Gastrobronchial Fistula: A Rare Complication of Postlaparasc
Obesity is one of the leading causes of morbidity and mortality in countries all over the world, and its prevalence has been increasing dramatically in recent years. Bariatric surgery is considered the gold standard of care for patients who failed conservative management. Laparoscopic sleeve gastrectomy (LSG) is of increasing popularity. One of its vicious consequences is the development of acquired fistula between the stomach and the tracheobronchial tract due to intractable gastric leak. A 25-year-old male presented to the emergency department 2 months post-LSG with an unremarkable postoperative course. At presentation, he had left upper quadrant abdominal pain associated with repeated vomiting, subjective fever, generalized body aches, and cough for two weeks. The cough was productive of greenish sputum with a tinge of blood and provoked by any oral intake. A review of other systems was unremarkable. Physical exam shows the following: RP 103 BPM, BP 129/70, RR 18, SpO2 99%, and temperature: 36.4°C. Abdomen examination shows soft and lax, mild generalized tenderness especially in epigastrium, normal bowel sounds. Chest examination shows no increased work of breathing, normal chest expansion, percussion note slight dullness in the left lower zone, chest sounds decreased breathe sounds in the left lower zone with bronchial breathing, and fine crackles.

Initial chest radiograph showed a left lower lung zone heterogeneous opacity silhouetting the left hemidiaphragm and left retrocardiac air lucency. A follow-up CT scan of the abdomen was done to rule out an intra-abdominal fluid collection (oral contrast was not given as the patient was intolerant of oral intake) and showed a left lower lobe consolidation with cavitation and tract connecting it with the gastric remnant lumen. The gastroenterology team was consulted, and esophagogastroduodenoscopy (EGD) confirmed the presence of a large fistula orifice just below the gastroesophageal junction. For more anatomic delineation of gastrobronchial fistula, an upper GI study with water-soluble contrast was performed which showed contrast leakage extending upwards from the gastric remnant into the left lung base with contrast opacification of the left lower lobe peripheral bronchial branches. After confirmation and proper surgical planning of gastrobronchial fistula, bariatric surgery was intervened by the laparoscopic approach. The operative technique was resection of the fistula (found connected to GE junction) and gastrojejunal anastomosis. The patient had a successful postoperative recovery.