2O. The operation was otherwise uneventful. During the surgery, an intraesophageal bougie was requested to be inserted by a senior anesthesiologist in order to confirm proper wrap size and placement, as well as testing the security of the sutures holding the wrap in place. The placement of the intraesophageal bougie was attempted several times with no success. Various methods, including stiffening the bougie with ice water, using a guide wire, blind insertion of an endotracheal tube as an introducer, and direct laryngoscopy and assistance with Magill’s forceps, failed to advance the bougie tip more than 14 cm to 15 cm from incisor into esophageal. Considering the inherent risk of esophagogastric perforation associated with this maneuver, the surgeons decided to proceed with the repair and fundoplication without the aid of a bougie. Towards the end of the surgery, an attempt was made to insert a gastric tube to facilitate gastric emptying, but the tube