Case Report—Complex Management of a Postoperative Bronchogastric Fistula After Laparoscopic Sleeve Gastrectomy

Abstract

Laparoscopic sleeve gastrectomy (LSG) is a new restrictive bariatric procedure increasingly indicated in the treatment of morbid obesity. Postoperative complications are mainly represented by gastric fistula with an occurrence rate of 0% to 5.1% in the literature. This complication is difficult to manage and requires multiple radiological, endoscopic, and surgical procedures. We report herein the case of a 23-year-old woman who underwent LSG for morbid obesity. This patient was reoperated for peritonitis due to a gastric fistula located on the top of the staple line. Five months later, she complained of a cough with fever and expectoration. A methylene blue test and a computed tomography scan diagnosed a postoperative bronchogastric fistula. After failure of aggressive conservative management, radical surgery was performed with total gastrectomy, reconstruction of the diaphragm using the extended latissimus dorsi flap, and a pulmonary lobectomy. This case report highlights the possible issue of the complex management of gastric fistula after LSG.

Gastrobronchial fistula after sleeve gastrectomy and gastric bypass: endoscopic management and prevention

“…The spontaneous communication of the subphrenic abscess with the bronchial tree suggests the previous existence of a persistent GF, possibly secondary to a chronic difficulty in gastric emptying [5,9]. The GBF of our patients occurred late in the postoperative period (5.7 months on average), consistent with other studies [5][6][7][8][9].…”

“…After RYGB and LSG, the closure of GF can be hindered by the presence of distal stenosis and abdominal infection [8,9,15]. The spontaneous communication of the subphrenic abscess with the bronchial tree suggests the previous existence of a persistent GF, possibly secondary to a chronic difficulty in gastric emptying [5,9].…”

“…GBF may have some possible predisposing factors such as recurrent abscesses in the upper abdomen without drainage or early withdrawal of the drain, with resultant chronic subphrenic inflammation [5,[7][8][9]. It also may have occurred after adjustable gastric band erosion [6].…”

“…Due to proximity with the respiratory tract, an abdominal infection can result into a gastrobronchial fistula (GBF), although its occurrence after bariatric surgery has seldom been reported (Table 1) [5][6][7][8][9][10][11]. GBF treatment can be challenging when performed by means of major abdominal and thoracic operations [6][7][8]11].…”

“…GBF treatment can be challenging when performed by means of major abdominal and thoracic operations [6][7][8]11].…”