Abstract
Introduction: Gastro-bronchial fistula (GBF) is a rare and challenging complication of sleeve gastrectomy as it is the result of a chronic gastric leak and subsequent long-standing sub-phrenic abscess. In this article we report the first case of GBF after a re-sleeve gastrectomy. Case Presentation: a 42-years-old patient was admitted to our Unit because of the arise of sepsis, hypothension and cough with expectoration of enteral nutrition. The patient had a history of sleeve (2010) and re-sleeve gastrectomy (2017) for weight regain. On admission radiological signs of consolidation of the left pulmonary lobe and, after the swallowing of oral contrast, a little backward trans-diaphragmatic opacification of the main bronchus was described. An open total gastrectomy with a trans-abdominal atypical lower pulmonary lobe resection were performed. A post-operative ERAS protocol was adopted, and the patient was discharged in POD 9 in good conditions, after an uneventful recovery and feeding per os. Conclusions: To our knowledge this is the first case of a GBF after a re-sleeve gastrectomy, more evidences are needed before routinely advice a re-sleeve gastrectomy after a failed sleeve gastrectomy. Indeed, given that in revisional bariatric surgery the risk of gastric leak may be higher due to a greater tension applied on the staple line, the incidence of rare but serious complications such GBF may consequently increase.
Highlights
Gastro-bronchial fistula (GBF) is a rare and challenging complication of sleeve gastrectomy as it is the result of a chronic gastric leak and subsequent long-standing sub-phrenic abscess
Leak after Laparoscopic Sleeve Gastrectomy (LSG) and re-sleeve gastrectomy is prone to evolve in a GBF, because the leak site is usually at the top of the staple line, near the cardia at the level of the angle of His, with a subsequent longstanding subphrenic abscess which, in the presence of distal stenosis of the gastric pouch, is continuously supplied by foods and acid gastric secretions [5]
An ischemia of the gastric wall next to the staple line has been advocated to result in a gastric leak that, if un-noticed or not adequately treated, could directly erode the diaphragm, causing a lung abscess that eventually drains into a bronchus
Summary
Laparoscopic Sleeve Gastrectomy (LSG) is quickly becoming the most common bariatric procedure for surgical treatment of morbid obesity. LSG carries several advantages, mainly the avoidance of gastrointestinal anastomosis, the rarity of malabsorbitive problems and dumping syndrome, the possibility to explore endoscopically the upper GI and biliopancreatic systems It is very effective as first stage operation for super-obese patients (BMI > 55 kg/m2) [1]. Lifestyle behaviors, and lack of follow-up, some technical factors (bougie size, leaving fundal remnant, size of antral remnant) as well as post-operative sleeve dilatation may be a cause of weight regain [2] In these cases, a redo surgery may be an option, with the possibility to convert LSG into a more malabsorbitive procedure like RYGB or duodenal switch. Two new findings were noticed: consolidation signs of the lower left pulmonary lobe (6 x 8.5 cm) with left pleural effusion, and, after the swallowing of oral contrast, a little backward trans-diaphragmatic opacification up to the main ipsi-lateral and contra-lateral bronchi
Sign-in/Register to view highlights & summary Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a callDisclaimer: All third-party content on this website/platform is and will remain the property of their respective owners and is provided on "as is" basis without any warranties, express or implied. Use of third-party content does not indicate any affiliation, sponsorship with or endorsement by them. Any references to third-party content is to identify the corresponding services and shall be considered fair use under The CopyrightLaw.
