Gastrobronchial fistula (GBF) is an extremely rare occurrence. Several cases of GBF have been described in the English literature but none have occurred secondary to bariatric surgery. We describe a case of GBF occurring after laparoscopic gastric banding.
A 31-year-old morbidly obese female with a body mass index of 47 underwent laparoscopic gastric banding. The surgery was successful and the patient lost 100 lbs over eight months at which time she developed a left pneumothorax and pleural effusion. A tube thoracostomy was placed with 1800 ml of purulent fluid removed. Cultures contained gram-positive cocci and gram-negative rods. The patient required a left thoracotomy with decortication. Despite several courses of antibiotics she continued to complain of left sided chest pain, dyspnea, and productive cough. On physical exam, she was hemodynamically stable, afebrile, with decreased breath sounds and dullness to percussion on the left side. The remainder of the exam was normal. Computer Tomography (CT) of the chest revealed an intrathoracic stomach, consolidated left lower lobe, and air-bronchograms. Upper gastrointestinal series (UGIS) demonstrated a displaced gastric band with a large portion of gastric fundus within the left hemithorax and extravasation of contrast into the left thoracic cavity. (Fig 1) Flexible bronchoscopy revealed thick secretions in the left lower lobe and esophagogastroduodenoscopy (EGD) revealed the herniated fundus with an area of inflammation in the superior aspect. No ulcer or perforation was appreciated. The patient was taken to the operating room electively where an exploratory laparotomy and left thoracotmy were performed. A fistula was identified between the fundus of the stomach and the left lower lobe bronchus measuring 5 mm in diameter and 4 cm in length. (Fig 2) Removal of the band, repair of the stomach, diaphragm, and left lower lobectomy were performed.
This is the first case report of a GBF secondary to a laparoscopic gastric band. Regardless of the etiology, GBF is a rare condition. A total of 35 cases have been reported in the literature. Postoperative complications following foregut surgery constitute the most common cause of GBF.(123) Trauma is the second leading cause.(4) Patients can present with expectoration of gastric contents, recurrent fever, hemoptysis, and pulmonary infections such as bronchitis, pneumonia, lung abscess, or bronchiectasis.(4) GBF should be suspected in any patient presenting with the above following surgery of the foregut or trauma. The investigation of choice is the esophagram or UGIS as in this case. Other diagnostic modalities include measurement of bronchial pH(2), instillation of methylene blue, bronchoscopy, EGD, and CT scan. We performed a lobectomy with complete excision of the fistulous tract.
We have described a case of gastrobronchial fistula secondary to laparoscopic gastric banding, a type of bariatric surgery. To our knowledge, there have been no previously reported cases. With the increase in the number of laparoscopic banding procedures performed in this country this complication may occur more often and awareness of this complication should be heightened.
D.J. Rassias, None.