Multimodal Management of Complicated Gastro-Bronchial Fistula after Revisional Sleeve Gastrectomy

Introduction: Revisional surgery has become a frequent challenge for bariatric surgeons, owing to the exceedingly high number of patients operated on for morbid obesity and the high failure rate of some procedures (e.g. Vertical Gastroplasty) in recent decades. The presence of anatomic modifications and fibrotic tissues makes revisional procedures undoubtedly more technically demanding and dangerous than primaries, with a complication rate of up to 20-30% in some series. Moreover, for the same reasons, the management of complications is usually more problematic in these patients. Thus only experienced surgeons in properly equipped units should undertake these procedures. Case: A 48-year-old female, submitted 4 months before to revisional sleeve gastrectomy after the failure of a previous Natalini procedure (adjustable vertical banded gastroplasty, in 1998) was referred to our Centre for an unhealed gastric leak complicated by a gastro-bronchial fistula (after the failure of a laparoscopic suture and drain). The patient presented fever, leucocytosis, incoercible cough and asthenia; the radiogram showed left lung basal consolidation and sodium amidotrizoate meal test results showed filling of the left bronchial tree and trachea. After the failure of endoscopic treatment (fibrine glue, metallic clips, covered stent), the patient was submitted to a thoracotomic pulmonary segmentectomy and transdiaphragmatic gastric suture, which led to the resolution of the bronchial fistula, while a gastric subphrenic leak persisted. Because of the failure of the conservative management, the patient was finally submitted to total gastrectomy 3 months later. The patient was discharged on postoperative day 8. No complication was detected at follow-up. Conclusions: The management of complicated revisional bariatric surgery often requires multimodal approaches. The variability of the cases and clinical responses makes it extremely difficult to assess standardized strategies.