Gastro-Pleural Fistula Following Laparoscopic Sleeve Gastrectomy Masquerading as Loculated Empyema Thoracis: a Diagnosti
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LETTER TO THE EDITOR
Gastro-Pleural Fistula Following Laparoscopic Sleeve Gastrectomy Masquerading as Loculated Empyema Thoracis: a Diagnostic Dilemma Rigved Gupta 1
&
Varun Madaan 1 & Supreet Kumar 1 & Devi Singh Dhankhar 1 & Deepak Govil 1
Received: 19 July 2020 / Revised: 13 August 2020 / Accepted: 14 August 2020 # Springer Science+Business Media, LLC, part of Springer Nature 2020
Laparoscopic sleeve gastrectomy (LSG) is one of the most frequently performed bariatric surgical procedures worldwide. It is a relatively simple procedure and major complications following LSG are unusual. Staple line leak following LSG is a rare but serious complication, which may result in significant morbidity. Staple line leaks occur in 1–3% of patients undergoing LSG, majority being located at proximal end of the staple line. [1, 2] Rarely, complex fistulae may form, which tend to have delayed presentations. Gastro-pleural fistula (GPF) is an exceedingly rare but potentially fatal complication following LSG. In a review of literature published in 2018, Alghanim et al. described only eight cases of GPF following sleeve gastrectomy. [3] With increasing incidence of morbid obesity and a corresponding increase in bariatric surgical procedures, more of such cases are now being reported. Our literature search revealed fewer than 50 cases of postsleeve gastrectomy GPF in medical literature. Surgeons must be aware of this entity so as to avoid undue morbidity and mortality. We, thus, report an unusual case of post-LSG leak with gastro-pleural fistula, manifesting as loculated empyema thoracis months after the surgery.
* Rigved Gupta [email protected] Varun Madaan [email protected] Supreet Kumar [email protected] Devi Singh Dhankhar [email protected] Deepak Govil [email protected] 1
Department of Surgical Gastroenterology, Indraprastha Apollo Hospital, Sarita Vihar, New Delhi 110076, India
A 35-year-old female underwent laparoscopic sleeve gastrectomy for morbid obesity 9 months back. Post-operative course was uneventful. Three months later, she developed left shoulder pain, fever with chills, and productive cough. She was evaluated at another hospital and diagnosed to have left empyema thoracis which was managed conservatively with antibiotics on and off for 5 months; however, she had no significant relief of symptoms. Eight months following LSG, she underwent left postero-lateral thoracotomy with drainage of empyema and intercostal chest drain (ICD) insertion. She presented to us 1-month post-thoracotomy (i.e., 9 months post-LSG), with persistent symptoms and ongoing purulent drainage from ICD. Although hemodynamically stable, she had tachycardia (~ 120/min) with high-grade fever. Abdominal examination revealed no signs of peritonitis. On auscultation, decreased air entry and conducted sounds were present in left lower lung field. Hematological investigations revealed leukocytosis (18,500/cumm). Chest x-ray showed a heterogeneous opacity in left lower zone (Fig. 1a). Contrast-enhanced computed tomog
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