A 50-year-old woman presented with chief complaints of fever and cough. She had a poorly controlled left lung abscess and a history of congenital left diaphragmatic hernia treated 9 years prior with composite mesh. Computed tomography showed suspected fistula formation between the left lower lung lobe and stomach, and the tract was visualized in a contrast study from an upper gastrointestinal endoscope. We suspected a gastrobronchial fistula associated with mesh infection and performed en bloc resection of the mesh and inflamed organ tissue, comprising resection of the left lower lung lobe and left diaphragm, partial gastrectomy, and splenectomy. The diaphragm was reconstructed using the latissimus dorsi and rectus abdominis muscles. To our knowledge, this is the first report describing this treatment strategy for gastrobronchial fistula associated with mesh infection. The patient\'s postoperative course was favourable.

A 44-year-old woman underwent sleeve gastrectomy, which was complicated by a leak. She was treated with two sessions of endoscopic internal drainage using plastic double-pigtail stents. Her clinical evolution was favorable, but four months after the initial stent placement, she became symptomatic, and a gastrobronchial fistula with the proximal end of the stents invading the diaphragm was diagnosed. She was treated with antibiotics, plastic stents were removed, and a partially covered metallic esophageal stent was placed. Eleven weeks later, the esophageal stent was removed with no evidence of fistula. Inappropriate stent size, position, stenting duration, and persistence of low-grade inflammation could explain the patient\'s symptoms and provide a mechanism for gradual muscle rupture and fistula formation. Although endoscopic internal drainage is usually safe and effective for the management of post-laparoscopic sleeve gastrectomy leaks, close clinical and radiological follow-up is mandatory.

BACKGROUND: Gastrobronchial fistulas are rare, but life-threatening, complications of esophagectomy. They are caused by anastomotic leakage and mainly occur around anastomotic sites. In the present paper, we report a rare case of leakage from the staple line of a gastric tube after esophagectomy for esophageal cancer, which was successfully treated using an intercostal muscle flap and lung resection.
METHODS: A 61-year-old male underwent subtotal esophagectomy with regional lymphadenectomy for esophageal cancer. The sutures along the staple line of the gastric tube failed 11 days after surgery, and a pulmonary abscess was also found on imaging. The abscess did not heal after conservative treatment; therefore, right lower lobectomy, gastrobronchial fistula resection, primary closure, and patching of the leaking portion of the gastric tube with an intercostal muscle flap were performed 9 months after the first operation. The patient\'s postoperative course was uneventful, and he was discharged on the 354th day.
CONCLUSIONS: We experienced a case involving a gastrobronchial fistula caused by leakage from the staple line of a gastric tube and successfully treated it by performing right lower lobectomy and patching the leak with an intercostal muscle flap.

Even in the hands of highly experienced bariatric surgeons, perioperative complications are inevitable. Of these, leaks and fistulas are amongst the scariest complications. Intrathoracic gastric fistulas (ITGF) can be associated with serious morbidity, mostly when cases are misdiagnosed or detected with delay. This is a systematic review of the literature to investigate the clinical and surgical outcomes of morbidly obese adult patients with a confirmed diagnosis of ITGF following bariatric surgery. A pooled analysis of 25 articles, encompassing 76 patients with post-bariatric ITGF, showed that the clinical outcome depends on the initial presentation, timing of the diagnosis in relation to symptom onset, and prompt and effective treatment. Any septic or unstable patient must undergo urgent surgical intervention, while stable patients might tolerate a step-up approach and watchful waiting for nonsurgical treatment. Among those who undergo surgery, treatment failure and the mortality rate are substantially high. Contingent upon a prompt management strategy, patients with postbariatric ITGF can generally have a favorable outcome in the long term.

Obesity and its related comorbidities is a major health problem worldwide. Sleeve gastrectomy is regarded to be one of the most effective bariatric surgeries with a relatively low risks of complications. Gastrobronchial fistula is an extremely rare and a serious complication after bariatric surgeries, it is associated with major morbidity. A 48-year-old obese lady with a BMI of 40 had underwent laparoscopic sleeve gastrectomy 7 years ago, she developed leak at the 10th postoperative day which was treated with drainage. After 4 years she presented with left subphrenic abscess which was treated with drainage, splenectomy and endoscopic stent. After one year she had repeated chest infections and was coughing-up recently ingested food items. CT-scan showed left subphrenic collection with abnormal fistulous tract between the bronchial tree and the subphrenic cavity. Left thoracotomy was performed, a complex fistula was found between the remnant parts of the gastric fundus, transverse colon and lung. Resection of the fistula was performed, the stomach and colon were closed in 2 layers, resection of the affected segment of lung was performed and the diaphragm was sutured. The BMI was 19 at the last admission. Gastro-colo-bronchial fistula is unreported after sleeve gastrectomy and the management is challenging. Surgeons may follow the same principles of management as in cases of gastrobronchial fistula, but we suggest earlier surgical intervention with the administration of broad spectrum antibiotics. Nutritional deficiencies must be corrected, and such patients must be treated with multidisciplinary team, with an extended duration of follow-up.

OBJECTIVE: Gastropleural and gastrobronchial fistulas (GPF/GBFs) are serious but rare complications after bariatric surgery whose management is not consensual. The aim was to establish a cohort and evaluate different clinical presentations and therapeutic options.
METHODS: A multicenter and retrospective study analyzing GPF/GBFs after bariatric surgery in France between 2007 and 2018, via a questionnaire sent to digestive and thoracic surgery departments.
RESULTS: The study included 24 patients from 9 surgical departments after initial bariatric surgery (21 sleeve gastrectomies; 3 gastric bypass) for morbid obesity (mean BMI = 42 ± 8 kg/m2). The GPF/GBFs occurred, on average, 124 days after bariatric surgery, complicating an initial post-operative gastric fistula (POGF) in 66% of cases. Endoscopic digestive treatment was performed in 79% of cases (n = 19) associated in 25% of cases (n = 6) with thoracic endoscopy. Surgical treatment was performed in 83% of cases (n = 20): thoracic surgery (n = 5), digestive surgery (n = 8), and combined surgery (n = 7). No patient died. Overall morbidity was 42%. The overall success rate of the initial and secondary strategies was 58.5% and 90%, respectively. The average healing time was approximately 7 months. Patients who had undergone thoracic surgery (n = 12) had more initial management failures (n = 9/12) than patients who had not (n = 3/12), p = 0.001.
CONCLUSIONS: Complex and life-threatening fistulas that are revealed late require a multidisciplinary strategy. Thoracic surgery should be reserved once the abdominal leak heals; otherwise, it is associated with a higher risk of failure.

暂无摘要。

BACKGROUND: With the high rates of obesity worldwide, laparoscopic sleeve gastrectomy (LSG) has become a very popular procedure. Due to its simple technique, rare complications might be overseen. Gastric leaks and fistula are fairly uncommon complications. In comparison to other types of fistulas, gastrobronchial fistulas are rarer with serious complications. Definitive management is yet to be determined. We intend to explore the literature on the management approach of such patients.
METHODS: A 46-year-old male, presented with on/off abdominal pain, productive cough, and vomiting. The patient had left sided rhonchi on examination. In addition to a history of laparoscopic sleeve gastrectomy (LSG) 4 years ago. Imaging confirmed the presence of a gastrobronchial fistula. Conservative and endoscopic treatment failed. Consecutively, surgery was indicated. A laparoscopic mini gastric bypass with refashioning of gastric fistula edges and closure with graham patch was done.
CONCLUSIONS: Given the increasing number of such surgeries performed the recognition of acute and chronic complications, and their optimal management is of great importance. Although performing a Roux-en-Y fistulojejunostomy was recommended in the literature, conservative and endoscopic treatment should be considered before.

Bariatric surgery has rapidly emerged as a modality for managing morbid obesity; however, despite being considered safe, some complications do exist. Formation of a gastrobronchial fistula is a rare complication of laparoscopic sleeve gastrectomy that is associated with high morbidity and mortality. Nowadays, novel endoscopic techniques have widely been adopted in the management of such cases, as they provide minimally invasive options that decrease the morbidity and mortality. Here, the author presents a report of a middle-aged, morbidly obese male who had previously undergone laparoscopic sleeve gastrectomy and returned with a 3-month history of productive cough. On upper gastrointestinal series, the patient was found to have a fistula communicating the stomach to the bronchial tree of his left lung (gastrobronchial fistula). He was treated with endoscopic fistula closure using an over-the-scope clip and a fully-covered Niti-S metallic stent. After this treatment, the patient\'s symptoms improved dramatically, and the stent was successfully removed 12 weeks later. This report highlights the management of a patient with gastrobronchial fistula formation following laparoscopic sleeve gastrectomy as well as provides a literature review of using combined endoscopic management to treat gastrobronchial fistulas.

We describe a patient who developed an intractable leak from the gastric sleeve after laparoscopic sleeve gastrectomy, resulting in the development of a gastrobronchial fistula. Affected individuals typically have a persistent leak from the gastric sleeve with recurrent subphrenic abscesses, and when a gastrobronchial fistula develops, these patients may present with paroxysms of coughing immediately after ingestion of solids or liquids. In the appropriate clinical setting, a barium study not only may show the leak, but also directly visualize the gastrobronchial fistula. If aggressive endoscopic dilation procedures and/or endoscopic placement of stents or clips fail to facilitate healing of the leak and fistula, these patients may require surgical intervention, with conversion of the sleeve to a Roux-en-Y gastric bypass or even a partial or total gastrectomy. The development of a gastrobronchial fistula after sleeve gastrectomy therefore can be extremely challenging to manage.