Saudi Surgical Journal

CASE REPORT
Year
: 2019  |  Volume : 7  |  Issue : 4  |  Page : 167--171

Bronchoesophageal fistula, a rare complication post laparoscopic sleeve gastrectomy: A case report and literature review


Ashraf A Maghrabi1, Saleh Aldagal1, Abdullah Sultan1, Nisar Haider Zaidi1, Murad M Aljiffry1, Moaz Abulfaraj1, Wisam Jamal2,  
1 Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
2 Department of Surgery, Faculty of Medicine, Jeddah University, Jeddah, Saudi Arabia

Correspondence Address:
Ashraf A Maghrabi
Department of Surgery, Faculty of Medicine, King Abdulaziz University, P.O. Box: 80215, Jeddah 21589
Saudi Arabia

Abstract

Acquired bronchoesophageal fistula (BEF) and tracheoesophageal fistula are rare disorders that result from medical disease or secondary to a complication of a procedure, most commonly due to the prolonged high-pressure endotracheal or tracheostomy cuffs in the presence of nasogastric tube in the esophagus. Rarely, esophageal injuries can result in BEF; presentation is usually after 1 week of the procedure, and the treatment is esophageal stenting or clips in the early phase, and failure will need definitive surgical management. Here, we present our case of a complex BEF post laparoscopic sleeve gastrectomy that required endoscopic and surgical management. This is a case report and literature review.



How to cite this article:
Maghrabi AA, Aldagal S, Sultan A, Zaidi NH, Aljiffry MM, Abulfaraj M, Jamal W. Bronchoesophageal fistula, a rare complication post laparoscopic sleeve gastrectomy: A case report and literature review.Saudi Surg J 2019;7:167-171


How to cite this URL:
Maghrabi AA, Aldagal S, Sultan A, Zaidi NH, Aljiffry MM, Abulfaraj M, Jamal W. Bronchoesophageal fistula, a rare complication post laparoscopic sleeve gastrectomy: A case report and literature review. Saudi Surg J [serial online] 2019 [cited 2020 Oct 31 ];7:167-171
Available from: https://www.saudisurgj.org/text.asp?2019/7/4/167/272848


Full Text

 Introduction



Obesity is raising both in developed and developing countries due to the changes in lifestyle and food habits. Surgical treatment of obesity has revolutionized in recent years with laparoscopic sleeve gastrectomy (LSG), being performed more commonly. Hemorrhage and leak are common complications of LSG. Late complication like bronchoesophageal fistula (BEF) is rare to find in literature. We present our case of LSG, which was complicated by the development of BEF and its management.

 Case Report



A 35-year-old female presented to obesity clinic with body mass index of 39 and with unremarkable past history except primary infertility. She failed to reduce her weight by diet and regular physical exercises referred from her obstetrician for consideration of bariatric surgery. After full assessment and preparations including esophagogastroduodenoscopy (EGD), the patient underwent uneventful LSG on May 28, 2015, with normal water-soluble oral contrast swallow and meal study day 1 postoperative; the patient started on clear fluid and discharged home with postbariatric diet, medicinal, and exercise instructions. Seen after 2 weeks in bariatric surgery clinic and her condition was stable, her wounds were checked and advanced to soft diet and multivitamins and proton-pump inhibitor medications were prescribed. Five weeks later, the patient presented with intractable vomiting and severe epigastric pain that was not responding to medical therapy, eventually resulted in electrolyte imbalance and hence she was admitted in a surgical ward for investigation and fluid replacement. Esophagogastroduodenoscopy (EGD) with minimal insufflation was done and showed stenosis at the site of the cardia (mid-sleeved stomach). Through-the-scope balloon dilatations were done up to 12 mm at the stricture site with no improvement in symptoms. Two days later, another EGD was done, and another narrowing was found 5 cm proximal to pylorus in addition to the previous one. A 15-cm long self-expandable totally covered metallic stent (SEMS) applied from the distal esophagus to the first part of the duodenum. Two weeks later, the patient still had recurrent nausea and vomiting, so another EGD showed migration of the SEMS distally. Readjustment of the stent was done and her vomiting improved, but 2 days later, the patient started to have tachycardia, hematemesis, melena, and hemoglobin dropped from 11.7 to 9.7 in 1 day. She was treated conservatively with close observation, pantoprazole infusion, and kept Nill Per Mouth diet. Total parental nutrition was started. Four days later, the patient had developed tachycardia, hypotension, shortness of breath, and pallor. Her hemoglobin level dropped to 4 this time, so urgent EGD was done after blood and fluid resuscitation which revealed ulceration at the upper limit of the stent (distal esophagus), argon beam applied over ulcer and the patient was kept under observation; there was no more hemoglobin drop, and the patient was tolerating oral feeding and was discharged home in stable condition 4 days later. Two weeks after her last admission, she presented to the emergency room with repeated vomiting and epigastric pain; ultrasound abdomen was done which showed gallbladder stones without evidence of cholecystitis. A water-soluble contrast swallow and meal study ruled out leak or obstruction with stent in place. Almost 6 weeks later, she was readmitted with recurrent vomiting and signs of dehydration and electrolyte imbalance as well as productive cough. A supportive management was initiated, and EGD was performed and removal of stent was done. There was suspicion of a fistula opening at the distal esophagus, so a computed tomography (CT) of the chest with oral and intravenous (IV) contrast showed dilated and thickened terminal esophagus with a complex fistula between the lower esophagus and the airways of the medial basal segment of the right lower lobe [Figure 1] and [Figure 2].{Figure 1}{Figure 2}

Bronchoscopy confirmed the presence of fistula in the distal right basal medial bronchus of the lower lobe. The patient was offered surgical management, but she refused initially, because of the patient's and her family's wish to avoid surgical management and as her hemodynamic status was stable with parenteral nutrition and broad spectrum antibiotics and antifungal therapy; she wanted to try more conservative management approach if she can avoid going through major surgery to repair the fistula. We entertained the trial of less invasive endoscopic and conservative management, which included NPO, high dose proton-pump inhibitor (PPI) therapy, IV broad-spectrum antibiotics, and antifungal, total parenteral nutrition and chest physiotherapy. Other attempts to place endoscopic SEMS stent with follow-up barium meal showed persistent leak of fistula and distal migration of the stent [Figure 3]. EGD and retrieval of the stent and placement of Ovesco clip (over-the-scope clip [OTSC]) was done. One week later, CT chest showed persistent of the fistula. The decision of operative surgical intervention was discussed again with the patient and her family who agreed to proceed for high-risk surgery to close the fistula, repair of esophageal fistula site, segmental lung resection and laparoscopic cholecystectomy.{Figure 3}

Intraoperative bronchoscopy showed the site of fistula at right lower basal medial segment, and EGD confirmed location of fistula, at distance 35 cm with multiple holes seen at the esophageal side. After preparations, double-lumen lung isolation, central line, Foley catheter, and pneumatic compression, the patient was placed in left lateral decubitus position, and right 7th intercostal space posterior thoracotomy was performed. We were able to identify the fistula site. Excision of fistulous tract was done, leaving 8 cm defect in lateral wall of the lower esophagus with thick mucosa that has been debrided to bleeding edges. Nonanatomical segmental resection was done with blue stapler 60 of the medial basal segment of right lower lobe. Air/water leak test was done which showed no air leak from the lung resection stapler line. A traction diverticulum was noted in the esophagus due to chronic inflammation, and stapling of the esophageal defect was done using stapler 60 TL green over in placed EGD to close the lateral defect without narrowing the esophageal lumen. The second layer of interrupted 3/0 PDS buttress sutures was carried out, followed by intercostal muscle flap and BioGlue to cover the fistula site. Air/water leak test was negative for leak in the esophagus, then insertion of two chest tubes, followed by abdominal laparoscopy for the removal of gallbladder and insertion of feeding jejunostomy tube in the same operative setting. Postoperative day 2, a water-soluble swallow and meal contrast study showed no leak and free passage of contrast to the duodenum. The patient started on oral fluid diet day 4 postoperative and advance to full fluid diet. The patient was discharged 10 days later in good condition with planned clinic follow-up in 2 weeks; pain medications, multivitamins, and PPI were prescribed to the patient.

On follow-up clinical visits, the patient was tolerating oral diet and her symptoms of reflux and obstruction improved. EGD at 6 months and CT chest showed no evidence of fistula recurrence and resolution of esophagitis with normal-looking sleeve stomach. At 1 year postoperative, the patient got pregnant and delivered a healthy baby girl with cesarean section approach.

 Discussion



LSG has emerged as the procedure of choice for morbid obesity.[1] It is a restrictive procedure, which works by restricting food intake and producing early satiety by removing ghrelin-producing portion of stomach.[2]

BEF is defined as an abnormal connection between bronchial tree and esophagus. Common causes are malignancies, but other causes such as infections, esophageal injury, surgery, foreign body, prolonged endotracheal intubation, ingestion of chemical products, and swallowed dental prosthesis have been reported.[3],[4],[5],[6] Diagnosis is usually delayed due to nonspecific symptoms with the most commonly pathognomonic symptom of cough or chocking during ingestion of food or fluid. Other presentations include recurrent Pneumonias and lung abscesses or gastrointestinal (GI) bleeding. Diagnosis requires a high index of suspicion. Imaging studies include plain chest radiography, contrast study, CT of the chest, EGD, and bronchoscopy. Bronchoscopy may reveal inflammatory changes; a discrete focus of heaped-up granulations, visualization of the fistula orifice, and appearance in the bronchus of dyed instilled in the esophagus would be diagnostic. Braimbridge and Keith classified tracheoesophageal fistula and BEF after reviewing 23 cases, Type Ia wide-necked congenital diverticulum of the esophagus. Stasis may occur in the dependent tip, which becomes inflamed and perforates into the lung. Type 2a short track runs directly from the esophagus to the lobar or segmental bronchus. Type III consists of a fistulous track connecting the esophagus to a cyst in the lobe, which in turn communicates with the bronchus. In Type IV, the fistula runs into a sequestrated segment, which is recognized by the presence of a systemic arterial supply from the aorta.[7]

Following sleeve gastrectomy, bleeding occurs in 1%–6% of cases.[8] Leaks occurs up to 5% of cases.[1] Gastric leak occurs mainly in the upper part of the stomach due various factors such as high intragastric pressure, impaired peristaltic activity, and ischemia, thereby decreasing oxygen supply and resulting delayed healing. Staple line dehiscence and thermal damage are other possible causes of leak. Early leaks are detected 1–4 days postoperatively, intermediated 5–9 days, and late after 10 days. Another classification is Type 1 when leak is local without dissemination or spillage and Type 2 when dissemination to peritoneal or thoracic cavity. If extraluminal leak is diagnosed late, then it may result in peritonitis, sepsis, gastrocutaneous fistula, or organ failure and even death.[9] Early diagnosis of leak is crucial for proper management; tachycardia and fever are two constant indicators in many studies.[10],[11]

The principles for successful fistula management are control of sepsis, establishment of a good nutritional status, pulmonary support rehabilitation, and endoscopic and/or surgical repair. In our case, the fistula appeared after the iatrogenic injury occurred during EGD, and the trial to remove the covered SEMS from the stomach and necrosis in the lower esophageal wall with argon beam coagulation (ABC) was the most likely culprit. Initial management includes the treatment of infection associated with the fistula formation (mediastinitis), endoscopic management OTSC,[12] SEMS,[13] and Amplatzer vascular plug.[14] SEMS has been widely used for malignant palliation, leaks, perforation, and fistula, with a high successful rate. Swinnen et al. reported the complications of SEMS, spontaneous migration occurred in 11.1% of stents, and there were minor complications (dysphagia, hyperplasia, and rupture of coating) in 20.9% and major complications (bleeding, perforation, and tracheal compression) in 5.9%.[13] OTSC is a new endoscopic modality, used for closure of full-thickness GI tract fistula tracts. Zolotarevsky et al. reported one case of BEF in a woman with esophageal diverticulum, with successful management and closure of fistula. We believe that the failure of conservative approach in our patient was due to many reasons such as chronic fistula, poor nutrition status, presence of reflux, and obstructive symptoms such as recurrent forcible vomiting which may lead to stent migrations and possible erosions, another cause in this patient fistula development that the fact of using ABC in inflamed bleeding wall of esophagus, which leads to necrosis of the wall and the fistula tract formation. The fact of finding multiple holes and defect with the development of esophageal diverticulum indicates the chronicity of the fistula which considers another reason for failure of conservative therapy with less invasive approaches for fistula closure with stent or clips applications. In chronic fistula, surgical approach is considered the gold standard. The standard operative procedure consists of right posterolateral thoracotomy or minimally invasive approach through video-assisted thoracoscopy, exposure and division of the fistula, primary repair of bronchus and esophagus, and pedicle tissue interposition in addition to J feeding tube through abdominal approach for postoperative nutrition. We have chosen the thoracotomy approach due to dense adhesions encountered in the chest cavity with the chronic and large defects in the esophagus. Complications after surgical repair of BEF are often due to poor general condition of the patient and pulmonary failure. Mangi et al. study showed that 6 out of 13 patients discharged home on postoperative day 10 and the other patients had complications including persistent pinhole fistula, thoracic duct leak which required re-operation, prolonged intubation and respiratory toilet, transient subglottic edema requiring re-intubation, and thoracentesis for persistent pleural effusion.

 Conclusion



BEF is a rare complication of sleeve gastrectomy, which is difficult to diagnose and require intensive management, nutritional support, control of sepsis, leak management, and eventually definitive surgical management, which is the gold standard. Endoscopic therapy includes SEMS and OTSC still good modalities with acceptable successful rates that can be used in selective cases with proper patient selection in acute presentation of BEF.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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