Regurgitation of gastric contents and subsequent pulmonary aspiration remain recognized complications of upper endoscopy performed under sedation or anesthesia (1–4). These risks are accentuated in patients with altered upper gastrointestinal anatomy—particularly those who have undergone total or proximal gastrectomy—because surgery disrupts the lower esophageal sphincter and the angle of His, facilitating reflux (5–7). Although strict fasting reduces gastric volume, aspiration cannot be completely eliminated; residual gastric contents are reported in up to 19% of apparently fasted patients (8).

Several strategies have been proposed to manage high aspiration risk during endoscopy. Performing the examination while the patient is fully awake preserves airway reflexes but is poorly tolerated and may itself provoke vomiting and reflux (9, 10). General anesthesia with endotracheal intubation provides reliable airway protection but requires neuromuscular blockade, specialized equipment and recovery resources, making it disproportionate for routine diagnostic gastroscopy (11). Various supraglottic airway devices (e.g., LMA^® Gastro™) permit deep sedation and airway management but do not prevent reflux (12). The Sengstaken–Blakemore tube, which incorporates both gastric and esophageal balloons, is primarily used to control variceal hemorrhage (13). Its esophageal balloon concept inspired our approach of temporarily occluding the esophageal lumen; however, the device's indications and hardware are not geared toward aspiration prevention during routine gastroscopy (14–16).

To our knowledge, esophageal balloon occlusion with continuous suction to enable sedated gastroscopy in post-gastrectomy patients has not previously been reported. Here we present a case in which this technique was used as an intermediate option between awake endoscopy and general anesthesia. We emphasize procedural details, placement confirmation, suction parameters and sedation targets to facilitate reproducibility and critically discuss its limitations and place in the continuum of airway-protective strategies.

This case illustrates a novel application of a commonly available device—a Foley urinary catheter—to mitigate aspiration risk during deeply sedated gastroscopy. By creating a controllable barrier within the esophagus and applying continuous suction, the technique allowed sedation without endotracheal intubation while permitting the endoscopist to control reflux dynamically.

Pulmonary aspiration remains a recognized complication of upper endoscopy even when fasting guidelines are followed, particularly in patients with altered anatomy or severe gastro-esophageal reflux (8, 17–19). Awake, unsedated examinations preserve airway reflexes yet are often intolerable and may provoke gagging or vomiting (9, 10). Routine prophylactic endotracheal intubation secures the airway but requires general anesthesia, neuromuscular blockade and prolonged recovery and carries risks of pharyngeal injury and ventilator-associated pneumonia (20–23). Specialized supraglottic devices such as the LMA^® Gastro™ facilitate deep sedation but do not prevent reflux (12). Our case therefore illustrates an intermediate strategy that balances patient comfort, procedural stimulation and airway protection through transnasal esophageal balloon occlusion with continuous suction. By creating a dynamic barrier at the source of reflux, the technique allowed deep sedation without intubation and may complement existing airway-management approaches for selected high-risk individuals.

The concept for this technique was inspired by the Sengstaken—Blakemore tube, a three-lumen two-balloon device used for gastro-esophageal variceal bleeding (15, 16). To actively control reflux in our case, we repurposed a standard 18-Fr silicone Foley catheter. The catheter is approximately 40 cm in total length, with the bifurcation located about 35 cm from its rounded tip; when inserted fully through the nostril, the tip rests in the mid-esophagus while the bifurcation remains at the nares. After measuring the distance from the nares to the xiphoid process to estimate esophageal insertion depth, we inflated the balloon with 20 ml of saline. In ex vivo measurements this inflation produced a diameter of roughly 3 cm, which approximates the upper range of the normal adult esophagus (~20–30 mm) (24)and is slightly larger than the inner diameters of most self-expanding esophageal stents (17–23 mm) (25, 26) or esophageal dilation balloons inflated with 50 ml (24–29 mm) (27). A 3 cm diameter balloon can occlude the esophageal lumen temporarily without excessive distention, while continuous suction through the drainage lumen decompresses the stomach and removes any refluxate.

Under light sedation, the patient was able to report discomfort, aiding confirmation that the catheter was in the esophagus rather than the trachea; after verifying correct placement, sedation was deepened and the balloon deflated under endoscopic visualization. If reflux were observed, the balloon could be reinflated to aspirate gastric contents before continuing. Total occlusion time was limited to about 4 min. Although guidelines for esophageal tamponade devices recommend deflating balloons every 2–8 h and removing them within 24 h to minimize mucosal necrosis (14, 16, 28), our occlusion was far shorter; should longer occlusion be necessary, we suggest limiting inflation to 10–15min, intermittently deflating the balloon and monitoring for mucosal ischemia. Future applications of this technique will incorporate bedside ultrasound and end-tidal carbon dioxide monitoring to confirm esophageal placement and avoid inadvertent tracheal insertion.

The limitations and risks of this method must be considered carefully. This report describes a single patient and cannot establish causality; the absence of aspiration may reflect the balloon, the suction, patient anatomy or chance. Transnasal insertion of a relatively large-bore catheter may be uncomfortable, and overinflation or prolonged inflation could injure the esophageal mucosa. The procedure demands close coordination between the anesthesiologist and endoscopist, and emergency airway equipment must be immediately available. Accordingly, the technique should only be attempted in centers with experienced teams and is most suitable for elective diagnostic examinations in patients at high risk of aspiration, such as those after gastrectomy, refractory gastro-esophageal reflux or severe gastric emptying disorders. It is contraindicated in suspected foreign-body impaction, strictures, varices or active bleeding. Importantly, acute airway obstruction from an impacted foreign body lodged in the upper esophagus represents a distinct scenario: such impaction can compress the posterior tracheal wall and cause rapid respiratory failure, necessitating emergent intubation and removal (29). Recognizing this continuum—from chronic aspiration risk to acute obstruction—helps clinicians select the appropriate airway-protection strategy.

Beyond its potential role in airway management, our case also exemplifies the creative repurposing of a common and inexpensive device to address a specific clinical challenge. A standard 18-Fr silicone Foley catheter served both as an occlusion balloon and a suction conduit, demonstrating that existing tools can be applied flexibly to manage complex situations. Similar inventive uses of Foley catheters have been reported in other settings—for example, using the catheter as a temporary traction device during laparoscopic surgery (30). Identifying such parallels encourages clinicians to leverage familiar equipment in novel ways and underscores the importance of innovation in resource-limited scenarios.

Transnasal esophageal balloon occlusion with suction may therefore offer a pragmatic compromise between awake endoscopy and general anesthesia with intubation. By establishing a temporary barrier and enabling dynamic control of reflux, the technique allowed us to perform sedated gastroscopy safely in a patient with extreme aspiration risk. Further cases and controlled studies are required to validate its safety, refine technical parameters (balloon size, inflation volume and duration) and define its role within the spectrum of perioperative airway management.

In this post-gastrectomy patient at extreme aspiration risk, transnasal esophageal balloon occlusion with continuous suction permitted deep sedation without endotracheal intubation and was associated with an uneventful endoscopic procedure. By creating a temporary barrier and actively controlling reflux, the technique may offer a pragmatic bridge between awake endoscopy and general anesthesia for selected high-risk individuals. Nevertheless, its use should be regarded as exploratory: evidence is limited to a single case, the potential for mucosal injury during longer procedures is unknown, and it is contraindicated in patients with esophageal lesions or foreign bodies. Additional cases and controlled studies are required to clarify its safety, efficacy and appropriate indications.