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      Mini gastric bypass for the management of gastrobronchial fistula: A case report

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          Highlights

          • Gastrobronchial fistula is uncommon with an ambiguous presentation.
          • It should be suspected among patients who underwent bariatric surgery.
          • Optimal management is yet to be determined.

          Abstract

          Introduction

          With the high rates of obesity worldwide, laparoscopic sleeve gastrectomy (LSG) has become a very popular procedure. Due to its simple technique, rare complications might be overseen. Gastric leaks and fistula are fairly uncommon complications. In comparison to other types of fistulas, gastrobronchial fistulas are rarer with serious complications. Definitive management is yet to be determined. We intend to explore the literature on the management approach of such patients.

          Presentation of case

          A 46-year-old male, presented with on/off abdominal pain, productive cough, and vomiting. The patient had left sided rhonchi on examination. In addition to a history of laparoscopic sleeve gastrectomy (LSG) 4 years ago. Imaging confirmed the presence of a gastrobronchial fistula. Conservative and endoscopic treatment failed. Consecutively, surgery was indicated. A laparoscopic mini gastric bypass with refashioning of gastric fistula edges and closure with graham patch was done.

          Conclusion

          Given the increasing number of such surgeries performed the recognition of acute and chronic complications, and their optimal management is of great importance. Although performing a Roux-en-Y fistulojejunostomy was recommended in the literature, conservative and endoscopic treatment should be considered before.

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          Most cited references 11

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          Gastric leaks post sleeve gastrectomy: review of its prevention and management.

          Gastric sleeve gastrectomy has become a frequent bariatric procedure. Its apparent simplicity hides a number of serious, sometimes fatal, complications. This is more important in the absence of an internationally adopted algorithm for the management of the leaks complicating this operation. The debates exist even regarding the definition of a leak, with several classification systems that can be used to predict the cause of the leak, and also to determine the treatment plan. Causes of leak are classified as mechanical, technical and ischemic causes. After defining the possible causes, authors went into suggesting a number of preventive measures to decrease the leak rate, including gentle handling of tissues, staple line reinforcement, larger bougie size and routine use of methylene blue test per operatively. In our review, we noticed that the most important clinical sign or symptom in patients with gastric leaks are fever and tachycardia, which mandate the use of an abdominal computed tomography, associated with an upper gastrointrstinal series and/or gastroscopy if no leak was detected. After diagnosis, the management of leak depends mainly on the clinical condition of the patient and the onset time of leak. It varies between prompt surgical intervention in unstable patients and conservative management in stable ones in whom leaks present lately. The management options include also endoscopic interventions with closure techniques or more commonly exclusion techniques with an endoprosthesis. The aim of this review was to highlight the causes and thus the prevention modalities and find a standardized algorithm to deal with gastric leaks post sleeve gastrectomy.
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            Case report-complex management of a postoperative bronchogastric fistula after laparoscopic sleeve gastrectomy.

            Laparoscopic sleeve gastrectomy (LSG) is a new restrictive bariatric procedure increasingly indicated in the treatment of morbid obesity. Postoperative complications are mainly represented by gastric fistula with an occurrence rate of 0% to 5.1% in the literature. This complication is difficult to manage and requires multiple radiological, endoscopic, and surgical procedures. We report herein the case of a 23-year-old woman who underwent LSG for morbid obesity. This patient was reoperated for peritonitis due to a gastric fistula located on the top of the staple line. Five months later, she complained of a cough with fever and expectoration. A methylene blue test and a computed tomography scan diagnosed a postoperative bronchogastric fistula. After failure of aggressive conservative management, radical surgery was performed with total gastrectomy, reconstruction of the diaphragm using the extended latissimus dorsi flap, and a pulmonary lobectomy. This case report highlights the possible issue of the complex management of gastric fistula after LSG.
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              Gastrobronchial Fistula as a Complication of Bariatric Surgery: A Series of 6 Cases

              Objective: To present a multicenter series of 6 patients who developed gastrobronchial fistula (GBF). GBF is a rare subtype of gastric leaks following bariatric surgery, which is the mainstay of treatment for the obesity pandemic. Methods : We retrospectively identified 6 patients with GBF (out of 2,308 cases performed: 0.2%). One patient had undergone Roux-en-Y gastric bypass, and 5 had a sleeve gastrectomy. Demographics, previous surgeries, clinical presentation, timing of fistula diagnosis, diagnostic and treatment measures employed, and outcome were collected. Results : Four patients were female, the average age and BMI were 42 years and 42.5 kg/m 2 , respectively. Three patients had previous surgeries (Nissen fundoplication, adjustable gastric banding, and vertical banded gastroplasty). Median time to fistula diagnosis was 40 days (range 15–90 days). Clinical presentation included chronic cough, hemoptysis, dyspnea and fever as well as persistent left pleural effusion or pneumonia. Diagnosis was confirmed by computed tomography in all cases. Two patients were treated nonoperatively, while 4 eventually required surgery for resolution. Left lower lobectomy was necessary in 3 of 4 cases. Concomitant procedures were total gastrectomy in 2 cases and conversion of a sleeve to a gastric bypass in 1 case. Resolution occurred 30 days to 2 years after initial surgery. No mortalities were encountered. Conclusions : GBF is a rare but devastating complication following bariatric surgery. It may develop as a late complication of a chronic upper gastric leak. Surgery is curative although nonoperative management may be warranted in selected cases.
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                Author and article information

                Contributors
                Journal
                Int J Surg Case Rep
                Int J Surg Case Rep
                International Journal of Surgery Case Reports
                Elsevier
                2210-2612
                09 December 2019
                2020
                09 December 2019
                : 66
                : 192-195
                Affiliations
                [a ]Department of Surgery, King Khalid University Hospital, P.O. Box 7805 #37, Riyadh, 11472, Saudi Arabia
                [b ]College of Medicine, King Saud University, P.O. Box 7805 #37, Riyadh, 11472, Saudi Arabia
                Author notes
                [* ]Corresponding author. abdulrahmanalsayyari@ 123456gmail.com
                Article
                S2210-2612(19)30699-6
                10.1016/j.ijscr.2019.11.064
                6928340
                31864149
                © 2019 The Authors

                This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

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