Fístula gastrobrônquica como complicação rara de gastroplastia para obesidade: relato de dois casos

Abstract

Gastrobronchial fistula is a rare condition as a complication following bariatric surgery. The management of this condition requires the active participation of a pulmonologist, who should be familiar with aspects of the main types of bariatric surgery. Herein, we report the cases of two patients who presented recurrent subphrenic and lung abscess secondary to fistula at the angle of His for an average of 19.5 months. After relaparotomy was unsuccessful, cure was achieved by antibiotic therapy and, more importantly, by stenostomy and endoscopic dilatation, together with the use of clips and fibrin glue in the fistula. These pulmonary complications should not be treated in isolation without a gastrointestinal evaluation since this can result in worsening of the respiratory condition, thus making anesthetic management difficult during endoscopic procedures.

Gastrobronchial fistula a rare complication post laparoscopic sleeve gastrectomy

“…[1] It has been postulated that most gastric fistulas and leaks occur not because of staple line dehiscence but because of ischemia in the gastric wall next to the staple line. [2] Stenosis of the gastric pouch increased the pressure and directed the food to the fistula at the angle of His, leading to the appearance of recurrent subphrenic infection.…”

“…[2] Stenosis of the gastric pouch increased the pressure and directed the food to the fistula at the angle of His, leading to the appearance of recurrent subphrenic infection. [1] Gastrobronchial fistula is caused secondary to subphrenic abscess. Infection may spread by lymphatic flow from below to above the diaphragm or by directly eroding through the diaphragm, causing a lung abscess that eventually drains into a bronchus.…”

“…[1] Laparoscopic sleeve gastrectomy is a relatively new and evolving surgical technique indicated in the treatment of morbid obesity. This procedure has been gaining widespread popularity among both patients and surgeons alike.…”

Therapeutic flexible endoscopy after bariatric surgery: a solution for complex clinical situations

“…These principles can be applied to Roux-en-Y bypasses, 2 but they seem to be more beneficial after gastric sleeve procedures. 3,4 The type of endotherapy (stent, stricturotomy or dilatation) depends on the time of the postoperative period, which is divided into 4 stages: acute (<7 days), early (7-45 days), late (1.5-3 months) and chronic (>3 months). The widest (28 mm) and longest (15 cm) self-expandable metallic stents promote the occlusion of the fistula orifice, rectify the deviation from the axis of the gastric pouch and expand distal stenosis, resulting in decreased endoluminal pressure.…”

“…We began using this approach some years ago due to the failure of isolated endoscopic dilatation in areas of intense tissue fibrosis, in late stages and in chronic cases. 4 Thus, immediately after the incision in the tough, stenotic area, we use dilatation with a 30-mm balloon, which corrects anatomic and functional alterations. 5 This early endoluminal approach reduces hospitalization and intensive care times especially in gastric sleeve procedures.…”