Case Study
Management of a rare gastrobronchial fistula following recurrent pancreatitis
Asian Cardiovascular & Thoracic Annals 2014, Vol. 22(8) 987–989 ß The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492313503965 aan.sagepub.com
Muhammad Asghar Nawaz1, Euan Dickson2 and Ian W Colquhoun1
Abstract A 41-year-old male smoker presented with choking and coughing up food associated with repeated vomiting. Four years previously, following recurrent episodes of pancreatitis, he required percutaneous necrosectomy. He subsequently had a cholecystectomy and mesh repair of the abdominal wall, and later developed multiple problems including a gastrobronchial fistula. Computed tomography revealed a fistulous connection for which he had a combined procedure. Through a thoracolaparotomy approach, the left lower lobe and fistulous connection were removed along with the surrounding diaphragm and the associated fundus of the stomach. The diaphragm defect was repaired without mesh.
Keywords Bronchial fistula, digestive system fistula, gastric fistula, pancreatitis, respiratory tract fistula
Introduction We report the rare occurrence of a large gastrobronchial fistula following pancreatitis. Thoracic and general surgeons treated the patient by a combined approach for en-block resection of the diaphragm and stomach through a left thoracolaparotomy via the 7th intercostal space, dividing the serratus anterior.
Case report A 41-year-old male smoker developed a chronic persistent gastrobronchial fistula as a complication of gall stone pancreatitis. Four years previously, following recurrent episodes of pancreatitis, he required a percutaneous necrosectomy. He subsequently had cholecystectomy and mesh repair of the abdominal wall, and later developed multiple problems including a gastrobronchial fistula. He was markedly symptomatic with choking and coughing up food particles. He also reported multiple episodes of chest infections and repeated vomiting, but maintained his nutrition with supplemental feeds. Although the diagnosis was evident clinically, the patient was properly assessed by chest radiography, oral gastric miro-contrast swallow, and endoscopy and bronchoscopy to assess the location and extent and to clearly demarcate the fistula.
Computed tomography revealed a chronic abscess cavity with the left lower lobe attached to the diaphragm by a small fistulous connection (Figure 1). Thoracic and general surgeons reviewed the patient jointly along with the anesthetist, and the potential complications and mortality associated with such major surgery were discussed with the patient and his family. Particular attention was paid to his nutritional status and lung function because of vomiting and smoking. He underwent a combined procedure and operative findings of widespread dense adhesions within the pleural and abdominal cavities were noted, in keeping with the longstanding infection. The chest was opened initially and the adhesions were taken down by sharp and blunt dissection. The fissure was poorly developed and was treated by diathermy dissection; the anterior end was treated using a linear stapler. 1 Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow, UK 2 Department of General Surgery, Glasgow Royal Infirmary, Glasgow, UK
Corresponding author: Muhammad Asghar Nawaz, Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Agamemnon Street, Glasgow G81 4HX, United Kingdom. Email: [email protected]
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Asian Cardiovascular & Thoracic Annals 22(8)
The pulmonary artery branches were eventually identified, and the lingular artery preserved while the mainstem lower lobe pulmonary artery was stapled using a Multifire 30 vascular stapler (U.S. Surgical Corporation, Norwalk, CT, USA). The inferior pulmonary vein was identified, mobilized, and also stapled. Access to the bronchus was very difficult between numerous large lymph nodes. These were progressively dissected free, and hemostasis was secured using diathermy and Ligaclips. The bronchus was stapled using a TX30 bronchial unit (Ethicon Endo-Surgery,
Cincinnati, OH, USA), and the lung was left attached to the fistula through the diaphragm. The wound was extended across the costal margin into the upper abdomen, and using a radial approach through the diaphragm, the intraabdominal component of the fistula was identified. Dissection around about the spleen was avoided in view of the known previous fixed abdomen. The fistula into the stomach was identified and resected using a 60-mm linear stapler. The stomach was oversewn with 3/0 polydioxanone suture. The defect in the diaphragm was repaired directly with 2/0 Prolene,
Figure 1. Computed tomography showing an abscess cavity in the lower lobe with surrounding inflammation and a clearly demarcated fistula tract with the stomach and raised left hemidiaphragm.
Figure 2. Histopathological slide of the gastrobronchial fistula, showing the fistula tract, gastric mucosa, and lung.
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avoiding the use of further mesh products in view of the infective history. Basal and apical drains were inserted and the wound was closed in layers. The patient made a straightforward recovery and was discharged home with no residual symptoms. A biopsy confirmed the diagnosis of gastropulmonary fistula with a surrounding chronic infective cavity and associated bronchiectasis, but with no other sinister features (Figure 2). At the 1-year follow-up, the patient had no recurrence of symptoms and a chest radiograph was satisfactory.
Discussion Gastrobronchial fistula is an extremely rare but distressing complication, with scarce data in the literature; approximately 30 cases have been reported.1 Our case report is unique because this gastrobronchial fistula resulted from recurrent episodes of pancreatitis. We are unsure about the mechanism of the association of pancreatitis with this fistula. Gastrobronchial fistula also occurs secondary to subphrenic abscess, where infection may be 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. Erosion into the stomach occurs at the same time. It is very rare for a lung abscess to perforate the diaphragm. Another less common cause may be traumatic perforation of the diaphragm with communication between the stomach and the lung during a previous laparotomy.2 Malignancy or complex infections or abscess following surgery above or below the diaphragm (e.g. gastric bypass surgery for obesity) are envisaged as probable instigators of this devastating condition.3 The clinical manifestations of gastrobronchial fistula can be as variable as its location and depend on the extent and location of the fistulous connection. Distinct symptoms may include post-prandial choking, cough associated with eating, dyspnea, vomiting, and recurrent chest infections.4 Bronchoscopy or endoscopy may fail to visualize the fistula, but gastrointestinal contrast studies and computed tomography are useful to ascertain the diagnosis. Assessment of nutritional status and pulmonary function testing are crucial before embarking on surgery. Involvement of the visceral structures determines the extent of resection. Preservation of lung function, when possible, is fundamental, but segmentectomy may not always be possible if the fistula is large, lung suffered recurrent pneumonitis, and the abscess cavity is
large, as in our case, necessitating a lobectomy. It may be argued whether a lower lobectomy and en-block resection of parts of the diaphragm was really necessary because the lower lobe abscess was just a few centimeters on the scan. We intended to perform a limited resection but the extensive adhesions and distorted anatomy forced a lobectomy. Thoracotomy and celiotomy may provide adequate exposure for resection of the lung and stomach, but if severe dense vascular adhesions constrain the exposure, thoracolaparotomy may be an alternative approach.5 Such cases require a collaborative multimodality endeavor.6 If the patient is considered very high-risk and debilitated with significant comorbidities, a less invasive approach such as stenting might be a suitable choice.7 Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflict of interest statement None declared.
References 1. Jha PK, Deiraniya AK, Keeling-Roberts CS and Das SR. Gastrobronchial fistula—a recent series. Interact Cardiovasc Thorac Surg 2003; 2: 6–8. 2. Al-Qudah A. Traumatic gastrobronchial fistula: case report and review of the literature. J Pediatr Surg 1997; 32: 1798–1800. 3. Aguilo´ Espases R, Lozano R, Navarro AC, Regueiro F, Tejero E and Salinas JC. Gastrobronchial fistula and anastomotic esophagogastric stenosis after esophagectomy for esophageal carcinoma. J Thorac Cardiovasc Surg 2004; 127: 296–297. 4. Campos JM, Siqueira LT, Meira MR, Ferraz AA, Ferraz EM and Guimara˜es MJ. Gastrobronchial fistula as a rare complication of gastroplasty for obesity: a report of two cases. J Bras Pneumol 2007; 4: 475–479. 5. Campos JM, Pereira EF, Evangelista LF, et al. Gastrobronchial fistula after sleeve gastrectomy and gastric bypass: endoscopic management and prevention. Obes Surg 2011; 21: 1520–1529. 6. Nawaz MA, Samarage M, O’Neill K and Punjabi P. Management of a giant thoracic hypervascular paraspinal ganglioma. Ann Thorac Surg 2012; 93: e7–e8. 7. Mao AW, Liu SY, Fang SM, et al. Gastrobronchial fistula: treatment with a covered tracheobronchial stent and an integrated Y-shaped metallic stent. Eur J Radiol Extra 2010;73:e61–4.
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Management of a rare gastrobronchial fistula following recurrent pancreatitis
Asian Cardiovascular & Thoracic Annals 2014, Vol. 22(8) 987–989 ß The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492313503965 aan.sagepub.com
Muhammad Asghar Nawaz1, Euan Dickson2 and Ian W Colquhoun1
Abstract A 41-year-old male smoker presented with choking and coughing up food associated with repeated vomiting. Four years previously, following recurrent episodes of pancreatitis, he required percutaneous necrosectomy. He subsequently had a cholecystectomy and mesh repair of the abdominal wall, and later developed multiple problems including a gastrobronchial fistula. Computed tomography revealed a fistulous connection for which he had a combined procedure. Through a thoracolaparotomy approach, the left lower lobe and fistulous connection were removed along with the surrounding diaphragm and the associated fundus of the stomach. The diaphragm defect was repaired without mesh.
Keywords Bronchial fistula, digestive system fistula, gastric fistula, pancreatitis, respiratory tract fistula
Introduction We report the rare occurrence of a large gastrobronchial fistula following pancreatitis. Thoracic and general surgeons treated the patient by a combined approach for en-block resection of the diaphragm and stomach through a left thoracolaparotomy via the 7th intercostal space, dividing the serratus anterior.
Case report A 41-year-old male smoker developed a chronic persistent gastrobronchial fistula as a complication of gall stone pancreatitis. Four years previously, following recurrent episodes of pancreatitis, he required a percutaneous necrosectomy. He subsequently had cholecystectomy and mesh repair of the abdominal wall, and later developed multiple problems including a gastrobronchial fistula. He was markedly symptomatic with choking and coughing up food particles. He also reported multiple episodes of chest infections and repeated vomiting, but maintained his nutrition with supplemental feeds. Although the diagnosis was evident clinically, the patient was properly assessed by chest radiography, oral gastric miro-contrast swallow, and endoscopy and bronchoscopy to assess the location and extent and to clearly demarcate the fistula.
Computed tomography revealed a chronic abscess cavity with the left lower lobe attached to the diaphragm by a small fistulous connection (Figure 1). Thoracic and general surgeons reviewed the patient jointly along with the anesthetist, and the potential complications and mortality associated with such major surgery were discussed with the patient and his family. Particular attention was paid to his nutritional status and lung function because of vomiting and smoking. He underwent a combined procedure and operative findings of widespread dense adhesions within the pleural and abdominal cavities were noted, in keeping with the longstanding infection. The chest was opened initially and the adhesions were taken down by sharp and blunt dissection. The fissure was poorly developed and was treated by diathermy dissection; the anterior end was treated using a linear stapler. 1 Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow, UK 2 Department of General Surgery, Glasgow Royal Infirmary, Glasgow, UK
Corresponding author: Muhammad Asghar Nawaz, Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Agamemnon Street, Glasgow G81 4HX, United Kingdom. Email: [email protected]
Downloaded from aan.sagepub.com at UCSF LIBRARY & CKM on March 10, 2015
988
Asian Cardiovascular & Thoracic Annals 22(8)
The pulmonary artery branches were eventually identified, and the lingular artery preserved while the mainstem lower lobe pulmonary artery was stapled using a Multifire 30 vascular stapler (U.S. Surgical Corporation, Norwalk, CT, USA). The inferior pulmonary vein was identified, mobilized, and also stapled. Access to the bronchus was very difficult between numerous large lymph nodes. These were progressively dissected free, and hemostasis was secured using diathermy and Ligaclips. The bronchus was stapled using a TX30 bronchial unit (Ethicon Endo-Surgery,
Cincinnati, OH, USA), and the lung was left attached to the fistula through the diaphragm. The wound was extended across the costal margin into the upper abdomen, and using a radial approach through the diaphragm, the intraabdominal component of the fistula was identified. Dissection around about the spleen was avoided in view of the known previous fixed abdomen. The fistula into the stomach was identified and resected using a 60-mm linear stapler. The stomach was oversewn with 3/0 polydioxanone suture. The defect in the diaphragm was repaired directly with 2/0 Prolene,
Figure 1. Computed tomography showing an abscess cavity in the lower lobe with surrounding inflammation and a clearly demarcated fistula tract with the stomach and raised left hemidiaphragm.
Figure 2. Histopathological slide of the gastrobronchial fistula, showing the fistula tract, gastric mucosa, and lung.
Downloaded from aan.sagepub.com at UCSF LIBRARY & CKM on March 10, 2015
Nawaz et al.
989
avoiding the use of further mesh products in view of the infective history. Basal and apical drains were inserted and the wound was closed in layers. The patient made a straightforward recovery and was discharged home with no residual symptoms. A biopsy confirmed the diagnosis of gastropulmonary fistula with a surrounding chronic infective cavity and associated bronchiectasis, but with no other sinister features (Figure 2). At the 1-year follow-up, the patient had no recurrence of symptoms and a chest radiograph was satisfactory.
Discussion Gastrobronchial fistula is an extremely rare but distressing complication, with scarce data in the literature; approximately 30 cases have been reported.1 Our case report is unique because this gastrobronchial fistula resulted from recurrent episodes of pancreatitis. We are unsure about the mechanism of the association of pancreatitis with this fistula. Gastrobronchial fistula also occurs secondary to subphrenic abscess, where infection may be 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. Erosion into the stomach occurs at the same time. It is very rare for a lung abscess to perforate the diaphragm. Another less common cause may be traumatic perforation of the diaphragm with communication between the stomach and the lung during a previous laparotomy.2 Malignancy or complex infections or abscess following surgery above or below the diaphragm (e.g. gastric bypass surgery for obesity) are envisaged as probable instigators of this devastating condition.3 The clinical manifestations of gastrobronchial fistula can be as variable as its location and depend on the extent and location of the fistulous connection. Distinct symptoms may include post-prandial choking, cough associated with eating, dyspnea, vomiting, and recurrent chest infections.4 Bronchoscopy or endoscopy may fail to visualize the fistula, but gastrointestinal contrast studies and computed tomography are useful to ascertain the diagnosis. Assessment of nutritional status and pulmonary function testing are crucial before embarking on surgery. Involvement of the visceral structures determines the extent of resection. Preservation of lung function, when possible, is fundamental, but segmentectomy may not always be possible if the fistula is large, lung suffered recurrent pneumonitis, and the abscess cavity is
large, as in our case, necessitating a lobectomy. It may be argued whether a lower lobectomy and en-block resection of parts of the diaphragm was really necessary because the lower lobe abscess was just a few centimeters on the scan. We intended to perform a limited resection but the extensive adhesions and distorted anatomy forced a lobectomy. Thoracotomy and celiotomy may provide adequate exposure for resection of the lung and stomach, but if severe dense vascular adhesions constrain the exposure, thoracolaparotomy may be an alternative approach.5 Such cases require a collaborative multimodality endeavor.6 If the patient is considered very high-risk and debilitated with significant comorbidities, a less invasive approach such as stenting might be a suitable choice.7 Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflict of interest statement None declared.
References 1. Jha PK, Deiraniya AK, Keeling-Roberts CS and Das SR. Gastrobronchial fistula—a recent series. Interact Cardiovasc Thorac Surg 2003; 2: 6–8. 2. Al-Qudah A. Traumatic gastrobronchial fistula: case report and review of the literature. J Pediatr Surg 1997; 32: 1798–1800. 3. Aguilo´ Espases R, Lozano R, Navarro AC, Regueiro F, Tejero E and Salinas JC. Gastrobronchial fistula and anastomotic esophagogastric stenosis after esophagectomy for esophageal carcinoma. J Thorac Cardiovasc Surg 2004; 127: 296–297. 4. Campos JM, Siqueira LT, Meira MR, Ferraz AA, Ferraz EM and Guimara˜es MJ. Gastrobronchial fistula as a rare complication of gastroplasty for obesity: a report of two cases. J Bras Pneumol 2007; 4: 475–479. 5. Campos JM, Pereira EF, Evangelista LF, et al. Gastrobronchial fistula after sleeve gastrectomy and gastric bypass: endoscopic management and prevention. Obes Surg 2011; 21: 1520–1529. 6. Nawaz MA, Samarage M, O’Neill K and Punjabi P. Management of a giant thoracic hypervascular paraspinal ganglioma. Ann Thorac Surg 2012; 93: e7–e8. 7. Mao AW, Liu SY, Fang SM, et al. Gastrobronchial fistula: treatment with a covered tracheobronchial stent and an integrated Y-shaped metallic stent. Eur J Radiol Extra 2010;73:e61–4.
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