Gastropleural fistulas are rare complications with significant mortality and morbidity. There are limited reports on the successful management of gastropleural fistulas with advanced endoscopic procedures. The following case of a 75-year-old woman with a history of recurrent pseudomyxoma peritonei secondary to ruptured low-grade appendiceal mucinous neoplasm status post cytoreductive surgery highlights the successful treatment of a gastropleural fistula with endoscopic suturing.

A rare complication of sleeve gastrectomy surgery is gastropleural fistulas (GPF), where a fistula develops between the stomach and the pleural cavity. This complication can be debilitating and present with many nonspecific symptoms making it hard to diagnose. This is a case report of a 45-year-old female who underwent robotic-assisted gastric sleeve revision after developing a GPF as a complication of her gastric sleeve six years later. This led to the development of a recurrent subdiaphragmatic abscess in the left upper quadrant. Before presenting to us, she underwent multiple hospitalizations and received numerous endoscopic stent treatments. However, the abscess continued to recur. Given her recurrent abscess, she consented to gastric sleeve revision. GPFs are amongst the rarest complications, with only 76 reported cases. Since this complication can cause shock, early diagnosis and treatment are necessary to improve patient outcomes and reduce morbidity.

We herein report a 79-year-old man diagnosed with primary gastric diffuse large B-cell lymphoma (DLBCL) with gastropleural fistula (GPF), successfully treated by chemotherapy without surgery. If primary gastric DLBCL perforates during chemotherapy, surgery is often warranted. Our patient\'s computed tomography findings showed loculated pleural effusion with air foci in the left lower lobe, suggesting GPF. After six cycles of rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) chemotherapy, the fistula fully closed, and complete remission was achieved. In conclusion, while gastric DLBCL can exhibit spontaneous GPF, it can be treated with chemotherapy alone, which was well-tolerated in our patient.

BACKGROUND: Gastropleural fistula is an exceptionally rare condition, the incidence of which is currently unknown (Kunieda et al. in Intern Med 51(3):331, 2012,  https://doi.org/10.2169/internalmedicine.51.6823 , Iqbal et al. in Cureus 11(2):e4136, 2019, https://doi.org/10.7759/cureus.4136 , Kathayanatt et al. in Lung India 37(2):174-175, 2020, https://doi.org/10.4103/lungindia.lungindia_242_17 ). The etiology varies from traumatic or iatrogenic injury to perforation in a herniated stomach due to ischemia, ulceration, or malignancy.
METHODS: A 27-year-old European male presented to our hospital with complaints of general weakness and shortness of breath. The patient had a single episode of hemoptysis before admission. A computed tomography scan demonstrated a left-sided pyopneumothorax, a defect in the left main bronchus, and signs of pneumonia in the lower sections of the right lung. Therefore, a rare complication of perforation of a gastric fundus ulcer with the formation of a subdiaphragmatic abscess, gastropleural fistula, gangrene of the left lung with circular necrosis of the left main bronchus and diastasis of its edges, and pleural empyema on the left is presented in this report.
CONCLUSIONS: Although, a radical surgery may be preferable for this suspected malignancy; it should be weighed carefully against the risk of sepsis and the morbidity associated with a prolonged procedure in a sick patient. Damage-control surgery may be a viable option for a very sick patient, with more extensive resection reserved for later, provided the risk of infection and bleeding has been mitigated.

Mucormycosis is a rare opportunistic fungal infection commonly affecting immunocompromised individuals. There has been a surge in the number of these cases during the second wave of the Coronavirus Disease 2019 (COVID-19) in India. Mucormycosis has been reported to occur concurrently or a few weeks post-recovery from COVID-19. There have been multiple case reports/case series of rhino-orbital mucormycosis in India as a complication in COVID-19 pneumonia. We report two unique presentations of COVID-19-associated mucormycosis (CAM) in patients recently recovered from COVID-19. The first patient is an uncontrolled diabetic with Fournier\'s gangrene at presentation, which on further evaluation, showed features of mucormycosis. The second one is a case of uncontrolled diabetes with a previous COVID-19 infection presenting with pulmonary mucormycosis and aspergillosis, complicated by a gastropleural fistula. While liposomal amphotericin B (L-ampB) was started for both patients, they significantly deteriorated during their course of hospital stay due to the severity of the disease.

Gastropleural fistula (GPF) is a pathological communication between stomach and pleural cavity. GPF is described rarely in adults following bariatric surgery, iatrogenic perforations, complicated empyema thoracis, penetrating chest trauma, perforated malignant gastric ulcers, and invasive tumors. GPF in children is extremely rare. The authors describe a female child with leukemia, who presented with left-sided pneumonia and chylothorax. After a delay of around 3 wk she was diagnosed with GPF, which was due to a perforated gastric ulcer induced by high-dose steroids which she was receiving as chemotherapy. She was managed with repair of GPF and had a favorable outcome.

Gastropleural fistula (GPF) is a rare pathological communication between the stomach and pleura. It may complicate sleeve gastrectomy (SG). An endoscopic application of OTSC can be used to manage GPF.

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.

Gastropleural fistula (GPF) can occur as a rare complication of laparoscopic sleeve gastrectomy (LSG). Here, we present the clinical presentation, radiological findings, and outcome of a 19-year-old female who underwent LGS in Mother and Child Hospital in Shiraz, Iran, but due to leakage in the proximal of the stapler line, the operation converted to a single anastomosis sleeve ileal (SASI) bypass to decrease intraluminal pressure and accelerate healing of leakage site. Three months later, the patient admitted with the impression of empyema and diagnosed finally with a GPF. Although the conversion of LSG to SASI bypass for post leakage may be efficient in controlling the intraabdominal leakage, it will not prevent GPF formation, so applying another surgery method such as classic bypass in this situation may be more effective in the management of stapler line leakage.

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.