OBES SURG (2009) 19:261–264 DOI 10.1007/s11695-008-9643-3
CASE REPORT
Case Report—Complex Management of a Postoperative Bronchogastric Fistula After Laparoscopic Sleeve Gastrectomy David Fuks & Frederic Dumont & Pascal Berna & Pierre Verhaeghe & Raphael Sinna & Charles Sabbagh & Fabien Demuynck & Thierry Yzet & Richard Delcenserie & Eric Bartoli & Jean-Marc Regimbeau
Received: 18 June 2008 / Accepted: 17 July 2008 / Published online: 12 August 2008 # Springer Science + Business Media, LLC 2008
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 D. Fuks : F. Dumont : P. Verhaeghe : C. Sabbagh : J.-M. Regimbeau (*) Department of Digestive Surgery, Amiens North Hospital, University of Picardy, place Victor Pauchet, 80054 Amiens, France e-mail:
[email protected] P. Berna Department of Thoracic Surgery, Amiens North Hospital, University of Picardy, place Victor Pauchet, 80054 Amiens, France R. Sinna Department of Plastic Surgery, Amiens North Hospital, University of Picardy, place Victor Pauchet, 80054 Amiens, France F. Demuynck : T. Yzet Department of Radiology, Amiens North Hospital, University of Picardy, place Victor Pauchet, 80054 Amiens, France R. Delcenserie : E. Bartoli Department of Gastroenterology, Amiens North Hospital, University of Picardy, place Victor Pauchet, 80054 Amiens, France
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. Keywords Laparoscopic sleeve gastrectomy . Postoperative gastric fistula . Bronchogastric fistula . Endoscopic management . Extended surgery
Introduction Bariatric surgery is currently the only effective treatment for morbid obesity. However, complications after surgery exist and staple line leaks can occur after laparoscopic sleeve gastrectomy (LSG) from 0% to 4.3% [1–2]. Treatment of postoperative gastric fistula (PGF) after LSG is difficult to manage with a combination of surgical or percutaneous drainage and exclusion of the leak site allowing the leak to heal. A very few cases of bronchogastric fistula (BGF) were reported anecdotally in the literature after esophagectomy for esophageal cancers [3–4] and successful endoscopic stenting of anastomotic leaks has been described [5–7]. We report herein a single case of BGF successfully managed with complex extended surgery, after failure of endoscopic treatment.
262
OBES SURG (2009) 19:261–264
Case Report A 23-year-old woman underwent LSG for morbid obesity (body mass index (BMI) 46 kg/m2) with comorbidities (hypertension, dyslipidemia, obstructive sleep apnea) in March 2006. On postoperative day 3, a brutal abdominal pain in the right-upper quadrant occurred with fever. A water-soluble upper gastrointestinal (GI) contrast (Gastrografin®) and a computed tomography (CT) scan diagnosed a PGF. Surgical drainage of this leakage was chosen. Complete exploration discovered inflammatory changes of tissues surrounding the stomach with local peritonitis. An intraoperative gastroscopy was necessary to locate the leakage by introduction of a hydrophilic guidewire. Gastric leakage was located in front of the spleen, on the upper part of the staple line (angle of His). A drain was inserted through the staple line defect and positioned in the gastric lumen. Two sets of extraluminal drains, each made from two soft silicone tubes (one 30 Fr and one 16 Fr in each set), and a drain were placed anterior and posterior to the leakage site, with a negative pressure of 30 cm H2O by suction applied to the 30-Fr tubes. Lavage of the abdominal cavity was performed in addition to a jejunostomy for continuous enteral nutrition. Antibiotic treatment and somatostatin analogs were established. Drains were removed 15 days after surgery, after abdominal CT with upper GI contrast to verify the absence of extra digestive extravasation. The patient was discharged from hospital 4 weeks after the treatment. Five months later, the patient was readmitted complaining of an acute cough with dyspnea and expectoration. Physical examination demonstrated severe right-upper quadrant tenderness with highgrade fever (39.2°C). The patient had lost 35 kg (38% of her excess weight). Laboratory examination revealed an increase of leukocytes (18,000 per cubic millimeter) and Creactive protein (137 mg/l). A CT scan revealed a rupture of the left-side diaphragm associated with a moderate pleural effusion and an abdominal subphrenic abscess (Fig. 1). A percutaneous drainage of the abdominal abscess was performed. Three days later, methylene blue was injected through the abdominal drain and was expectorated by the patient during cough. A bronchoscopy did not find the fistula but identified blue traces in the left tracheobronchial tree. The suspected diagnosis was BGF. We decided initially to manage the patient without iterative surgery because sepsis was well tolerated and because of the distal location of BGF. The conservative management went for 8 months. This strategy included different antibiotics (piperacillin–tazobactam, amoxicillin– clavulanic acid), total parenteral nutrition, pulmonary recovery (physical therapy), and somatostatin analogs. The patient required four additional percutaneous drainages for recurrent intra-abdominal collections. The patient had
Fig. 1 Oblique reformatted unenhanced thoracic and abdominal CT with upper GI contrast showing PGF (arrow) with low abundance left pleural effusion and disruption of the left-side diaphragm
three procedures of covered stent placement (one or two stents during each procedure) to temporarily exclude the site of leakage. The stents also allowed maintenance of oral nutrition. During the 8 months of conservative treatment, seven injections of glue through the gastric leakage were performed per endoscopy in addition to the covered stent (Fig. 2). During the first procedure, we used fibrin glue but the GF persisted so we used histoacryl glue which seemed to be more effective in abdominal cavity but not on BGF. The last stent was endoscopically removed after 4 weeks. Thanks to the conservative treatment, the patient was discharged from hospital on two occasions and returned to oral alimentation 4 weeks after the treatment. After 9 months of conservative management including three recurrences of pulmonary infections with abdominal abscesses, it was decided, in a pluridisciplinary staff meeting, to perform a radical and aggressive surgery. The patient underwent total gastrectomy with intrathoracic esojejunostomy, left inferior lobectomy, and reconstruction of the diaphragm using the extended latissimus dorsi flap (Fig. 3). Postoperative outcomes were acceptable (lymphorrhea, dorsal hematoma) and the patient was discharged 4 weeks after the extended resection. After a follow-up of 12 months,
OBES SURG (2009) 19:261–264
Fig. 2 Water-soluble upper GI contrast highlighting GF with extra digestive extravasation
the patient is healthy and can eat normally. The excess weight loss was 100%.
Discussion The growing prevalence of morbid obesity and the increasing incidence of superobese patients (BMI>50 kg/m2) seeking surgical treatment has led to the development of surgical techniques designed to provide adequate excess weight loss with the lowest possible morbidity. LSG, a restrictive operation, consists of a vertical gastrectomy including the entire greater curvature of the stomach. Indications of LSG were validated with the recent First International Consensus Summit for Sleeve Gastrectomy [8]. One hundred and sixty-five consecutive patients underwent LSG between July 2004 and May 2008 in Amiens North Hospital. In our series, there was no mortality and the major complication rate, corresponding Fig. 3 Perioperative pictures of a sample total gastrectomy with esojejunostomy and reconstruction of the diaphragm
263
to GF in every case, was 4.3% (n=7) [1]. To the best of our knowledge, this is the first time that a published study reports a case of BGF after LSG. Benign BGFs are rare and the literature on this complication is limited, consisting of a few case reports [3–4]. The most likely cause of BGF is a leak from the esophagogastric anastomosis after esophagectomy for cancer [3, 9]. The BGF usually occurred after mediastinal abscess with rupture into the posterior wall of the tracheobronchial tree. In our observation, despite the lack of intrathoracic GI anastomosis, the gastric leakage, located on the top of the staple line, was responsible for a primary subphrenic abscess and a secondary diaphragm rupture with occurrence of a BGF. In our series of 135 LSG, location of GF was always on the upper part of the staple line [1]. The clinical presentation of BGF includes a cough upon swallowing, fever, dyspnea, hemoptysis, and recurrent pneumonia [4]. The fistula may connect at any site in the respiratory tract so as to be difficult to locate and may not be visualized during bronchoscopy. In such cases, a methylene blue dye test may show bluish sputum. In our observation, the BGF occurred after rupture of the leftside diaphragm due to the erosion from local infection. This cause explains the difficulty to diagnose and locate the BGF. The CT scan is helpful in arriving at the correct diagnosis and shows mediastinal abscess. Patients often present in poor general condition with malnutrition and chronic pulmonary infection [4]. For this reason, an initially conservative management (in the absence of major signs of sepsis) with antibiotics, attention to fluid and electrolyte balance, nutritional support, and chest physiotherapy and interventional procedures (radiological abscess drainage, covered stent placement, and fibrin glue) is probably preferable [4]. In our patient, the primary conservative treatment facilitated the surgery thanks to a significant decrease of inflammatory changes and an increase of general conditions. In a second step, surgical treatment with thoracotomy and resection of fistula with direct closure of the openings in the stomach and the respiratory tree seems to be the treatment of choice [4, 10– 12].
264
Development of BGF is a very rare complication after LSG. This complication may be difficult to diagnose but important to correctly identify. When the location of BGF is very distal, conservative treatment with stent placement and fibrin glue may be performed. In case of failure, aggressive management with surgical resection should be performed for those patients with benign disease.
References 1. Fuks D, Verhaeghe P, Brehant O, et al. Results of laparoscopic sleeve gastrectomy—a prospective study in 135 patients with morbid obesity. Surgery. 2008; in press 2. Nocca D, Krawczykowsky D, Bomans B, et al. A prospective multicenter study of 163 sleeve gastrectomies: results at 1 and 2 years. Obes Surg 2008;18:560–565. [Epub ahead of print]. 3. Pramesh CS, Sharma S, Saklani AP, et al. Broncho-gastric fistula complicating transthoracic esophagectomy. Dis Esophagus. 2001;14:271–3. 4. Devbhandari MP, Jain R, Galloway S, et al. Benign gastrobronchial fistula—an uncommon complication of esophagectomy: case report. BMC Surg 2005;5:16.
OBES SURG (2009) 19:261–264 5. Langer FB, Wenzl E, Prager G, et al. Management of postoperative esophageal leaks with the polyflex self-expanding covered plastic stent. Ann Thorac Surg 2005;79:398–403. 6. Hünerbein M, Stroszczynski C, Moesta KT, Schlag PM. Treatment of thoracic anastomotic leaks after esophagectomy with selfexpanding plastic stents. Ann Surg 2004;240:801–7. 7. Schubert D, Scheidbach H, Kuhn R, et al. Endoscopic treatment of thoracic esophageal anastomotic leaks by using silicone covered, selfexpanding polyester stents. Gastrointest Endosc 2005;61:897–900. 8. Deitel M, Crosby RD, Gagner M. The First International Consensus Summit for Sleeve Gastrectomy (SG), New York City, October 25–27, 2007. Obes Surg 2008;18:487–496. [Epub ahead of print]. 9. Lee JH, Lee JY, Jang MK, et al. Bronchogastric fistula. Gastrointest Endosc 2005;61:289–90. 10. Sakamoto K, Ogawa M, Yamamoto S, et al. Closure of gastric tube-tracheal fistula by transposition of a pedicled sternocleidomastoid muscle flap. Surg Today 1997;27:181–5. 11. Aguilo Espases R, Lozano R, Navarro AC, et al. Gastrobronchial fistula and anastomotic esophagogastric stenosis after esophagectomy for esophageal carcinoma. J Thorac Cardiovasc Surg 2004;127:297–9. 12. Brega Massone PP, Infante M, Valente M, et al. Gastrobronchial fistula repair followed by esophageal leak-rescue by transesophageal drainage of the pleural cavity. J Thorac Cardiovasc Surg 2002;50:113–6.
