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.