Case Description:
Our patient is an 11 years old boy who underwent SG due to morbid
obesity (BMI=55.6). Surgery took place in a private hospital outside the
country. It was reported as uneventful and the patient was discharged
after 1 week with a nutritional plan and vitamin supplements.
Postoperatively, he had no complaints apart from one admission to his
local hospital for gastroenteritis and dehydration that was treated with
IV fluids and antibiotics.
Five months after his operation, the patient developed fever, followed
by productive cough and dyspnea. He was admitted to the local hospital
and managed as a case of community acquired pneumonia (CAP) based on the
chest x-ray (CXR) findings of localized left lower lobe opacity. A
barium meal at that time was reported to be normal. He was not
improving, so he was referred to his primary surgeon who did a CT chest
with oral contrast which showed a left lower lobe abscess measuring 5x6
cm and a leak of contrast to the pleural space indicating the presence
of a GPF. They elected to manage him with laparoscopic surgery for
fistula closure and left lower lobe lobectomy via thoracotomy.
The patient was still having a chronic cough and fluctuating fever, a
follow-up barium meal showed a leak at the site of the fistula. And a
repeated chest CT scan revealed multiple encysted pockets of fluid
within the pleura (Figure 1). These thoracic complications were treated
with video assisted thoracoscopic surgery (VATS) for decortication with
chest tube insertion and to prevent further injury, gastrojeujonal (GJ)
tube was inserted for feeding with a second tube introduced through the
fistula opening for drainage.
The patient was then referred to our tertiary center to further manage
his persistent GPF. He was having a history of fever and chronic dry
cough. Upon admission, he was barely reactive due to a depressive state
which mandated a psychiatric evaluation; however, he didn’t require any
medication. His initial lab work-up showed leukocytosis and elevated
inflammatory markers. He was managed with empirical broad-spectrum
antibiotics covering anaerobes and kept NPO with strict GJ feeding. He
then underwent an endoscopy which showed a 5 mm fistula opening in the
upper part of the stomach. An over the scope clip (OTSC) was applied to
close the fistula (Figure 2). He had no post procedural complication and
was discharged on GJ feeding and a follow up to ensure that there is no
persistent leak.
Four weeks after endoscopy, barium meal showed no evidence of leak into
the pleura and a follow-up CXR displayed marked improvement in the
aeration of the left lung (Figure 1). A repeated CT scan with oral
contrast at 8 weeks post endoscopy showed no leak and the pockets of
encysted pleural fluid had regressed (Figure1). Informed consent was
obtained from the patient’s family. Currently, he is completely
recovered and tolerating oral feeding.