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Management of gastrobronchial fistula after laparoscopic sleeve gastrectomy
Surgery for Obesity and Related Diseases ] (2013) 00–00
Original article
Management of gastrobronchial fistula after laparoscopic sleeve gastrectomy Lionel Rebibo, M.D.a, Abdennaceur Dhahri, M.D.a, Pascal Berna, M.D., Ph.D.b, Thierry Yzet, M.D.c, Pierre Verhaeghe, M.D., Ph.D., F.A.C.S.a, Jean-Marc Regimbeau, M.D., Ph.D.a,* a
Departments of Digestive Surgery, Amiens University Medical Center and the Jules Verne University of Picardie, Amiens, France Departments of Thoracic Surgery, Amiens University Medical Center and the Jules Verne University of Picardie, Amiens, France c Departments of Radiology, Amiens University Medical Center and the Jules Verne University of Picardie, Amiens, France Received June 5, 2013; accepted August 7, 2013
b
Abstract
Background: Gastric fistula (GF) is a serious complication after laparoscopic sleeve gastrectomy (LSG). Furthermore, gastrobronchial fistula (GBF) may appear some time after a primary LSG. The objective of this study was to characterize GBF after LSG and establish standardized treatment procedures. Methods: All patients undergoing surgery for GBF after LSG at a public university medical center in France between November 2004 and January 2013 were included in this study. Surgical and perioperative care was standardized. The primary efficacy criterion was the complication rate. Secondary efficacy criteria were the mortality rate, surgical data, types of complications, and the length of stay (LOS) in hospital. Results: Six patients were treated for GBF after LSG: 2 presented GBF after primary LSG performed in our institution and 4 had been referred by tertiary centers. The median (range) time to onset of GBF after LSG was 136 days (99–238 d). Preoperative refeeding was performed in 5 cases. The median time interval between the discovery of GBF and its surgical treatment was 31 days (7–137 d). Five patients underwent simultaneous abdominal and thoracic procedures. The abdominal procedures consisted of total gastrectomy (n ¼ 1) and 60-cm Roux-en-Y gastrojejunal anastomosis (n ¼ 6). There were no postoperative mortalities. Four postoperative complications occurred (66.6%), 2 of which were postoperative fistulas (33.3%) requiring revisional surgery. The median time to oral refeeding was 10 days (8–65 d) and the median LOS was 14 days (13–25 d). Conclusions: Our treatment of GBF is based on effective drainage with endoscopic procedures, allowing optimal preoperative refeeding before combined abdominal and thoracic surgery. For the abdominal procedure, we prefer a 60-cm Roux-en-Y gastrojejunal anastomosis to total gastrectomy, because the former is simpler and minimizes the long-term risk of postoperative malabsorption. (Surg Obes Relat Dis 2013;]:00-00.) r 2013 American Society for Metabolic and Bariatric Surgery. All rights reserved.
Keywords:
Laparoscopic sleeve gastrectomy; Gastric fistula; Gastrobronchial fistula; Thoracic surgery; Roux-en-Y gastrojejunal anastomosis
Laparoscopic sleeve gastrectomy (LSG) is an increasingly popular bariatric procedure because of its relative *
Correspondence: Professor J.-M. Regimbeau, Service de chirurgie digestive, Hôpital Nord, CHU d’Amiens, Place Victor Pauchet, F-80054, Amiens cedex 01, France. E-mail: [email protected]
simplicity (compared with RYGB), its good weight loss outcomes (excess weight loss [EWL] 450% at 5 years) [1], and its ability to improve co-morbidities associated with obesity [2]. The most prevalent acute complications after LSG are gastric fistula (GF) and hemorrhage, whereas the most prevalent long-term complications are gastric strictures and
1550-7289/13/$ – see front matter r 2013 American Society for Metabolic and Bariatric Surgery. All rights reserved. http://dx.doi.org/10.1016/j.soard.2013.08.015
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gastroesophageal reflux disease. Gastric fistula is a rare but serious complication that affects approximately 2% of LSGs (according to 2 recent meta-analyses) [3,4]. It necessitates optimal pharmacologic treatment, multiple endoscopic procedures, and in some cases, revisional surgery [5]. This complication extends hospitalization and may even be lifethreatening. Hemorrhage along the staple line occurs in o 5% of cases and may necessitate immediate revisional surgery [6]. With the increasing use of the LSG procedure worldwide, new types of complication are being described; these include pseudoaneurysms (in the case of postLSG GF) [7] and postLSG gastrobronchial fistula (GBF) [8]. The latter is a rare complication that may appear some time after the primary LSG. Most GBF patients have been described in case reports (rather than in series) [9]. A typical clinical presentation after LSG is the appearance of recurrent lung infection (affecting the left lower lobe) or recurrent cough. Although this rare postLSG complication has already been described, there are no guidelines on how it should be managed. The present study sought to characterize postLSG GBF, establish standardized surgical and perioperative care procedures for this rare complication, and identify associated risk factors.
Definition and management of GF The presentation, time to onset, and staple line site of gastric leakage were classified according to the modified U. K. Surgical Infection Study Group definitions [11,12]. The patient’s clinical presentation was further described in terms of systemic signs of inflammation (tachycardia, 4100 beats/ min, and hyperthermia 4381C), peritonitis (diffuse abdominal tenderness), pulmonary symptoms (cough and expectoration), and intraabdominal abscess (localized abdominal tenderness). We differentiated between early-onset gastric leakage (from postoperative day [POD] 1 to POD 7) and late-onset gastric leakage (ZPOD 8). Furthermore, we used abdominal computed tomography (CT) to distinguish between leakage from the upper third of the staple line and leakage from the lower third. The procedure used to treat postLSG GF in our institution was standardized and has been described previously [5,13]. During the study period, endoscopic management of GF changed. Before 2008, we used covered, with antireflux valve, self-expandable metallic stents; after 2008, we progressively abandoned the covered metallic stent and started to use the double pigtail stent to drain the GF inside the stomach [5]. Gastrobronchial fistula events
Methods Population We performed a retrospective analysis of our prospective database for a group of patients presenting GBF after LSG between November 2004 and January 2013. Two bariatric surgeons performed abdominal procedures, whereas all thoracic procedures were performed by the same thoracic surgeon. The primary LSGs in our institution and in other institutions were performed according to a 4-trocar procedure, as described by Verhaeghe et al. [10]. A 34-French bougie was used to guide the staple line. Gastric section was initiated 6 cm from the pylorus. An ENDO GIA Universal XL 60 device (Covidien France SAS, Elancourt, France) with 2 green reloads and then 3 or 4 blue reloads was used to staple the stomach. A methylene blue test was always performed after gastric stapling. Reinforcement of the gastric section line was not always performed. During the study period, 750 patients underwent primary LSG in our institution. Eighteen of these presented postLSG GF (2.4%). During the same period, 6 patients underwent surgery for postLSG GBF. Two of these 6 patients had undergone primary LSG in our institution (corresponding to .2% of all LSGs performed and 11% of all GFs after LSG) and the remaining 4 were referred to us by tertiary centers for the treatment of GBF. The objective of this retrospective study was to characterize GBF and suggest standardized management procedures for this rare complication of LSG.
Definition of gastrobronchial fistula. Gastrobronchial fistula corresponds to an abnormal connection between the stomach and the lung and was diagnosed here by observation of intrathoracic fluid collections and an opacified fistula on a CT scan of the thorax and abdomen with oral contrast. The diagnosis was always confirmed by the endoscopic observation of an opacified connection between the stomach and the lung (Fig. 1), although a CT scan of the abdomen with oral contrast did show the connection between the stomach and the lung in a few cases. Indication for surgery. The management of patients with GBF and the indication for surgery was discussed in a multidisciplinary staff meeting comprising bariatric surgeons, thoracic surgeons, gastroenterologists, radiologists, and anesthesiologists. Repeat surgery was indicated by the presence of recurrent lung infection and GBF, which (in our experience) cannot be treated with antibiotics or endoscopy alone. The Clavien classification of surgical complications [14], Cases of GBF were classified according to Clavien’s guidelines, as follows: Grade I: Any deviation from the normal postoperative course without the need for pharmacologic treatment or surgical, endoscopic, and radiologic interventions. The allowed therapeutic regimens are drugs as antiemetics, antipyretics, analgetics, diuretics, electrolytes, and physiotherapy. This grade also includes wound infections opened at the bedside. Grade II: Requiring pharmacologic treatment with drugs other than such allowed for grade I complications. Blood transfusions and total parenteral nutrition are also included.
Procedure for Gastrobronchial Fistula / Surgery for Obesity and Related Diseases ] (2013) 00–00
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Fig. 1. Imaging of post-laparoscopic sleeve gastrectomy gastrobronchial fistula. (A) Preoperative X-ray with oral contrast, showing the presence of a connection between the stomach and the lung (white arrow). (B) Preoperative CT scan of the thorax and abdomen, showing the GBF.
Grade III: Requiring surgical, endoscopic, or radiologic intervention, including grade IIIa (intervention not under general anesthesia) and grade IIIb (intervention under general anesthesia). Grade IV: Life-threatening complication requiring intensive care/intensive care unit management, including grade IVa (single organ dysfunction, including dialysis and grade IVb (multiorgan dysfunction). Grade V: Death of a patient. Management of GBF Preoperative management of GBF. After GBF had been diagnosed, all patients underwent a preoperative nutritional assessment, with measurement of the body mass index (BMI), EWL, and the percentage weight loss. Serum albumin and prealbumin levels were also assayed. Our laboratory’s normal value for serum albumin ranged from 3.7 to 5.3 g/dL, whereas the normal value for serum prealbumin ranged from 21 to 41 mg/dL. Preoperative refeeding was variously performed via a feeding jejunostomy, a nasojejunal tube, or parenteral nutrition. Refeeding was performed via jejunostomy in case of GF after LSG and necessitating immediate revisional procedure if a jejunostomy was implemented during revisional procedure. Otherwise, nasojejunal tube was preferred to parenteral refeeding. A second nutritional assessment was performed immediately before surgery for GBF. Surgery was delayed if the patient’s nutritional status was unsatisfactory. Surgical procedures for GBF. All abdominal procedures were performed by midline laparotomy. All thoracic procedures were performed by left posterolateral thoracotomy. We always combined thoracic procedures with lung resection and diaphragmatic reconstruction, to minimize the risk of a postoperative fistula between the gastrojejunal anastomosis and the lung. The latter risk is present if the diaphragm is not resected and if the intrathoracic pressure is lower than the intraabdominal pressure.
Abdominal procedures. The abdominal procedure constituted the first step in the surgical treatment of GBF. The left colic flexure was lowered by a median laparotomy. First, splenectomy provided easy access to the GBF’s orifice and enabled diaphragmatic resection by thoracotomy (given that in GBF, the spleen adheres to the abdominal aspect of the diaphragm). Next, the anterior and posterior aspects of the stomach were released. After visualization of the GBF in an oral methylene blue test, the intraabdominal fistula tract was removed. Total gastrectomy [8] or a 60-cm Roux-en-Y side-to-side gastrojejunal anastomosis was performed and an oral methylene blue test was again performed to check for the absence of leakage. A drainage tube was placed next to the gastrojejunal anastomosis or, for a total gastrectomy, the esophagojejunal anastomosis. A feeding jejunostomy was always implemented at the end of the abdominal procedure. Thoracic procedures. The second step in the procedure consisted of lung and diaphragm resection via left posterolateral thoracotomy. Depending on the patient, left lower lobectomy or segmental lung resection was performed. Diaphragm resection was used to remove all the infected tissues. The diaphragm was rebuilt by simple suturing, the use of a muscle flap [15], or the implantation of a prosthesis (GORE DUALMESH Biomaterial, W. L. Gore & Associates, Inc., Flagstaff, AZ). The thoracic cavity was drained via 2 18-French vacuum drains (Fig. 2). Postoperative management. After surgery, all patients were admitted to the intensive care unit (ICU). Postoperative nutrition was initiated on POD 1, with a feeding jejunostomy. Respiratory therapy was initiated on POD 2. In the absence of abnormal clinical and biochemical indicators, an oral methylene blue test and a CT scan of the thorax and abdomen with oral contrast were performed on POD 7. In the absence of an anastomotic fistula, oral refeeding was authorized and thoracic (and then abdominal) drains were removed. The feeding jejunostomy was maintained for 1 month. Patients were seen in consultation 1
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Fig. 2. A photograph taken during gastrobronchial fistula surgery. (A) Gastric fistula orifice (white arrow) with a nasogastric tube (black arrow) inserted into the fistula orifice during the abdominal procedure. (B) Creation of an anastomosis between the fistula orifice (black arrow) and the jejunum (white arrow). (C) The final view of the gastrojejunal anastomosis (white arrow). (D) Thoracic view after left lower lobectomy and diaphragmatic resection (black arrow), showing the intraabdominal drains (white arrow).
month after discharge from hospital and underwent another CT scan of the thorax and abdomen. If the CT results and oral feeding were normal, the feeding jejunostomy was removed during the consultation. No vaccines were given before surgery because of the presence of the GBF. Hence, pneumococcal and meningococcal vaccines were administered within 10 days of GBF surgery (in the absence of sepsis and/or anastomotic fistula). After surgery, all patients received prophylactic treatment with penicillin V (as recommended in the French guidelines) [16]. Inclusion criteria Patients included in the study had to meet the following criterion: postLSG GBF treated surgically via abdominal and thoracic procedures during the same operating session. Endpoints and data recorded The study’s primary efficacy endpoint was the complication rate in patients undergoing surgery for postLSG GBF. The secondary endpoints were operative data, complications (according to the Clavien classification [16]), the mortality rate, the length of hospital stay (LOS, including time in the ICU and time in a hospital ward), and follow-up data. We retrospectively searched for risk factors for postoperative GBF in a database of all LSGs performed in our institution (n ¼ 750) during the study period.
The recorded study parameters included data collected before GBF surgery (age, gender, BMI, preoperative comorbidities, the time interval between the primary LSG and the GBF surgery, other bariatric procedures before LSG, and complications after primary LSG); data on the GBF (time to onset of GBF, the type of care [including the type of nutritional assessment and endoscopic management procedures], nutritional assessments [BMI, EWL, percentage weight loss, serum albumin and serum prealbumin] at the time of diagnosis of GBF and immediately before surgery, and lastly, the time interval between GBF diagnosis and surgery; operative data (overall operating time, operating time for each procedure, blood loss, perioperative red blood cell transfusions, and adverse events during surgery); postoperative data (LOS in the ICU and overall LOS, postoperative complications according to the Clavien classification [14] in general and postoperative anastomotic fistula in particular, revisional surgery, time to oral refeeding, and the duration of follow-up). Results Status before the primary LSG The patient group consisted of 1 man and 5 women (83.3%) and had a median age of 34 years (range, 23–53 years) and a median BMI of 44.3 kg/m2 (range, 37–48.4 kg/ m2). Preoperative co-morbidities were diabetes mellitus
Procedure for Gastrobronchial Fistula / Surgery for Obesity and Related Diseases ] (2013) 00–00
(in 33.3% of cases; n ¼ 2), hypertension (33.3%, n ¼ 2), dyslipidemia (33.3%, n ¼ 2), and metabolic syndrome (33.3%, n ¼ 2). All patients underwent laparoscopic LSG without conversion to laparotomy. None of the patients had undergone other types of bariatric surgery. Four of the 6 patients (66.6%) developed postoperative GF; 3 patients underwent revisional surgery for early-onset GF and then endoscopy, and the remaining patient was treated (with endoscopy only) for delayed-onset GF. The median time to GF was 8 days (4–60 d). One patient presented postoperative hemorrhage, which necessitated immediate revisional surgery. Diagnosis of GBF Gastrobronchial fistula presented as chronic cough in 3 cases (50%) and a recurrent lung infection in 3 cases (50%). The condition was diagnosed after a contrast-enhanced CT scan of the thorax and abdomen in 5 cases and gastroscopy discovery of communication between the stomach and the lung in 1 case. The GBF was located at the angle of His in all cases. The median (range) time interval between LSG and the onset of GBF was 136 days (99–238 d). Preoperative management of GBF Before GBF surgery, the median preoperative BMI was 31.3 kg/m2 (17.2–40.7 kg/m2), the median EWL was 43.7% (33%–150.8%), and median percentage weight loss was 19% (15.8%–57.6%). At the time of diagnosis of GBF, the median serum albumin level was 2.0 g/dL (1.69–2.4 g/dL), and the median serum prealbumin level was 10 mg/dL (8–20 mg/dL). Preoperative nutritional support was administered to 5 patients (83.3%), with enteral nutrition via a nasojejunal tube in 3 cases (50%), enteral nutrition via a feeding jejunostomy in 1 case (16.6%), and parenteral nutrition in 1 case (16.6%). Before GBF surgery, the median serum albumin level was 2.6 g/dL (1.69–3.5 g/dL), and the median serum prealbumin level was 24 mg/dL (8–28 mg/dL). The median time interval between GBF discovery and surgery was 31 days (7–137 d). One month before surgery for GBF, 1 patient (#6) underwent left posterolateral thoracotomy (in another institution) for pleural decortication. This patient had been referred to us after treatment in another institution for pleural empyema. Operative data The median (range) operating time was 240 minutes (200–280 min) for abdominal surgery, 100 minutes (80–240 min) for thoracic surgery, and 340 minutes (300–520 min) for the entire surgical session. One patient (#1) underwent a total gastrectomy with an additional distal pancreatectomy because of the close connection between the spleen and the tail of the pancreas. The median (range) perioperative blood
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loss was 700 mL (600–2500 mL). Four patients (66.6%) required perioperative blood cell transfusions (median number of units: 2 [0–15 units]). One patient (#6) required clamping of the thoracic aorta for 9 minutes because of intrathoracic bleeding (caused by multiple intrathoracic adhesions after pleural decortication, making left lower lobectomy more difficult to perform). Four patients were extubated in the operating room after GBF surgery. Postoperative data There were no postoperative deaths. The median LOS in the ICU was 10 days (9–16 d), and the median overall LOS was 14 days (13–25 d). There were 4 postoperative complications (66.6%), including 2 Clavien grade IIIb postoperative fistulas (33.3%) treated with revisional surgery. One of these cases (in patient #2) was treated with revisional surgery (because of early-onset fistula) and then several endoscopic procedures with double pigtail stents (a standard procedure in our institution). The second case (in patient #3) was treated by revisional surgery only and required suturing of the gastrojejunal anastomosis fistula’s dehiscence. The other complications were erysipelas (n ¼ 1, treated with antibiotics) and scar infection (n ¼ 2, Clavien grade II) treated with vacuum therapy. The median time to oral refeeding was 10 days (8–65 d), and the median postoperative follow up time was 4 months (1–14 mo). Risk factors for GBF As mentioned above, 750 primary LSGs were performed during the study period. Eighteen of these cases developed postoperative GF (2.4%). When analyzing data for the LSG (including age, gender, BMI, and preoperative co-morbidities) and the postoperative GF (including time to onset, revisional procedures, endoscopic procedures, and time to treatment), no significant risk factors for the development of postLSG GBF were identified. Discussion Laparoscopic sleeve gastrectomy is an effective treatment for morbid obesity, with an EWL Z50% 6 years after surgery [17,18] and the ability to improve obesity-related co-morbidities [19]. It is a reproducible procedure, with a short operating time and few postoperative complications. The main postoperative complication is GF (in about 2% of LSGs) [3]. However, the treatment of GF is difficult and lengthy (mean treatment duration, 62 d) and requires revisional surgery and additional endoscopic procedures [5]. With as many as 12,000 LSGs performed per year in France, complications such as gastric stricture [20], pseudoaneurysm [7], and GBF [8] are now being described. This type of complication appears to be more frequent after esophagectomy [21,22]. Few cases of postLSG GBF have
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been comprehensively described [23]. In our institution, .2% of all LSGs are followed by GBF. Considering the increase in the number of LSGs performed, the number of cases of GBF is also likely to have increased, with perhaps as many as 24 cases per year in France alone. Gastrobronchial fistula is a rare complication that occurs some time after the primary LSG [24,25] (a median of 136 days in the present series) and often follows postoperative GF (with 4 such instances in our series). When analyzing the data on our series of 750 LSGs, we did not identify any significant risk factors for GBF. The first 2 patients treated for GBF had undergone LSG in our center. One of these patients had previously undergone revisional surgery and then stenting. The other patient developed GBF immediately. At that time, GF was treated endoscopically with a stent. Since then, we have performed almost 600 other LSG procedures, and no further cases of GBF have been observed. This improvement is probably due to standardization of our surgical procedures [13] and the use of a double pigtail stent [5], which reduces the LOS and the treatment time by promoting internal drainage of the GF. The 4 other patients with GBF were referred to us by tertiary centers. Three had developed GF soon after LSG and were referred as soon as the GBF was discovered. This suggests that optimal management of early-onset GF is essential for avoiding GBF, although the small size of the sample studied here may have prevented us from identifying GF management as a risk factor for GBF. In the absence of any predictive factors for GBF, a focus on properly treating this complication is necessary. Five of the 6 GBF patients received nutritional support before GBF surgery. We suspect that this contributed to the good overall surgical outcome, because only 1 of these 5 patients presented a postoperative anastomotic fistula (and was successfully treated with suturing only). The only patient not to receive preoperative nutritional support had
complicated outcomes, with an anastomotic fistula requiring multiple postoperative endoscopic procedures and a longer time to oral refeeding. This observation suggests that GBF is not a surgical emergency; it requires preoperative nutritional support to help the patient achieve an adequate nutritional status and the use of appropriate antibiotics to treat infection, thus promoting recovery from subsequent surgery. In view of the lack of literature data on GBF, there is no consensus on the surgical treatment of this rare complication [26]. In a series of 9 patients, Serra et al. [27] performed total gastrectomy for persistent GF after a duodenal switch. Although there were no deaths, the postoperative outcomes were complicated, with several cases of revisional surgery, some life-threatening situations, and a mean LOS of 4.5 months. Our first patient (#1) underwent total gastrectomy and pancreatectomy; this corresponded to the longest operation in our series and involved major blood loss (2000 mL) and 15 units of red blood cells. This type of procedure also requires close postoperative monitoring for any vitamin and protein deficiencies. Although our outcomes were uneventful (for the above-mentioned reasons), we prefer Roux-en-Y gastrojejunal anastomosis in this context; it has an acceptable complications rate [28] and a shorter operating time and is associated with lower blood loss. We used a 60-cm Roux-en-Y gastrojejunal anastomosis, which reduces the risk of postoperative malabsorption and, thus, avoids the need for burdensome postoperative monitoring for vitamin and protein deficiencies. This procedure allows passage of the food bolus through both the sleeve and the Roux-en-Y gastrojejunal anastomosis and, thus, further reduces the risk of postoperative malabsorption (because most of the bolus will pass through the sleeve) (Fig. 3). In the series described by Campos et al. [9], the patients had undergone other surgical procedures before endoscopic treatment. Furthermore, the surgical procedures were not combined and failed to treat GBF. In our present series, all
Fig. 3. Imaging after gastrobronchial fistula surgery. (A) Oral contrast study (the gastrograffin test) 1 month after surgery, showing the effective passage of contrast into the stomach (black arrow) and the jejunum (white arrow) via the Roux-en-Y gastrojejunal anastomosis (white arrowhead). (B) Frontal pattern of a Roux-en-Y gastrojejunal anastomosis (from [26]).
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Table 1 Preoperative data Patient
#1
#2
#3
#4
#5
#6
Gender Age (y) Initial BMI (kg/m²) GF after primary LSG Revisional surgery Endoscopic procedure Number of endoscopic procedures (n) Time to onset of GBF (d) Preoperative nutrition Preoperative serum albumin (g/dL) Preoperative serum prealbumin (mg/dL) Time between GBF diagnosis and surgery GBF (d)
Female 23 40.2 Yes Yes Yes 1 136 Yes 2.0 17 137
Female 34 44.3 No Yes No 0 238 No 1.69 8 7
Female 53 44.4 Yes Yes Yes 3 161 Yes 3.5 28 30
Female 46 37 No No No 0 110 Yes 2.6 25 100
Male 35 48.4 Yes No Yes 2 167 Yes 2.9 24 31
Female 23 48 Yes Yes Yes 2 99 Yes 3.0 25 32
BMI ¼ body mass index; GBF ¼ gastrobronchial fistula; GF ¼ gastric fistula; LSG ¼ laparoscopic sleeve gastrectomy. Normal value of serum albumin ranged from 3.7 to 5.3 g/dL. Normal value of serum prealbumin ranged from 21 to 41 mg/dL.
but one of our patients (#6) underwent combined surgical procedures. Overall, the outcomes were good for all of our patients except #1 (total gastrectomy) and #6 (for whom the thoracic procedure was complicated by previous pleural decortication). The latter complication resulted in a longer thoracic operating time, greater blood loss, inability to extubate the patient in the operating room, and thoracic aorta clamping (which can endanger the blood vessels around the Roux-en-Y gastrojejunal anastomosis). Campos et al. [9] suggested that GBF could be treated with purely endoscopic procedures. Almost all their cases of GBF were treated successfully (except for 1 patient with GBF after a RYGB), with a mean of 4.5 endoscopic procedures per patient and a mean treatment duration of 4.4 months. In contrast to the series by Campos et al., all of our patients were treated successfully and no postoperative deaths were recorded. The morbidity rate in our study was acceptable, with a shorter LOS and more rapid oral
refeeding. These findings are important because patients treated for postoperative fistulas often develop depression due to the burdensome procedure and the extended LOS. One of the key findings of this retrospective report is that surgery for GBF should not be considered as an emergency procedure. Surgery for GBF has a good outcome if preoperative refeeding has been performed and if abdominal and thoracic procedures are combined. The results associated with our standardized GBF management procedures need to be confirmed in a larger series. In view of the above results, we currently perform Roux-en-Y gastrojejunal anastomosis for chronic GF after LSG (albeit without the thoracic and diaphragmatic procedures) (Table 1 and 2). Conclusions Gastrobronchial fistula is a rare complication after LSG. In our experience, surgery for GBF is never an emergency.
Table 2 Intraoperative and postoperative data Patient
#1
#2
#3
#4
#5
#6
Abdominal surgery Splenectomy Additional procedures Thoracic surgery Diaphragm repair Operating time (min) Abdominal operating time (min) Thoracic operating time (min) Blood loss (mL) Abdominal blood loss (mL) Thoracic blood loss (mL) Red blood cell transfusions (n) Extubation in the operating room Postoperative fistula Revisional surgery Endoscopic procedure Time to oral refeeding (d)
Total gastrectomy Yes Distal pancreatectomy Segmental Flap 520 280 240 2000 1500 500 15 No No No No 9
GJ anastomosis Yes No LLL Suture 370 220 150 1500 1200 300 4 Yes Yes Yes Multiple 35
GJ anastomosis Yes No LLL Suture 320 240 80 600 450 150 2 Yes Yes Yes No 18
GJ anastomosis Yes No LLL Suture 340 240 100 700 500 200 0 Yes No No No 10
GJ anastomosis Yes No Segmental Suture 300 200 100 600 400 200 0 Yes No No No 10
GJ anastomosis Yes No LLL Prosthesis 480 240 240 2500 500 2000 7 No No No No 8
GJ ¼ gastrojejunal; LLL ¼ left lower lobe.
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Treatment is based on effective drainage of the fistula with endoscopic procedures, which allows optimal preoperative refeeding before the performance of combined abdominal and thoracic surgical procedures. With respect to the abdominal procedure, 60-cm Roux-en-Y gastrojejunal anastomosis appears to be an appropriate conservative treatment for GBF if preoperative nutritional support has been provided. Relative to total gastrectomy, the Roux-en-Y procedure is simpler and avoids the risk of postoperative deficiency during long-term follow-up. Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article. References [1] Bohdjalian A, Langer FB, Shakeri-Leidenmühler S, et al. Sleeve gastrectomy as sole and definitive bariatric procedure: 5-year results for weight loss and ghrelin. Obes Surg 2010;20:535–40. [2] Péquignot A, Dhahri A, Verhaeghe P, Desailloud R, Lalau JD, Regimbeau JM. Efficiency of laparoscopic sleeve gastrectomy on metabolic syndrome disorders: two years results. J Visc Surg 2012;149:e350–5. [3] Parikh M, Issa R, McCrillis A, Saunders JK, Ude-Welcome A, Gagner M. Surgical strategies that may decrease leak after laparoscopic sleeve gastrectomy: a systematic review and meta-analysis of 9991 cases. Ann Surg 2013;257:231–7. [4] Aurora AR, Khaitan L, Saber AA. Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients. Surg Endosc 2012;26: 1509–15. [5] Pequignot A, Fuks D, Verhaeghe P, et al. Is there a place for pigtail drains in the management of gastric leaks after laparoscopic sleeve gastrectomy? Obes Surg 2012;22:712–20. [6] Lalor PF, Tucker ON, Szomstein S, Rosenthal RJ. Complications after laparoscopic sleeve gastrectomy. Surg Obes Relat Dis 2008;4: 33–8. [7] Rebibo L, Fuks D, Blot C, et al. Gastrointestinal bleeding complication of gastric fistula after sleeve gastrectomy: consider pseudoaneurysms. Surg Endosc 2013;27:2849–55. [8] Fuks D, Dumont F, Berna P, et al. Case report—complex management of a postoperative bronchogastric fistula after laparoscopic sleeve gastrectomy. Obes Surg 2009;19:261–4. [9] Campos JM, Pereira EF, Evangelista LF, et al. Gastrobronchial fistula after sleeve gastrectomy and gastric bypass: endoscopic management and prevention. Obes Surg 2011;21:1520–9. [10] Verhaeghe P, Dhahri A, Qassemyar Q, Regimbeau J-M. Technique de la gastrectomie longitudinal (sleeve gastrectomy) par laparoscopie. EMC (Elsevier Masson SAS, Paris), Techniques chirurgicales–Appareil digestif, 2011:40–385.
[11] Csendes A, Diaz JC, Burdiles P, et al. Classification and treatment of anastomotic leakage after extended total gastrectomy in gastric carcinoma. Hepatogastroenterology 1990;37(Suppl 2):174–7. [12] Bruce J, Krukowski ZH, Al-Khairy G, Russell EM, Park KG. Systematic review of the definition and measurement of anastomotic leak after gastrointestinal surgery. Br J Surg 2001;88:1157–68. [13] Rebibo L, Dhahri A, Verhaeghe P, Regimbeau JM. Early gastric fistula after laparoscopic sleeve gastrectomy: surgical management. J Visc Surg 2012;149:e319–24. [14] Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;240:205–13. [15] Sinna R, De Dominicis F, Quassemyar Q, et al. Diaphragmatic reconstruction using combined reversed extended latissimus dorsi and serratus anterior fascia flaps. Ann Thorac Surg 2011;91:922–4. [16] Chambon JP, Vallet B, Caiazzo R, Zerbib P. Management of splenectomized patients [article in French]. Presse Med 2003;32 (Suppl 28):S20–3. [17] Himpens J, Dobbeleir J, Peeters G. Long-term results of laparoscopic sleeve gastrectomy for obesity. Ann Surg 2010;252:319–24. [18] Sarela AI, Dexter SP, O’Kane M, Menon A, McMahon MJ. Longterm follow-up after laparoscopic sleeve gastrectomy: 8–9-year results. Surg Obes Relat Dis 2012;8:679–84. [19] Zhang N, Maffei A, Cerabona T, Pahuja A, Omana J, Kaul A. Reduction in obesity-related comorbidities: is gastric bypass better than sleeve gastrectomy? Surg Endosc 2012;27:1273–80. [20] Dapri G, Cadière GB, Himpens J. Laparoscopic seromyotomy for long stenosis after sleeve gastrectomy with or without duodenal switch. Obes Surg 2009;19:495–9. [21] Stal JM, Hanly PJ, Darling GE. Gastrobronchial fistula: an unusual complication of esophagectomy. Ann Thorac Surg 1994;58: 886–7. [22] Miwa K, Takamori S, Hayashi A, Shirouzu K. Gastrobronchial fistula after esophagectomy. Eur J Cardiothorac Surg 2004;25:460. [23] Abraham A, Virdi RP, Rajan D, et al. Gastrobronchial fistula following laparoscopic sleeve gastrectomy. BMJ Case Rep. Epub 2012 Sept 12. [24] Campos JM, Siqueira LT, Ferraz AA, Ferraz EM. Gastrobronchial fistula after obesity surgery. J Am Coll Surg 2007;204:711. [25] Sakran N, Assalia A, Keidar A, Goitein D. Gastrobronchial fistula as a complication of bariatric surgery: a series of 6 cases. Obes Facts 2012;5:538–45. [26] De Dominicis F, Dhahri A, Verhaeghe P, et al. Treatment of a chronic fistula after sleeve gastrectomy by a Roux-en-Y limb. J Visc Surg 2010;147:71–4. [27] Serra C, Baltasar A, Pérez N, Bou R, Bengochea M. Total gastrectomy for complications of the duodenal switch, with reversal. Obes Surg 2006;16:1082–6. [28] Baltasar A, Serra C, Bengochea M, Bou R, Andreo L. Use of Roux limb as remedial surgery for sleeve gastrectomy fistulas. Surg Obes Relat Dis 2008;4:759–63.
Original article
Management of gastrobronchial fistula after laparoscopic sleeve gastrectomy Lionel Rebibo, M.D.a, Abdennaceur Dhahri, M.D.a, Pascal Berna, M.D., Ph.D.b, Thierry Yzet, M.D.c, Pierre Verhaeghe, M.D., Ph.D., F.A.C.S.a, Jean-Marc Regimbeau, M.D., Ph.D.a,* a
Departments of Digestive Surgery, Amiens University Medical Center and the Jules Verne University of Picardie, Amiens, France Departments of Thoracic Surgery, Amiens University Medical Center and the Jules Verne University of Picardie, Amiens, France c Departments of Radiology, Amiens University Medical Center and the Jules Verne University of Picardie, Amiens, France Received June 5, 2013; accepted August 7, 2013
b
Abstract
Background: Gastric fistula (GF) is a serious complication after laparoscopic sleeve gastrectomy (LSG). Furthermore, gastrobronchial fistula (GBF) may appear some time after a primary LSG. The objective of this study was to characterize GBF after LSG and establish standardized treatment procedures. Methods: All patients undergoing surgery for GBF after LSG at a public university medical center in France between November 2004 and January 2013 were included in this study. Surgical and perioperative care was standardized. The primary efficacy criterion was the complication rate. Secondary efficacy criteria were the mortality rate, surgical data, types of complications, and the length of stay (LOS) in hospital. Results: Six patients were treated for GBF after LSG: 2 presented GBF after primary LSG performed in our institution and 4 had been referred by tertiary centers. The median (range) time to onset of GBF after LSG was 136 days (99–238 d). Preoperative refeeding was performed in 5 cases. The median time interval between the discovery of GBF and its surgical treatment was 31 days (7–137 d). Five patients underwent simultaneous abdominal and thoracic procedures. The abdominal procedures consisted of total gastrectomy (n ¼ 1) and 60-cm Roux-en-Y gastrojejunal anastomosis (n ¼ 6). There were no postoperative mortalities. Four postoperative complications occurred (66.6%), 2 of which were postoperative fistulas (33.3%) requiring revisional surgery. The median time to oral refeeding was 10 days (8–65 d) and the median LOS was 14 days (13–25 d). Conclusions: Our treatment of GBF is based on effective drainage with endoscopic procedures, allowing optimal preoperative refeeding before combined abdominal and thoracic surgery. For the abdominal procedure, we prefer a 60-cm Roux-en-Y gastrojejunal anastomosis to total gastrectomy, because the former is simpler and minimizes the long-term risk of postoperative malabsorption. (Surg Obes Relat Dis 2013;]:00-00.) r 2013 American Society for Metabolic and Bariatric Surgery. All rights reserved.
Keywords:
Laparoscopic sleeve gastrectomy; Gastric fistula; Gastrobronchial fistula; Thoracic surgery; Roux-en-Y gastrojejunal anastomosis
Laparoscopic sleeve gastrectomy (LSG) is an increasingly popular bariatric procedure because of its relative *
Correspondence: Professor J.-M. Regimbeau, Service de chirurgie digestive, Hôpital Nord, CHU d’Amiens, Place Victor Pauchet, F-80054, Amiens cedex 01, France. E-mail: [email protected]
simplicity (compared with RYGB), its good weight loss outcomes (excess weight loss [EWL] 450% at 5 years) [1], and its ability to improve co-morbidities associated with obesity [2]. The most prevalent acute complications after LSG are gastric fistula (GF) and hemorrhage, whereas the most prevalent long-term complications are gastric strictures and
1550-7289/13/$ – see front matter r 2013 American Society for Metabolic and Bariatric Surgery. All rights reserved. http://dx.doi.org/10.1016/j.soard.2013.08.015
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gastroesophageal reflux disease. Gastric fistula is a rare but serious complication that affects approximately 2% of LSGs (according to 2 recent meta-analyses) [3,4]. It necessitates optimal pharmacologic treatment, multiple endoscopic procedures, and in some cases, revisional surgery [5]. This complication extends hospitalization and may even be lifethreatening. Hemorrhage along the staple line occurs in o 5% of cases and may necessitate immediate revisional surgery [6]. With the increasing use of the LSG procedure worldwide, new types of complication are being described; these include pseudoaneurysms (in the case of postLSG GF) [7] and postLSG gastrobronchial fistula (GBF) [8]. The latter is a rare complication that may appear some time after the primary LSG. Most GBF patients have been described in case reports (rather than in series) [9]. A typical clinical presentation after LSG is the appearance of recurrent lung infection (affecting the left lower lobe) or recurrent cough. Although this rare postLSG complication has already been described, there are no guidelines on how it should be managed. The present study sought to characterize postLSG GBF, establish standardized surgical and perioperative care procedures for this rare complication, and identify associated risk factors.
Definition and management of GF The presentation, time to onset, and staple line site of gastric leakage were classified according to the modified U. K. Surgical Infection Study Group definitions [11,12]. The patient’s clinical presentation was further described in terms of systemic signs of inflammation (tachycardia, 4100 beats/ min, and hyperthermia 4381C), peritonitis (diffuse abdominal tenderness), pulmonary symptoms (cough and expectoration), and intraabdominal abscess (localized abdominal tenderness). We differentiated between early-onset gastric leakage (from postoperative day [POD] 1 to POD 7) and late-onset gastric leakage (ZPOD 8). Furthermore, we used abdominal computed tomography (CT) to distinguish between leakage from the upper third of the staple line and leakage from the lower third. The procedure used to treat postLSG GF in our institution was standardized and has been described previously [5,13]. During the study period, endoscopic management of GF changed. Before 2008, we used covered, with antireflux valve, self-expandable metallic stents; after 2008, we progressively abandoned the covered metallic stent and started to use the double pigtail stent to drain the GF inside the stomach [5]. Gastrobronchial fistula events
Methods Population We performed a retrospective analysis of our prospective database for a group of patients presenting GBF after LSG between November 2004 and January 2013. Two bariatric surgeons performed abdominal procedures, whereas all thoracic procedures were performed by the same thoracic surgeon. The primary LSGs in our institution and in other institutions were performed according to a 4-trocar procedure, as described by Verhaeghe et al. [10]. A 34-French bougie was used to guide the staple line. Gastric section was initiated 6 cm from the pylorus. An ENDO GIA Universal XL 60 device (Covidien France SAS, Elancourt, France) with 2 green reloads and then 3 or 4 blue reloads was used to staple the stomach. A methylene blue test was always performed after gastric stapling. Reinforcement of the gastric section line was not always performed. During the study period, 750 patients underwent primary LSG in our institution. Eighteen of these presented postLSG GF (2.4%). During the same period, 6 patients underwent surgery for postLSG GBF. Two of these 6 patients had undergone primary LSG in our institution (corresponding to .2% of all LSGs performed and 11% of all GFs after LSG) and the remaining 4 were referred to us by tertiary centers for the treatment of GBF. The objective of this retrospective study was to characterize GBF and suggest standardized management procedures for this rare complication of LSG.
Definition of gastrobronchial fistula. Gastrobronchial fistula corresponds to an abnormal connection between the stomach and the lung and was diagnosed here by observation of intrathoracic fluid collections and an opacified fistula on a CT scan of the thorax and abdomen with oral contrast. The diagnosis was always confirmed by the endoscopic observation of an opacified connection between the stomach and the lung (Fig. 1), although a CT scan of the abdomen with oral contrast did show the connection between the stomach and the lung in a few cases. Indication for surgery. The management of patients with GBF and the indication for surgery was discussed in a multidisciplinary staff meeting comprising bariatric surgeons, thoracic surgeons, gastroenterologists, radiologists, and anesthesiologists. Repeat surgery was indicated by the presence of recurrent lung infection and GBF, which (in our experience) cannot be treated with antibiotics or endoscopy alone. The Clavien classification of surgical complications [14], Cases of GBF were classified according to Clavien’s guidelines, as follows: Grade I: Any deviation from the normal postoperative course without the need for pharmacologic treatment or surgical, endoscopic, and radiologic interventions. The allowed therapeutic regimens are drugs as antiemetics, antipyretics, analgetics, diuretics, electrolytes, and physiotherapy. This grade also includes wound infections opened at the bedside. Grade II: Requiring pharmacologic treatment with drugs other than such allowed for grade I complications. Blood transfusions and total parenteral nutrition are also included.
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Fig. 1. Imaging of post-laparoscopic sleeve gastrectomy gastrobronchial fistula. (A) Preoperative X-ray with oral contrast, showing the presence of a connection between the stomach and the lung (white arrow). (B) Preoperative CT scan of the thorax and abdomen, showing the GBF.
Grade III: Requiring surgical, endoscopic, or radiologic intervention, including grade IIIa (intervention not under general anesthesia) and grade IIIb (intervention under general anesthesia). Grade IV: Life-threatening complication requiring intensive care/intensive care unit management, including grade IVa (single organ dysfunction, including dialysis and grade IVb (multiorgan dysfunction). Grade V: Death of a patient. Management of GBF Preoperative management of GBF. After GBF had been diagnosed, all patients underwent a preoperative nutritional assessment, with measurement of the body mass index (BMI), EWL, and the percentage weight loss. Serum albumin and prealbumin levels were also assayed. Our laboratory’s normal value for serum albumin ranged from 3.7 to 5.3 g/dL, whereas the normal value for serum prealbumin ranged from 21 to 41 mg/dL. Preoperative refeeding was variously performed via a feeding jejunostomy, a nasojejunal tube, or parenteral nutrition. Refeeding was performed via jejunostomy in case of GF after LSG and necessitating immediate revisional procedure if a jejunostomy was implemented during revisional procedure. Otherwise, nasojejunal tube was preferred to parenteral refeeding. A second nutritional assessment was performed immediately before surgery for GBF. Surgery was delayed if the patient’s nutritional status was unsatisfactory. Surgical procedures for GBF. All abdominal procedures were performed by midline laparotomy. All thoracic procedures were performed by left posterolateral thoracotomy. We always combined thoracic procedures with lung resection and diaphragmatic reconstruction, to minimize the risk of a postoperative fistula between the gastrojejunal anastomosis and the lung. The latter risk is present if the diaphragm is not resected and if the intrathoracic pressure is lower than the intraabdominal pressure.
Abdominal procedures. The abdominal procedure constituted the first step in the surgical treatment of GBF. The left colic flexure was lowered by a median laparotomy. First, splenectomy provided easy access to the GBF’s orifice and enabled diaphragmatic resection by thoracotomy (given that in GBF, the spleen adheres to the abdominal aspect of the diaphragm). Next, the anterior and posterior aspects of the stomach were released. After visualization of the GBF in an oral methylene blue test, the intraabdominal fistula tract was removed. Total gastrectomy [8] or a 60-cm Roux-en-Y side-to-side gastrojejunal anastomosis was performed and an oral methylene blue test was again performed to check for the absence of leakage. A drainage tube was placed next to the gastrojejunal anastomosis or, for a total gastrectomy, the esophagojejunal anastomosis. A feeding jejunostomy was always implemented at the end of the abdominal procedure. Thoracic procedures. The second step in the procedure consisted of lung and diaphragm resection via left posterolateral thoracotomy. Depending on the patient, left lower lobectomy or segmental lung resection was performed. Diaphragm resection was used to remove all the infected tissues. The diaphragm was rebuilt by simple suturing, the use of a muscle flap [15], or the implantation of a prosthesis (GORE DUALMESH Biomaterial, W. L. Gore & Associates, Inc., Flagstaff, AZ). The thoracic cavity was drained via 2 18-French vacuum drains (Fig. 2). Postoperative management. After surgery, all patients were admitted to the intensive care unit (ICU). Postoperative nutrition was initiated on POD 1, with a feeding jejunostomy. Respiratory therapy was initiated on POD 2. In the absence of abnormal clinical and biochemical indicators, an oral methylene blue test and a CT scan of the thorax and abdomen with oral contrast were performed on POD 7. In the absence of an anastomotic fistula, oral refeeding was authorized and thoracic (and then abdominal) drains were removed. The feeding jejunostomy was maintained for 1 month. Patients were seen in consultation 1
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Fig. 2. A photograph taken during gastrobronchial fistula surgery. (A) Gastric fistula orifice (white arrow) with a nasogastric tube (black arrow) inserted into the fistula orifice during the abdominal procedure. (B) Creation of an anastomosis between the fistula orifice (black arrow) and the jejunum (white arrow). (C) The final view of the gastrojejunal anastomosis (white arrow). (D) Thoracic view after left lower lobectomy and diaphragmatic resection (black arrow), showing the intraabdominal drains (white arrow).
month after discharge from hospital and underwent another CT scan of the thorax and abdomen. If the CT results and oral feeding were normal, the feeding jejunostomy was removed during the consultation. No vaccines were given before surgery because of the presence of the GBF. Hence, pneumococcal and meningococcal vaccines were administered within 10 days of GBF surgery (in the absence of sepsis and/or anastomotic fistula). After surgery, all patients received prophylactic treatment with penicillin V (as recommended in the French guidelines) [16]. Inclusion criteria Patients included in the study had to meet the following criterion: postLSG GBF treated surgically via abdominal and thoracic procedures during the same operating session. Endpoints and data recorded The study’s primary efficacy endpoint was the complication rate in patients undergoing surgery for postLSG GBF. The secondary endpoints were operative data, complications (according to the Clavien classification [16]), the mortality rate, the length of hospital stay (LOS, including time in the ICU and time in a hospital ward), and follow-up data. We retrospectively searched for risk factors for postoperative GBF in a database of all LSGs performed in our institution (n ¼ 750) during the study period.
The recorded study parameters included data collected before GBF surgery (age, gender, BMI, preoperative comorbidities, the time interval between the primary LSG and the GBF surgery, other bariatric procedures before LSG, and complications after primary LSG); data on the GBF (time to onset of GBF, the type of care [including the type of nutritional assessment and endoscopic management procedures], nutritional assessments [BMI, EWL, percentage weight loss, serum albumin and serum prealbumin] at the time of diagnosis of GBF and immediately before surgery, and lastly, the time interval between GBF diagnosis and surgery; operative data (overall operating time, operating time for each procedure, blood loss, perioperative red blood cell transfusions, and adverse events during surgery); postoperative data (LOS in the ICU and overall LOS, postoperative complications according to the Clavien classification [14] in general and postoperative anastomotic fistula in particular, revisional surgery, time to oral refeeding, and the duration of follow-up). Results Status before the primary LSG The patient group consisted of 1 man and 5 women (83.3%) and had a median age of 34 years (range, 23–53 years) and a median BMI of 44.3 kg/m2 (range, 37–48.4 kg/ m2). Preoperative co-morbidities were diabetes mellitus
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(in 33.3% of cases; n ¼ 2), hypertension (33.3%, n ¼ 2), dyslipidemia (33.3%, n ¼ 2), and metabolic syndrome (33.3%, n ¼ 2). All patients underwent laparoscopic LSG without conversion to laparotomy. None of the patients had undergone other types of bariatric surgery. Four of the 6 patients (66.6%) developed postoperative GF; 3 patients underwent revisional surgery for early-onset GF and then endoscopy, and the remaining patient was treated (with endoscopy only) for delayed-onset GF. The median time to GF was 8 days (4–60 d). One patient presented postoperative hemorrhage, which necessitated immediate revisional surgery. Diagnosis of GBF Gastrobronchial fistula presented as chronic cough in 3 cases (50%) and a recurrent lung infection in 3 cases (50%). The condition was diagnosed after a contrast-enhanced CT scan of the thorax and abdomen in 5 cases and gastroscopy discovery of communication between the stomach and the lung in 1 case. The GBF was located at the angle of His in all cases. The median (range) time interval between LSG and the onset of GBF was 136 days (99–238 d). Preoperative management of GBF Before GBF surgery, the median preoperative BMI was 31.3 kg/m2 (17.2–40.7 kg/m2), the median EWL was 43.7% (33%–150.8%), and median percentage weight loss was 19% (15.8%–57.6%). At the time of diagnosis of GBF, the median serum albumin level was 2.0 g/dL (1.69–2.4 g/dL), and the median serum prealbumin level was 10 mg/dL (8–20 mg/dL). Preoperative nutritional support was administered to 5 patients (83.3%), with enteral nutrition via a nasojejunal tube in 3 cases (50%), enteral nutrition via a feeding jejunostomy in 1 case (16.6%), and parenteral nutrition in 1 case (16.6%). Before GBF surgery, the median serum albumin level was 2.6 g/dL (1.69–3.5 g/dL), and the median serum prealbumin level was 24 mg/dL (8–28 mg/dL). The median time interval between GBF discovery and surgery was 31 days (7–137 d). One month before surgery for GBF, 1 patient (#6) underwent left posterolateral thoracotomy (in another institution) for pleural decortication. This patient had been referred to us after treatment in another institution for pleural empyema. Operative data The median (range) operating time was 240 minutes (200–280 min) for abdominal surgery, 100 minutes (80–240 min) for thoracic surgery, and 340 minutes (300–520 min) for the entire surgical session. One patient (#1) underwent a total gastrectomy with an additional distal pancreatectomy because of the close connection between the spleen and the tail of the pancreas. The median (range) perioperative blood
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loss was 700 mL (600–2500 mL). Four patients (66.6%) required perioperative blood cell transfusions (median number of units: 2 [0–15 units]). One patient (#6) required clamping of the thoracic aorta for 9 minutes because of intrathoracic bleeding (caused by multiple intrathoracic adhesions after pleural decortication, making left lower lobectomy more difficult to perform). Four patients were extubated in the operating room after GBF surgery. Postoperative data There were no postoperative deaths. The median LOS in the ICU was 10 days (9–16 d), and the median overall LOS was 14 days (13–25 d). There were 4 postoperative complications (66.6%), including 2 Clavien grade IIIb postoperative fistulas (33.3%) treated with revisional surgery. One of these cases (in patient #2) was treated with revisional surgery (because of early-onset fistula) and then several endoscopic procedures with double pigtail stents (a standard procedure in our institution). The second case (in patient #3) was treated by revisional surgery only and required suturing of the gastrojejunal anastomosis fistula’s dehiscence. The other complications were erysipelas (n ¼ 1, treated with antibiotics) and scar infection (n ¼ 2, Clavien grade II) treated with vacuum therapy. The median time to oral refeeding was 10 days (8–65 d), and the median postoperative follow up time was 4 months (1–14 mo). Risk factors for GBF As mentioned above, 750 primary LSGs were performed during the study period. Eighteen of these cases developed postoperative GF (2.4%). When analyzing data for the LSG (including age, gender, BMI, and preoperative co-morbidities) and the postoperative GF (including time to onset, revisional procedures, endoscopic procedures, and time to treatment), no significant risk factors for the development of postLSG GBF were identified. Discussion Laparoscopic sleeve gastrectomy is an effective treatment for morbid obesity, with an EWL Z50% 6 years after surgery [17,18] and the ability to improve obesity-related co-morbidities [19]. It is a reproducible procedure, with a short operating time and few postoperative complications. The main postoperative complication is GF (in about 2% of LSGs) [3]. However, the treatment of GF is difficult and lengthy (mean treatment duration, 62 d) and requires revisional surgery and additional endoscopic procedures [5]. With as many as 12,000 LSGs performed per year in France, complications such as gastric stricture [20], pseudoaneurysm [7], and GBF [8] are now being described. This type of complication appears to be more frequent after esophagectomy [21,22]. Few cases of postLSG GBF have
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been comprehensively described [23]. In our institution, .2% of all LSGs are followed by GBF. Considering the increase in the number of LSGs performed, the number of cases of GBF is also likely to have increased, with perhaps as many as 24 cases per year in France alone. Gastrobronchial fistula is a rare complication that occurs some time after the primary LSG [24,25] (a median of 136 days in the present series) and often follows postoperative GF (with 4 such instances in our series). When analyzing the data on our series of 750 LSGs, we did not identify any significant risk factors for GBF. The first 2 patients treated for GBF had undergone LSG in our center. One of these patients had previously undergone revisional surgery and then stenting. The other patient developed GBF immediately. At that time, GF was treated endoscopically with a stent. Since then, we have performed almost 600 other LSG procedures, and no further cases of GBF have been observed. This improvement is probably due to standardization of our surgical procedures [13] and the use of a double pigtail stent [5], which reduces the LOS and the treatment time by promoting internal drainage of the GF. The 4 other patients with GBF were referred to us by tertiary centers. Three had developed GF soon after LSG and were referred as soon as the GBF was discovered. This suggests that optimal management of early-onset GF is essential for avoiding GBF, although the small size of the sample studied here may have prevented us from identifying GF management as a risk factor for GBF. In the absence of any predictive factors for GBF, a focus on properly treating this complication is necessary. Five of the 6 GBF patients received nutritional support before GBF surgery. We suspect that this contributed to the good overall surgical outcome, because only 1 of these 5 patients presented a postoperative anastomotic fistula (and was successfully treated with suturing only). The only patient not to receive preoperative nutritional support had
complicated outcomes, with an anastomotic fistula requiring multiple postoperative endoscopic procedures and a longer time to oral refeeding. This observation suggests that GBF is not a surgical emergency; it requires preoperative nutritional support to help the patient achieve an adequate nutritional status and the use of appropriate antibiotics to treat infection, thus promoting recovery from subsequent surgery. In view of the lack of literature data on GBF, there is no consensus on the surgical treatment of this rare complication [26]. In a series of 9 patients, Serra et al. [27] performed total gastrectomy for persistent GF after a duodenal switch. Although there were no deaths, the postoperative outcomes were complicated, with several cases of revisional surgery, some life-threatening situations, and a mean LOS of 4.5 months. Our first patient (#1) underwent total gastrectomy and pancreatectomy; this corresponded to the longest operation in our series and involved major blood loss (2000 mL) and 15 units of red blood cells. This type of procedure also requires close postoperative monitoring for any vitamin and protein deficiencies. Although our outcomes were uneventful (for the above-mentioned reasons), we prefer Roux-en-Y gastrojejunal anastomosis in this context; it has an acceptable complications rate [28] and a shorter operating time and is associated with lower blood loss. We used a 60-cm Roux-en-Y gastrojejunal anastomosis, which reduces the risk of postoperative malabsorption and, thus, avoids the need for burdensome postoperative monitoring for vitamin and protein deficiencies. This procedure allows passage of the food bolus through both the sleeve and the Roux-en-Y gastrojejunal anastomosis and, thus, further reduces the risk of postoperative malabsorption (because most of the bolus will pass through the sleeve) (Fig. 3). In the series described by Campos et al. [9], the patients had undergone other surgical procedures before endoscopic treatment. Furthermore, the surgical procedures were not combined and failed to treat GBF. In our present series, all
Fig. 3. Imaging after gastrobronchial fistula surgery. (A) Oral contrast study (the gastrograffin test) 1 month after surgery, showing the effective passage of contrast into the stomach (black arrow) and the jejunum (white arrow) via the Roux-en-Y gastrojejunal anastomosis (white arrowhead). (B) Frontal pattern of a Roux-en-Y gastrojejunal anastomosis (from [26]).
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Table 1 Preoperative data Patient
#1
#2
#3
#4
#5
#6
Gender Age (y) Initial BMI (kg/m²) GF after primary LSG Revisional surgery Endoscopic procedure Number of endoscopic procedures (n) Time to onset of GBF (d) Preoperative nutrition Preoperative serum albumin (g/dL) Preoperative serum prealbumin (mg/dL) Time between GBF diagnosis and surgery GBF (d)
Female 23 40.2 Yes Yes Yes 1 136 Yes 2.0 17 137
Female 34 44.3 No Yes No 0 238 No 1.69 8 7
Female 53 44.4 Yes Yes Yes 3 161 Yes 3.5 28 30
Female 46 37 No No No 0 110 Yes 2.6 25 100
Male 35 48.4 Yes No Yes 2 167 Yes 2.9 24 31
Female 23 48 Yes Yes Yes 2 99 Yes 3.0 25 32
BMI ¼ body mass index; GBF ¼ gastrobronchial fistula; GF ¼ gastric fistula; LSG ¼ laparoscopic sleeve gastrectomy. Normal value of serum albumin ranged from 3.7 to 5.3 g/dL. Normal value of serum prealbumin ranged from 21 to 41 mg/dL.
but one of our patients (#6) underwent combined surgical procedures. Overall, the outcomes were good for all of our patients except #1 (total gastrectomy) and #6 (for whom the thoracic procedure was complicated by previous pleural decortication). The latter complication resulted in a longer thoracic operating time, greater blood loss, inability to extubate the patient in the operating room, and thoracic aorta clamping (which can endanger the blood vessels around the Roux-en-Y gastrojejunal anastomosis). Campos et al. [9] suggested that GBF could be treated with purely endoscopic procedures. Almost all their cases of GBF were treated successfully (except for 1 patient with GBF after a RYGB), with a mean of 4.5 endoscopic procedures per patient and a mean treatment duration of 4.4 months. In contrast to the series by Campos et al., all of our patients were treated successfully and no postoperative deaths were recorded. The morbidity rate in our study was acceptable, with a shorter LOS and more rapid oral
refeeding. These findings are important because patients treated for postoperative fistulas often develop depression due to the burdensome procedure and the extended LOS. One of the key findings of this retrospective report is that surgery for GBF should not be considered as an emergency procedure. Surgery for GBF has a good outcome if preoperative refeeding has been performed and if abdominal and thoracic procedures are combined. The results associated with our standardized GBF management procedures need to be confirmed in a larger series. In view of the above results, we currently perform Roux-en-Y gastrojejunal anastomosis for chronic GF after LSG (albeit without the thoracic and diaphragmatic procedures) (Table 1 and 2). Conclusions Gastrobronchial fistula is a rare complication after LSG. In our experience, surgery for GBF is never an emergency.
Table 2 Intraoperative and postoperative data Patient
#1
#2
#3
#4
#5
#6
Abdominal surgery Splenectomy Additional procedures Thoracic surgery Diaphragm repair Operating time (min) Abdominal operating time (min) Thoracic operating time (min) Blood loss (mL) Abdominal blood loss (mL) Thoracic blood loss (mL) Red blood cell transfusions (n) Extubation in the operating room Postoperative fistula Revisional surgery Endoscopic procedure Time to oral refeeding (d)
Total gastrectomy Yes Distal pancreatectomy Segmental Flap 520 280 240 2000 1500 500 15 No No No No 9
GJ anastomosis Yes No LLL Suture 370 220 150 1500 1200 300 4 Yes Yes Yes Multiple 35
GJ anastomosis Yes No LLL Suture 320 240 80 600 450 150 2 Yes Yes Yes No 18
GJ anastomosis Yes No LLL Suture 340 240 100 700 500 200 0 Yes No No No 10
GJ anastomosis Yes No Segmental Suture 300 200 100 600 400 200 0 Yes No No No 10
GJ anastomosis Yes No LLL Prosthesis 480 240 240 2500 500 2000 7 No No No No 8
GJ ¼ gastrojejunal; LLL ¼ left lower lobe.
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Treatment is based on effective drainage of the fistula with endoscopic procedures, which allows optimal preoperative refeeding before the performance of combined abdominal and thoracic surgical procedures. With respect to the abdominal procedure, 60-cm Roux-en-Y gastrojejunal anastomosis appears to be an appropriate conservative treatment for GBF if preoperative nutritional support has been provided. Relative to total gastrectomy, the Roux-en-Y procedure is simpler and avoids the risk of postoperative deficiency during long-term follow-up. Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article. References [1] Bohdjalian A, Langer FB, Shakeri-Leidenmühler S, et al. Sleeve gastrectomy as sole and definitive bariatric procedure: 5-year results for weight loss and ghrelin. Obes Surg 2010;20:535–40. [2] Péquignot A, Dhahri A, Verhaeghe P, Desailloud R, Lalau JD, Regimbeau JM. Efficiency of laparoscopic sleeve gastrectomy on metabolic syndrome disorders: two years results. J Visc Surg 2012;149:e350–5. [3] Parikh M, Issa R, McCrillis A, Saunders JK, Ude-Welcome A, Gagner M. Surgical strategies that may decrease leak after laparoscopic sleeve gastrectomy: a systematic review and meta-analysis of 9991 cases. Ann Surg 2013;257:231–7. [4] Aurora AR, Khaitan L, Saber AA. Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients. Surg Endosc 2012;26: 1509–15. [5] Pequignot A, Fuks D, Verhaeghe P, et al. Is there a place for pigtail drains in the management of gastric leaks after laparoscopic sleeve gastrectomy? Obes Surg 2012;22:712–20. [6] Lalor PF, Tucker ON, Szomstein S, Rosenthal RJ. Complications after laparoscopic sleeve gastrectomy. Surg Obes Relat Dis 2008;4: 33–8. [7] Rebibo L, Fuks D, Blot C, et al. Gastrointestinal bleeding complication of gastric fistula after sleeve gastrectomy: consider pseudoaneurysms. Surg Endosc 2013;27:2849–55. [8] Fuks D, Dumont F, Berna P, et al. Case report—complex management of a postoperative bronchogastric fistula after laparoscopic sleeve gastrectomy. Obes Surg 2009;19:261–4. [9] Campos JM, Pereira EF, Evangelista LF, et al. Gastrobronchial fistula after sleeve gastrectomy and gastric bypass: endoscopic management and prevention. Obes Surg 2011;21:1520–9. [10] Verhaeghe P, Dhahri A, Qassemyar Q, Regimbeau J-M. Technique de la gastrectomie longitudinal (sleeve gastrectomy) par laparoscopie. EMC (Elsevier Masson SAS, Paris), Techniques chirurgicales–Appareil digestif, 2011:40–385.
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