Diagnosis and Management of Gastro-pleural Fistula in Metastatic Malignancy

Abstract

Gastro-pleural fistula is a rare condition, and the diagnosis can be challenging, as demonstrated in our case. The management is even more complex, with wide gamut of management strategies from more conservative management such as endoscopic closures and minimally invasive video-assisted thoracoscopic surgery (VATS) to open surgical repair. We present the case of a 55-year-old female with metastatic renal cell cancer with prior radiation therapy and cabozantinib treatment who was diagnosed with gastro-pleural fistula after extensive workup. She underwent endoscopic closure and subsequent jejunostomy tube feeding, venting gastrostomy tube, and draining chest tube. Antibiotics and chest tube drainage were primary modalities for treatment of her empyema. Subsequently, she required laparoscopic surgery for fistula repair.

Gastropulmonary Fistula in a Renal Transplanted Patient! Who Knew?

“…3 Most cases of gastro pulmonary fistula occur in patients with one or more of the following risk factors: surgery and/or trauma to the gastro-intestinal tract or abdomen, perforated gastric ulcers, a history of recurrent or prolonged pulmonary infections, malignancy, and radiation therapy. 4 In our literature search we were unable to find any case or association between Klebsiella infections & gastro pulmonary fistulas. Klebsiella pneumoniae is one of the most common gram-negative bacteria encountered by physicians particularly in solid organ transplantation, with immunosuppressant therapy, mechanical ventilation, prolonged use of invasive devices and use of antimicrobial agents.…”

Simultaneous Tumor Shrinkage and Bronchial Perforation Induced by Nivolumab plus Cabozantinib Combination Therapy in a Patient with Collecting Duct Carcinoma

“…However, little information is known on the frequency of bronchial perforation. There are few case reports of aero-digestive fistula following cabozantinib use [5,6] and a case report of bronchial fistula following sunitinib use [7]. Moreover, there are few reports on ICI-induced perforation, with a case report on tracheoesophageal fistula following pembrolizumab use for squamous cell lung cancer [8] and bronchoesophageal fistula following nivolumab use for cancer of unknown primary origin [9].…”

“…The mechanism of VEGFR-TKI-induced organ perforation is not yet fully understood, but tissue necrosis may occur due to the vasoconstrictive effect of nitric oxide [10]. Risk factors for organ perforation include a history of surgery, intestinal and abdominal trauma, presence of gastric ulcer or diverticulum, prolonged respiratory infection, and prior radiation therapy [6, 11].…”

Delayed gastropleural fistula: a rare cause of a persistent pleural effusion after blunt force trauma

“…Published approaches include endoscopic techniques for fistula occlusion (e.g. fistula clipping, argon coagulation, fibrin glue, mesh application) [ 2 , 6 , 7 ], direct laparoscopic repair [ 2 , 8 ], and open repair using either an abdominal [ 2 ] or thoracic approach [ 9 ]. Classically an open approach via laparotomy was preferred, with a thoracotomy in cases with high-volume thoracic contamination [ 2 ].…”

“…Ultimately, the choice of technique is guided by surgeon preference. Current evidence does not support the use of conservative management [ 6 ]. Despite complex management strategies, the morbidity associated with GPF is high.…”