Clin Endosc.  2022 Jan;55(1):141-145. 10.5946/ce.2021.033.

A Gastrobronchial Fistula Secondary to Endoscopic Internal Drainage of a Post-Sleeve Gastrectomy Fluid Collection

• Gkolfakis P
• Bureau MA
• Arvanitakis M
• Devière J
• Blero D

• KMID: 2525061
• DOI: http://doi.org/10.5946/ce.2021.033

Abstract

A 44-year-old woman underwent sleeve gastrectomy, which was complicated by a leak. She was treated with two sessions of endoscopic internal drainage using plastic double-pigtail stents. Her clinical evolution was favorable, but four months after the initial stent placement, she became symptomatic, and a gastrobronchial fistula with the proximal end of the stents invading the diaphragm was diagnosed. She was treated with antibiotics, plastic stents were removed, and a partially covered metallic esophageal stent was placed. Eleven weeks later, the esophageal stent was removed with no evidence of fistula. Inappropriate stent size, position, stenting duration, and persistence of low-grade inflammation could explain the patient’s symptoms and provide a mechanism for gradual muscle rupture and fistula formation. Although endoscopic internal drainage is usually safe and effective for the management of post-laparoscopic sleeve gastrectomy leaks, close clinical and radiological follow-up is mandatory.

Keyword

bariatric endoscopy; endoscopy complications; endoscopic internal drainage; gastrobronchial fistula; sleeve gastrectomy

Figure

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  Fig. 1. (A, B) Post-laparoscopic sleeve gastrectomy leak communicating with subphrenic fluid collection appeared opacified during gastroscopy. (C) Endoscopic internal drainage was performed by deployment of two double-pigtail stents with the proximal part in the collection and the distal part in the gastric sleeve. (D) Initial stents were removed endoscopically two months later. (E) Contrast injection showed persistence of collection but no sign of fistula. (F) Deployment of three new stents was done.

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  Fig. 2. (A) Computed tomography demonstrated double-pigtail stents invading the diaphragm. (B, C) Inflammatory collection with presence of a hydroaeric level around the stents and opacification of the left lower bronchus communicating with them was seen.

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  Fig. 3. (A) A gastrobronchial fistula was demonstrated during barium swallow study four days after esophageal stent deployment. (B) Three weeks later, esophagogram showed sealing of the two ends of the esophageal stent with distal and proximal hyperplasia and no sign of fistula persistence was evident.

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  Fig. 4. (A, B, C) A second fully-covered metallic stent was used to remove the initial partially covered esophageal stent (stent-in-stent technique). (D, E, F) Follow-up esophagogram and computed tomography showed no evidence of residual fistula.

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