Gastro-Bronchial Fistula post Sleeve Gastrectomy 4 cases endoscopic surgical and conservative management

1. Gastro-Bronchial Fistula
post Sleeve Gastrectomy
HUSSEIN MCHEIMECH.MD
GEORGES KHALIFEH PGY IV
AL ZAHRAA UNIVERSITY HOSPITAL

2. Case 1
44 yo male patient ,kth hypertension , operated with sleeve gastrectomy 3 months
ago
BMI : 33.8
Weight: 100kg
Chief complaint: fever, epigastric pain, vomiting, cough with greenish sputum
Gastroscopic finding: at the level of GE junction, above the cardia, 9mm fistula
Surgery type/date: Roux en Y Eso-Jejunostomy
LOS : 18 days

11. Case 2
27 yo female patient kth DM DL ,operated with sleeve gastrectomy
BMI :44
Weight: 115 kg
Chief complaint: fever, epigastric pain, vomiting, cough with greenish sputum
After 10 months :fistula+ collection
Gastroscopy, fistula identified 1cm below GEJ
Diagnosed to have Gastro pleural fistula on Ct scan
First procedure: drainage + feeding jejunostomy
Second procedure :Eso-jejunostomy (after 1 month)
LOS: 15 days

12. 16 yo female patient ,operated with sleeve gastrectomy 2 months ago
BMI : 44
Weight: 123 kg
Chief complaint: fever, epigastric pain and productive cough
CT scan showed collection in celiac region and irregular soft tissue mass in lower lobe
left lung
Gastroscopy showed small fistula around GE junction
Endoscopic treatment:
Ovesco clip
Stenosis at incisura (necessitates three pneumatic dilation)
LOS: 5 days
CASE 3

13. Case 4
31 yo female patient , operated with sleeve gastrectomy 36 months ago
BMI : 31
Weight: 92 kg
Chief complaint: fever ,cough , pneumonia
Surgical procedure: RYGB distal to fistula
Then Eso-jejunostomy (few months later)

14. LAPAROSCOPIC SLEEVE GASTRECTOMY
Most popular bariatric procedure
Gold standard surgical treatment for morbid obesity
Complicated by gastric fistula in 0-8% :
1) Mechanical fistula: early, within 2 days
2) Classic ischemic fistula: late, after 7 days

16. GASTROBRONCHIAL FISTULA
Rare late complication (11% of GF)
Life threatening complications
Challenging in diagnosis & treatment

17. CLINICAL PRESENTATION
Fever (100%)
Tachycardia
Productive cough with expectoration of saliva +++
Recurrent pneumonia
Dyspnea/ Wheezing
Abdominal pain
Thoracic pain
Expectorations of food residues/ surgical endoclips

18. DIAGNOSIS
Onset: 2 months to 3 years
Tools:
1) Abdominal CT Scan with PO contrast
2) UGI
3) Gastroscopy

19. PATHOPHYSIOLOGY
Failure of conservative/ endoscopic treatment of GF (especially in case of distal stenosis)
Diaphragmatic injury
Weak point is the fibrotic zone of diaphragm;positive intra-abdominal pressure & negative intra-
thoracic pressure

20. MANAGEMENT
Medical treatment:
1) TPN
2) Antibiotics (broad-spectrum) & Antifungal
3) PPI
4) Hydration
Endoscopic treatment:
1) Stent
2) Ovesco clip
3) Balloon dilation

21. MANAGEMENT
Surgical treatment:
1. Total gastrectomy
2. Roux-en-y
3. Fistulo-jejunostomy

22. Fistulo-jejunostomy

23. CONCLUSION
GBF is a serious complication
It may appear up to 3 years postop
Conservative & endoscopic management (dilation, stent, clip..) :
Several procedures
Frequent hospitalization
Long hospital stay (up to several months)
Surgery offers definitive treatment for GBF

24. Thank you …