Cardiothoracic Surgery |

Recurrent Pneumonias in the Setting of a Large Diaphragmatic Hernia: The Management and Treatment Dilemma of a Gastropulmonary Fistula FREE TO VIEW

Mark Joseph*, MD; Benjamin Haithcock, MD
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University of North Carolina at Chapel Hill, Chapel Hill, NC

Chest. 2012;142(4_MeetingAbstracts):42A. doi:10.1378/chest.1390389
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SESSION TYPE: Surgery Student/Resident Case Report Posters

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: Gastropulmonary fistulas are exceedingly rare and usually present as a complication after an esophagectomy or bariatric surgery. There are some reports of unusual late complications of fistulization associated with hiatal hernias. We present the case and management of a patient who presented with recurrent pneumonias from a gastropulmonary fistula, in the setting of a longstanding diaphragmatic hernia.

CASE PRESENTATION: A 55 year old male with a history of COPD and known diaphragmatic hernia presented in respiratory distress and a history of recurrent pneumonias over a period of 2 years. His initial admission involved a GI bleed with symptoms of fever and cough and postprandial cough. Chest radiographs showed an infiltrative process with a CT scan revealing a large cavitary lesion at the left lung base abuting the gastric fundus. He was treated with IV antibiotics and discharged twice only to be readmitted within 72hrs of discharge. During both readmissions, he was treated with IV antibiotics and steroids for respiratory failure, thought to be from multidrug resistant pneumonias. Past medical history was significant for a remote history of right thoracotomy and known diaphragmatic hernia from a penetrating stab wound 30 years prior. On arrival, the patient was placed on a ventilator for respiratory distress. An UGI study was performed showed a small outpouching of the gastric fundus overlying the left lung base, suggestive of gastropulmonary fistula. Despite high PEEP, he maintained poor oxygen saturations due to severe ARDS and developed significant abdominal distension despite good bowel decompression. He eventually underwent resection of gastropulmonary fistula and diaphragmatic repair, pulmonary decortications via a thoracoabdominal incision with single lung ventilation.

DISCUSSION: Gastropulmonary fistulas with ARDS pose a diagnostic as well a therapeutic challenge. Due to the persistent pneumonias, history of COPD and development of ARDS, the patient was not the ideal candidate for a prolonged surgical repair. However, needing positive pressure ventilation in the setting of a gastropulmonary fistula also made oxygenation very challenging. With increases in PEEP and tidal volume, this in turn caused increased gastric distention and loss of volume. In this case, the patient was initially treated with nasogastric tube decompression and IV antibiotics and aggressive diuresis for ARDS. This allowed an elective surgical procedure rather than an emergent one in the case of a critically ill patient with comorbid conditions.

CONCLUSIONS: Gastropulmonary fistulas are exceedingly rare, thus posing a diagnostic as well a therapeutic challenge. Careful preoperative planning with a multi disciplinary team can often assist in the optimization of these patients prior to surgery.

1) Doubit M, Doubit G, Shamji FM et al. Gastropulmonary fistula after bariatric surgery. Can J Gastroenterol 2009;23(3):215-216.

DISCLOSURE: The following authors have nothing to disclose: Mark Joseph, Benjamin Haithcock

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University of North Carolina at Chapel Hill, Chapel Hill, NC




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