SESSION TYPE: Surgery Case Report Posters
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM
INTRODUCTION: Bariatric surgery is an increasingly common procedure to treat obesity. A rare complication of laparoscopic sleeve gastrectomy is gastrobronchial fistulation.
CASE PRESENTATION: A 30-year-old woman presented with a productive cough for 1 year. This was made worse when she was in a recumbent position and after meals. Over the last month, she even coughed out food particles. Her past medical history was significant for morbid obesity. A laparoscopic sleeve gastrectomy had been performed 15 months earlier. This was complicated by a persistent fundal leak secondary to staple line dehiscence resulting in a left subphrenic abscess and stenosis of the stomach body. There were also recurrent admissions for vomiting and aspiration pneumonia into the left lower lobe. Flexible bronchoscopic examination revealed no endobronchial abnormality. Bronchoalveolar lavage yielded Klebsiella species. Oesophageal stenting and dilatation of the stenosis did not improve the aspiration and she had been placed on long term feeding via a jejunostomy. However she was non compliant and was still taking orally. On examination, the patient had a temperature of 39oC. Her BMI was 23kg/m2. There was clubbing and crepitations over the left lower chest. Her chest radiograph showed a left lower zone consolidation that had been largely unchanged over the past year. A water-soluble contrast study demonstrated the presence of a gastrobronchial fistula. This was seen on computed tomography as well. She was treated for pneumonia with broad-spectrum antibiotics and underwent laparoscopic repair of the fistula.
DISCUSSION: Campos et al described 15 cases in 3 institutions specialising in the postoperative complications of bariatric surgery. There are only 8 other cases in the literature. It is a late postoperative complication. The persistent subphrenic abscess and our patient’s non-compliance to stop oral feeding contributed to the problem. The diagnosis and management requires multi-disciplinary team input and a high index of suspicion.
CONCLUSIONS: Gastrobronchial fistula after laparoscopic sleeve gastrectomy is a rare but well recognised complication that can be easily missed resulting in delayed diagnosis.
1) Buchwald H et al. Metabolic/bariatric surgery worldwide 2008. Obes Surg 2009;19(12):1605-11
2) Campos JM et al. Gastrobronchial fistula after sleeve gastrectomy and gastric bypass: endoscopic management and prevention. Obes Surg 2011;21(10):1520-29
DISCLOSURE: The following authors have nothing to disclose: Aik Hau Tan, Devanand Anantham, Pasupathy Shanker
No Product/Research Disclosure InformationSingapore General Hospital, Singapore, Singapore