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J Thorac Cardiovasc Surg 2005;130:914-915
© 2005 The American Association for Thoracic Surgery
Brief Communication |
a Division of Cardiothoracic Surgery, Oregon Health and Sciences University, Portland, Ore.
b Department of Surgery, Oregon Health and Sciences University, Portland, Ore.
Received for publication February 23, 2005; accepted for publication March 18, 2005. * Address for reprints: Paul H. Schipper, MD, Oregon Health and Sciences University, Department of Surgery, Division of Cardiothoracic Surgery L353, 3181 SW Sam Jackson Park Rd, Portland OR 97201 (Email: schippep{at}ohsu.edu).
We present a case of gastrobronchial fistula after laparoscopic Nissen fundoplication. Although a known complication of antireflux surgery, this is the first case reported occurring after laparoscopic Nissen fundoplication or fundoplication with an intra-abdominal wrap. All previously reported cases involved an initial open operation and an intrathoracic wrap either intentionally left or subsequently herniating into the chest.
Clinical Summary
A 46-year-old man came to the emergency department with hemoptysis. His symptoms began 5 days before admission, with a cough and shortness of breath that progressed to hemoptysis. History was significant for asthma, cigarette smoking, and a Nissen fundoplication 5 years previously. His admission hematocrit value was 18.7%, for which packed red cells were transfused. White blood cell count was 17,000, platelet count was 631,000, creatinine level was 1.3 mg/dL, international normalized ratio was 1.2, and partial thromboplastin time was 34.9 seconds. Soon after admission, his respiratory status decompensated, and he required emergency intubation. A chest radiograph showed mild bilateral infiltrates, and bronchoscopy showed nonbloody bilious secretions in the airways bilaterally. Esophagogastroduodenoscopy demonstrated Mallory-Weiss tears and an esophageal ulcer. Initial treatment was for exacerbation of asthma, an upper gastrointestinal bleed, and aspiration. On hospital day 6, a computed tomographic scan demonstrated a left pleural effusion (Figure 1). An upper gastrointestinal series revealed contrast flowing from the gastroesophageal junction into the left pleural space through the hiatus (Figure 2). On review of his fundoplication operative note, the wrap was accomplished with 3 simple sutures, each incorporating the anterior esophagus. The crural closure consisted of 2 sutures placed anteriorly.
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The patient had no air leak postoperatively. His postoperative course was prolonged, including 41 days on a ventilator requiring a tracheostomy, a wound infection, and a calf vein thrombosis. Abscess culture grew Candida albicans, which was treated with 2 months of fluconazole. The patient was discharged to a skilled nursing facility 64 days after admission. He was last seen in follow-up 4 months postoperatively, at which time he was doing well, with a healing chest wound, increasing exercise tolerance, gradual weight gain, and mild reflux symptoms.
Conclusions
Acquired fistulas involving the tracheobronchial tree and the upper gastrointestinal tract are rare but life-threatening complications of malignancy, trauma, infection, or surgical intervention. These most commonly occur in the setting of advanced malignancy
1
or after esophageal resection. There have been approximately 6 previously reported cases of gastrobronchial fistula after Nissen fundoplication.
2,3
Four of the 6 cases involved a transthoracic Nissen fundoplication, and the remaining 2 were done transabdominally. All of these cases involved a wrap that was left above the diaphragm. This is the first reported case of an intra-abdominal Nissen fundoplication with an intact crural closure associated with gastropleurobronchial fistula formation.
2
In this case the patient presented with hemoptysis. This presentation is shared by 2 of the 6 previously reported cases.
2,3
Other symptoms included gastrointestinal bleeding, chronic cough, and recurrent pneumonia. Related complications after fundoplication include gastropericardial fistula, esophagobronchial fistula, and aortogastric fistula.
4
The diagnosis of this rare complication is often difficult. Patients commonly present with mild chest pain or pneumonia but can potentially become very ill. As in this case, bilious secretions on bronchoscopy might be thought to be caused by aspiration, and neither bronchoscopy nor endoscopy reliably reveals the fistula.
2
As such, an upper gastrointestinal tract series is the most reliable diagnostic modality. Care must be taken to not misinterpret the findings as aspiration of contrast.
Once the diagnosis has been made, surgical intervention is the mainstay of treatment. Regardless of cause, surgical management involves repair of the gastric perforation, diaphragmatic repair, and, frequently, pulmonary resection.
5
References
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