Gastro-bronchial Fistula After Laparoscopic Nissen Fundoplication

Abstract

Gastro-bronchial fistula (GBF) is an unusual complication of Nissen fundoplication, particularly when performed via a transabdominal approach. The mechanism of such fistula is thought to be related to a previously untreated ulcer in the mucosa of the wall of the gastric wrap or to a subclinical injury to the gastric wall during the process of division of the short gastric vessels and gastric mobilization. This process is greatly aided by herniation of the wrap into the chest in the postoperative period, placing the stomach in intimate contact with the bronchial tree. The diagnosis of GBF is often difficult to establish and requires a high index of suspicion. Most investigative studies tend to be unrevealing. Historically, an upper gastrointestinal series was the recommended study of choice in the literature. Newer reports, however, highlight the value and importance of upper endoscopy as a diagnostic tool in this condition. The majority of GBF were reported in the era of transthoracic Nissen fundoplication. The incidence of this complication seems to have markedly decreased after the widespread adoption of the transabdominal approach to the treatment of GERD. We are reporting the second case in the literature of a GBF developing after a laparoscopic Nissen fundoplication in a 28-year-old male patient. This case report should serve to increase awareness of this uncommon complication that should be considered in the differential diagnosis of patients with recurrent pneumonia or refractory hemoptysis after major upper gastrointestinal surgical procedures.

Surgical Repair of a Traumatic Gastrobronchial Fistula

“…On the other hand, the fistula may have been a result of chronic inflammation with erosion of lung and stomach tissue as a result of the (recurrent) traumatic diaphragmatic hernia. Gastrobronchial fistulas after previous Nissen fundoplication is described in the literature [ 8 ]. The authors discuss a microtrauma of the gastric wall during the division of the short gastric vessels.…”

“…The authors discuss a microtrauma of the gastric wall during the division of the short gastric vessels. A subsequent postoperative herniation of the gastric wrap into the chest led to close contact between the injured gastric tissue and the bronchial system and triggered the fistula [ 8 ].…”

Nissen Fundoplication

“…Similar mechanisms as described above have been implicated in the pathogenesis of gastrobronchial and esophagobronchial fistulae following fundoplication. 24,32-35 An important etiopathological factor is believed to be the placement of the wrap above the diaphragm (an intrathoracic wrap) leading to close proximity of the stomach to the bronchial tree. Negative intrathoracic pressure leads to gastric distension causing gastrin production, with subsequent ulceration and fistula formation.…”

“…36 With a higher incidence reported in fundoplication done by the transthoracic approach, this complication has also been described in association with transabdominal and laparoscopic approaches. 32 Treatment would involve repair of the fistula and medical management of the pulmonary complications.…”