Bronchoaspiration During Endoscopy Under Sedation in a Patient with a History of Gastrectomy and Prolonged Fasting: A Case Report

Introduction: Bronchoaspiration is defined as the inhalation of oropharyngeal or gastric contents into the lower respiratory tract, which may lead to different pulmonary syndromes. Although aspiration risk assessment is commonly based on fasting times, current clinical guidelines were developed for healthy patients undergoing elective surgery and are not reliable in patients with comorbidities that alter gastric kinetics. Non-operating room anesthesia (NORA) procedures further increase this risk due to the logistical challenges inherent to the environment. Case presentation: A 63-year-old woman with a history of gastric adenocarcinoma treated with subtotal gastrectomy and Roux-en-Y reconstruction, chemotherapy, and radiotherapy subsequently developed post-radiation gastric stenosis, intestinal hypomotility, and delayed gastric emptying. Computed tomography revealed a markedly dilated stomach with persistent abundant food content, and diagnostic upper gastrointestinal endoscopy was indicated. During upper gastrointestinal endoscopy performed under sedation, abundant semisolid gastric contents were documented despite a reported fasting period of more than 36 hours. The patient developed regurgitation with bronchoaspiration and severe hypoxemia, requiring immediate advanced airway management. Chemical pneumonitis secondary to massive aspiration was diagnosed. The patient showed favorable clinical evolution without respiratory sequelae. Conclusion: Preoperative fasting, even when prolonged, does not eliminate the risk of bronchoaspiration in patients with prior gastric surgery, oncologic disease, or impaired gastric emptying. The occurrence of a severe bronchoaspiration event in a NORA setting despite strict adherence to fasting protocols highlights the importance of individualized anesthetic assessment, consideration of additional airway protection strategies, and the potential use of gastric ultrasound for more accurate risk stratification.