LAUSR

Bariatric surgery has become one of the main treatments for morbid obesity. Sleeve gastrectomy (SG) is among the most performed surgical techniques worldwide, surpassing Roux-en-Y Gastric By-Pass (RYGBP) as the most popular procedure in recent years 1. Regarding its safety, the main limitation of this technique is gastric fistulae (GF). What causes them is still unclear, but an increase in intragastric pressure and a modification in the vascularization after surgery can lead to a leak (usually in the upper part of the staple line, closer to the gastroesophageal junction) 2, hence developing a GF. Most GF can be safely managed with conservative treatment or with endoscopic or minimally invasive surgical procedures, but in some cases, these are not sufficient and a more radical approach is needed [1]. Acute GF (AGF) incidence ranges between 1 and 3% 3 after SG, while Chronic GF (CGF) is much lower at 0.1% 4, 5 after SG. A particular kind of CGF is the one that also affects the pleura or even the lungs, developing an esogastrobronchopleural fistula (EGBPF). Among the available treatments for CGF, there are endoscopic and surgical options, such as Roux-en-Y fistulojejunostomy 6, conversion to a RYGBP or total gastrectomy 1. If the pleura and/or lungs are affected, it may require lung or diaphragmatic resections. We present a patient who developed an EGBPF after SG and the treatment she underwent. A 56-year-old woman who underwent a SG (open surgery due to a large incisional hernia from a previous surgery that was repaired in the same operation) for class II obesity (BMI 36.7) associated with high blood pressure and type-2 diabetes. One year after surgery, she was readmitted to the hospital due to a subphrenic abscess caused by a proximal GF. It was treated with antibiotics and she was discharged a week later. For personal reasons, the patient was lost in follow-up. Eleven years later, she was admitted to the emergency room with fever and hemoptysis. The abdominal CT showed a left subphrenic abscess, also affecting the pleura, and with the contrast administered by endoscopy seen inside the bronchium (EGBPF) (Figure 1). She was initially treated with broad-spectrum antibiotics and a trans-gastric drainage of the abscess, but the fever persisted. An endoluminal vacuum therapy device (Endosponge©) was used, with no improvement, so the patient was programmed for elective surgery. Through a midline incision, the subphrenic space was accessed and the abscess debrided. The fistula was identified and removed with a stapler. A gastric pouch was created, with a Roux limb that was sutured laterally to the gastric pouch (fistulojejunostomy), covering the fistula defect (similar to the original Fobi-Capella technique 7), with a manual, termino-lateral gastrojejunostomy (Figure 2). The path through which the abscess accessed the thorax was not found. The patient presented no postoperative complications and was discharged on the 6th postoperative day. Nine months later, she has not developed any complications. The esogastro-bronchopleural fistula (EGBPF) is an uncommon, yet challenging complication of SG. It usually starts as an abdominal GF that extends towards the thorax, goes through the diaphragm, and invades the pleura and lung parenchyma and bronchia. Conservative management is usually not sufficient, and requires a surgical approach in most cases, including lung and diaphragmatic resections. Among the surgical options, we believe resecting the fistula, and completing a RYGBP without entering the pleural space is a safe technique, since the fistula is closed and no longer connected to the thorax. * Jesus Badia-Closa [email protected]