Successful treatment of gastrobronchial fistula following laparoscopic sleeve gastrectomy: A case report and review of literature

Abstract

BACKGROUND

Gastrobronchial fistula (GBF) is a rare but severe complication after sleeve gastrectomy (SG). GBF is associated with significant morbidity and mortality. Diagnosis is often delayed due to nonspecific symptoms. Therefore, timely recognition and management are critical. Endoscopic management, as the cornerstone of initial therapy, can be performed in a combined or stepwise manner for chronic or refractory cases.

CASE SUMMARY

A 48-year-old male with class II obesity and metabolic syndrome underwent laparoscopic SG. Six months later, he developed poor oral intake, chest pain, and dyspnea. Chest radiography and computed tomography revealed massive left pleural effusion, and laboratory tests showed leukocytosis. Video-assisted thoracoscopic surgery and esophagogastroduodenoscopy revealed a fistulous tract between the sleeved stomach and pleural cavity. Management included decortication, nasoduodenal feeding, and multiple sessions of endoscopic vacuum therapy. Although the fistula orifice decreased in size, an upper gastrointestinal series performed during follow-up indicated progression to GBF. We repeated decortication and placed a covered self-expandable metallic stent. Six weeks later, the stent was removed. Esophagogastroduodenoscopy confirmed that the GBF successfully healed.

CONCLUSION

Early suspicion, prompt diagnosis, and adequate intervention of GBF are crucial when the complication arises after laparoscopic SG. Endoscopic approaches, such as endoscopic vacuum therapy and stenting, are effective first-line therapies.

Key Words: Sleeve gastrectomy; Bariatric surgery; Gastric leak; Gastrobronchial fistula; Gastropleural fistula; Endoscopic vacuum therapy; Stent; Case report

Core Tip: Treatment for gastropleural fistula/gastrobronchial fistula ranges from minimally invasive endoscopic procedures to major surgical interventions. Endoscopic therapy, such as endoscopic vacuum therapy and self-expandable metallic stent placement, is an increasingly favored initial treatment of gastrobronchial fistula due to its safety and efficacy. In complex or refractory cases a combined or stepwise approach can achieve successful closure while avoiding the morbidity of extensive surgery.

INTRODUCTION

Sleeve gastrectomy (SG) is one of the most widely performed bariatric procedures worldwide. It is popular because of its technical simplicity, absence of anastomosis, and broad applicability[1]. Despite these advantages gastric leakage is a serious postoperative complication that can lead to rare but severe sequelae such as gastropleural fistula (GPF) or gastrobronchial fistula (GBF) with an incidence of 0.2%-0.4%[2,3]. The management of GPF and GBF is challenging because of their rarity and lack of standardized guidelines. Treatment options include conservative measures, endoscopic therapies, and surgical interventions. Endoscopic approaches, particularly endoscopic vacuum therapy (EVT) and self-expandable metallic stent (SEMS) placement, are increasingly utilized as first-line strategies due to favorable safety and efficacy profiles[4]. Surgery is generally reserved for patients who are unstable or who have refractory fistulas[5]. We report a rare case of GPF progressing to GBF after SG that was successfully managed with sequential endoscopic therapies. This case highlights the effectiveness of minimally invasive techniques and the value of treating a complex fistula with a multimodal strategy.

CASE PRESENTATION

Chief complaints

A 48-year-old male presented with poor oral intake, left-sided chest pain, and dyspnea that occurred during the 3 weeks prior to presentation.

History of present illness

The patient underwent laparoscopic SG in 2015 to alleviate symptoms from class II obesity and metabolic syndrome. A laparoscopic re-SG was performed in 2023 for weight regain. His postoperative course was complicated by gastric leakage, which resolved with total parenteral nutrition. However, he developed persistent chest pain, dyspnea, and reduced oral intake 6 months later.

History of past illness

There was no other past illnesses reported.

Personal and family history

The patient denied cigarette smoking, alcohol use, and significant family illness.

Physical examination

Upon admission the patient’s vital signs were: Blood pressure of 78/51 mmHg; heart rate of 76 bpm; respiratory rate of 28 breaths/minute; body temperature of 35.1 °C; and oxygen saturation of 92%. Chest examination revealed dullness to percussion and decreased breath sounds over the left lung. No abdominal tenderness nor rebound was noted.

Laboratory examinations

Laboratory results demonstrated leukocytosis with white blood cell of 17.58 × 10⁹/L [normal range: (4.5-11) × 10⁹/L], neutrophil-to-lymphocyte ratio of 89.8/4.3, creatinine of 2.5 mg/dL (normal range: 0.7-1.2 mg/dL), and C-reactive protein level of 27.95 mg/dL (normal range: 0-0.8 mg/dL).

Imaging examinations

Chest radiography revealed a large pleural effusion on the left (Figure 1A). Computed tomography showed a left hydropneumothorax (Figure 1B). Due to the patient’s history of SG, esophagogastroduodenoscopy (EGD) was performed and revealed a fistula orifice with purulent discharge along the staple line (Figure 1C). A guidewire was inserted through the EGD working channel into the fistula, and video-assisted thoracoscopic surgery (VATS) was performed. Intraoperatively, pus and fruit seeds were identified in the pleural cavity with the guidewire passing through the diaphragm (Figure 1D).

Figure 1 Imaging at presentation. A: Chest X-ray revealed a left-sided pleural effusion; B: Computed tomography showed a hydropneumothorax; C: Esophagogastroduodenoscopy identified a fistula with purulent discharge near the staple line (arrow heads) of the sleeved stomach; D: Thoracoscopic view of a guidewire (arrow heads) passing from the fistula through the diaphragm into the pleural cavity.

FINAL DIAGNOSIS

The final diagnosis was GPF.

TREATMENT

Intravenous antibiotics were initiated when the patient was admitted. Decortication and diaphragmatic repair were performed during VATS. EVT was subsequently applied to the fistula orifice (Figure 2A) by attaching a polyurethane sponge to a nasogastric tube and commencing continuous negative pressure suction under EGD guidance. The sponge was replaced as needed (every few days to once a week). Nutrition was maintained via nasoduodenal feeding. EGD revealed a marked reduction in the fistula size after 2 months (Figure 2B). However, an upper gastrointestinal series indicated that the GPF progressed to GBF (Figure 3A). Repeat VATS with decortication and placement of a covered SEMS were performed (Figure 3B). The timeline of interventions is summarized in Figure 4.

Figure 2 Esophagogastroduodenoscopy images during treatment. A: Endoscopic vacuum therapy with a polyurethane sponge (arrow heads) applied to the fistula orifice; B: Marked reduction in fistula size; C: Successful closure of the fistula.

Figure 3 Treatment imaging. A: Upper gastrointestinal series revealed a left-sided gastrobronchial fistula (arrowhead); B: Chest X-ray demonstrated the proper position of the covered self-expandable metallic stent (arrowhead); C: Upper gastrointestinal series after stent removal showed no contrast leak into the pleural cavity.

Figure 4 Timeline of interventions and outcomes. VATS: Video-assisted thoracoscopic surgery; EVT: Endoscopic vacuum therapy; SEMS: Self-expandable metallic stent; GPF: Gastropleural fistula; GBF: Gastrobronchial fistula.

OUTCOME AND FOLLOW-UP

The patient recovered without dysphagia, cough, or chest pain. After 6 weeks the stent was removed, and follow-up EGD and upper gastrointestinal series confirmed complete closure of the fistula (Figures 2C and 3C).

DISCUSSION

We describe herein a rare case of GBF as a complication following SG that was successfully managed with sequential EVT and SEMS placement. This case illustrates the challenges and the effectiveness of multimodal endoscopic therapy in treating complex post-bariatric fistulas. Although laparoscopic SG is the most commonly performed bariatric and metabolic surgery worldwide due to its safety profile, leaks occur in 2.4% of cases. Leaks most often occur along the proximal staple line near the angle of His[6,7]. Chronic leaks may evolve into GPF or GBF via subphrenic abscess formation eroding through the diaphragm and draining into a bronchus[8].

A consensus on the management strategies of GPF and GBF has not been reached due to the rarity of these fistulas. Approaches include conservative therapy (antibiotics, parenteral nutrition, nasoenteric feeding), endoscopic closure methods (stents, clips, drains, fibrin glue, occluders, argon plasma coagulation, EVT), and surgery (revision, Roux-en-Y fistulojejunostomy, or completion gastrectomy)[9-12]. Roux-en-Y fistulojejunostomy, which avoids the need for total or proximal gastrectomy, is the most commonly performed procedure for chronic gastric leaks. Completion gastrectomy entails total gastrectomy. Both procedures should be reserved for patients with adequate nutritional status and only after failure of well-conducted endoscopic management[13,14]. However, the advancement of therapeutic endoscopy has led to an increased preference for endoscopic procedures as first-line treatment[4] with surgery reserved for severe or refractory cases[5,15].

We conducted a literature review of GPF and GBF occurrence after bariatric surgery and identified 179 cases. The overall treatment success rate was 87.5% with one-third of the cases managed exclusively by endoscopic interventions (Table 1). EVT has gained particular attention. The technique was first described by Wedemeyer et al[16] in 2008 in the treatment of upper intestinal anastomotic leaks. EVT promotes closure by sealing the leak site, draining necrotic material, reducing inflammation, and enhancing tissue healing[17,18]. A meta-analysis demonstrated that EVT was superior to stenting with a higher closure rate and a lower mortality rate[19]. However, the use of EVT to treat GPF and GBF after bariatric surgery has been reported in only 3 cases[20,21]. One was treated successfully with EVT followed by re-bypass while the other two were successfully managed with EVT alone.

Table 1 Literature review of gastrobronchial or gastropleural fistula following bariatric surgery.

No.	Ref.	Case number	Type of bariatric surgery	Type of fistula	Treatment	EVT	Episode of postoperative leakage	Interval from bariatric surgery to fistula diagnosis	Closure rate
1	Serra et al[23], 2007	1	LSG	GBF	Endoscopic1	No	Yes	1 month	1/1
2	Campos et al[24], 2007	1	RYGB	GBF	Endoscopic1	No	No	2.5 years	1/1
3	Doumit et al[9], 2009	1	RYGB	GPF	Decortication; bypass; endoscopic1	No	No	3 months	1/1
4	Fuks et al[25], 2009	1	LSG	GBF	Endoscopic1; bypass; lung lobectomy	No	Yes	5 months	1/1
5	Sinna et al[26], 2011	1	LSG	GBF	Bypass; lung lobectomy	No	Yes	5 months	1/1
6	Campos et al[27], 2011	15	RYGB; LSG	GBF	Endoscopic1; primary repair; lung resection	No	NA	6.7 months (1-30 months)	14/15
7	Abraham et al[28], 2012	1	LSG	GBF	Endoscopic1	No	No	20 months	1/1
8	Sakran et al[10], 2012	6	AGB; VBG; LSG; RYGB	GBF	Bypass; lung lobectomy	No	Yes	40 days (15-90 days)	6/6
9	Albanopoulos et al[29], 2013	2	LSG	GBF	Bypass	No	Yes	20 months and 13 months	1/2
10	Alharbi[30], 2013	1	LSG	GBF	Endoscopic1	No	Yes	4 months	1/1
11	Rebibo et al[31], 2014	6	LSG	GBF	Bypass; decortication	No	NA	136 days (99-238 days)	6/6
12	Santacruz et al[32], 2014	1	VBG; DS	GBF	Bypass	No	Yes	4 years	1/1
13	Garcia-Quintero et al[33], 2015	2	SG; RYGB	GPF	Bypass; decortication	No	Yes	1 year and 13 years	1/1
14	Guerrero-Silva et al[34], 2015	1	LSG	GBF	Primary repair; endoscopic1	No	No	14 days	1/1
15	Tabbara et al[35], 2015	1	VBG; SG	GPF	Endoscopic1; bypass	No	Yes	5 months	1/1
16	Guillaud et al[36], 2015	13	VBG; AGB; LSG	GPF	Endoscopic1; bypass; decortication; lung lobectomy	No	Yes	129 days (14-277 days)	13/13
17	Mendoza Ladd et al[37], 2015	1	SG	GPF	Endoscopic1	No	No	8 weeks	1/1
18	Praveenraj et al[38], 2015	1	LSG	GBF	Endoscopic1; bypass	No	No	7 months	1/1
19	Nguyen et al[39], 2016	1	LSG	GPF	Bypass	No	Yes	9 months	1/1
20	Ghanem et al[40], 2017	1	VBG; RYGB	GPF	Endoscopic1	No	Yes	6 months	1/1
21	Al-Shurafa et al[41], 2017	1	Laparoscopic VBG; OAGB	GPF	Bypass; decortication	No	No	2 years	1/1
22	Andrawes and El Douaihy[42], 2017	1	SG; DS	GPF	Endoscopic1	No	No	11 years	1/1
23	Greilsamer et al[43], 2017	1	SG	GBF	Bypass; lung lobectomy	No	Yes	5 years	1/1
24	Alshammari et al[44], 2018	1	LSG	GBF	Decortication; lung lobectomy; bypass	No	Yes	15 months	1/1
25	Ben Nun et al[45], 2018	13	LSG	GBF	Primary repair; lung lobectomy; bypass	No	NA	14 months (7-36 months)	12/13
26	Alghanim et al[46], 2018	1	LSG	GPF	Endoscopic1	No	No	9 months	1/1
27	Takahashi et al[47], 2018	1	AGB; SG; RYGB	GPF	Endoscopic1; bypass; decortication	No	Yes	NA	1/1
28	Al-Lehibi[48], 2019	1	LSG	GBF	Endoscopic1	No	Yes	1 year	1/1
29	Boru et al[49], 2019	3	LSG	GBF	Endoscopic1; lung lobectomy; bypass	No	Yes	33 months (6-84 months)	3/3
30	Saliba et al[50], 2019	1	LSG	GBF	Bypass	No	No	2 months	1/1
31	Mohammed and Arif[51], 2020	1	LSG	GBF	Endoscopic1; primary repair; lung lobectomy	No	Yes	7 years	1/1
32	Gupta et al[52], 2020	1	LSG	GPF	Decortication; primary repair	No	No	9 months	1/1
33	Alharbi et al[53], 2020	1	LSG	GBF	Endoscopic1; bypass	No	Yes	4 years	1/1
34	Sobhani et al[54], 2020	1	LSG	GPF	Bypass	No	Yes	3 months	0/1
35	Marie et al[55], 2020	24	LSG; SG; RYGB	GBF; GPF	Endoscopic1; bypass; decortication; lung lobectomy	No	Yes (67%)	124 days (7-760 days)	23/24
36	Saber et al[56], 2021	1	AGB; OAGB	GBF	Endoscopic1; bypass	No	No	5 years	1/1
37	Sabawi et al[57], 2021	1	LSG	GBF	Bypass	No	No	2 months	1/1
38	Albassam et al[58], 2021	1	SG	GPF	Decortication; lung lobectomy; primary repair; endoscopic1	No	No	5 months	1/1
39	Najjari et al[59], 2021	2	LSG	GBF	Endoscopic1; bypass	No	No	5 years and 6 months	2/2
40	Montana et al[60], 2021	8	LSG	GBF; GPF	Endoscopic1; bypass	No	NA	1-120 days	8/8
41	Sobhani et al[61], 2021	1	LSG; SASI	GPF	Endoscopic1	No	Yes	NA	1/1
42	Odemis and Turan Gökçe[62], 2021	1	RYGB	GBF	Endoscopic1	No	No	4 months	1/1
43	Bestetti et al[22], 2022	1	LSG	GPF	Endoscopic1	No	No	6 months	1/1
44	D’Alessandro et al[63], 2022	40	LSG	GBF	Endoscopic1	No	NA	265.6 ± 521.0 days (7-2307 days)	19/40
45	Gkolfakis et al[64], 2022	1	LSG	GBF	Endoscopic1	No	Yes	4 months	1/1
46	Mongardini et al[65], 2022	1	LSG	GBF	Endoscopic1; autologous stem cell grafting	No	NA	5 months	1/1
47	Koussayer et al[66], 2023	1	AGB; LSG	GPF	Primary repair	No	Yes	6 years	1/1
48	Movahhed et al[67], 2023	1	RYGB	GPF	Primary repair; lung resection; endoscopic1	No	No	1 month	1/1
49	Parkash et al[68], 2023	1	LSG	GPF	Decortication; endoscopic1	No	No	2 weeks	1/1
50	Shahabi et al[69], 2023	1	LSG	GPF	Endoscopic1; bypass	No	No	2 months	1/1
51	Boerkoel et al[70], 2023	1	SG	GPF	Decortication; lung lobectomy; primary repair	No	No	3 years	1/1
52	Shin et al[20], 2024	1	LSG	GBF	Endoscopic1; bypass	Yes	Yes	20 days	1/1
53	Michel Macareno et al[21], 2025	2	SG	GPF	Endoscopic1	Yes	No	NA	2/2
54	Hany et al[71], 2025	1	LSG	GBF	Endoscopic1; bypass; decortication; lung resection	No	No	14 days	1/1
55	Hifni et al[72], 2024	1	LSG	GPF	Endoscopic1; primary repair	No	No	12 years	1/1
56	Hany et al[71], 2025	1	LSG	GPF	Endoscopic1; bypass	No	No	14 days	1/1

¹Endoscopic includes clipping, drainage, cardiac septal defect occluder, stent, over-the-scope-clip, argon plasma coagulation, fibrin glue, etc.

EVT: Endoscopic vacuum therapy; LSG: Laparoscopic sleeve gastrectomy; GBF: Gastrobronchial fistula; RYGB: Roux-en-Y gastric bypass; NA: Not available; AGB: Adjustable gastric banding; VBG: Vertical banded gastroplasty; DS: Duodenal switch; SG: Sleeve gastrectomy; GPF: Gastropleural fistula; OAGB: One anastomosis gastric bypass; SASI: Single anastomosis sleeve ileal bypass.

In our patient, distinct from the other cases reported previously, EVT reduced the fistula size but did not achieve complete closure, likely due to chronicity. Sequential SEMS placement ultimately sealed the tract. A prior report also showed that chronic fistulas were 20% less responsive to endoscopy alone than acute leaks and often required multimodal procedures[22]. Nonetheless, endoscopic management is a cornerstone of initial GPF and GBF treatment that offers both effective leak control and the potential for definitive treatment. This case underscores the importance of a stepwise endoscopic approach in achieving successful closure.

CONCLUSION

GBF is a rare but serious complication of SG. It should be considered in the differential diagnosis of patients presenting with chronic cough, shortness of breath, chest pain, or recurrent pulmonary or subphrenic abscesses. A tailored, early, multimodal, stepwise strategy beginning with endoscopic therapy and escalating as needed offers a high rate of success while minimizing surgical morbidity. EVT followed by SEMS placement are key components of first-line management in these complex cases, with the EVT reducing the fistula size and the subsequent SEMS achieving complete closure.