Laparoscopic Repair of a Gastropleural Fistula

Abstract

Introduction:

Gastropleural fistula is defined as an abnormal connection between the stomach and the pleural space. It is most often of malignant or iatrogenic etiology. There are currently three cases of gastropleural fistula reported in the pediatric surgery literature. ^{1 –3} Empyema is a manifestation of a long-standing gastropleural fistula. Here we describe the first case of self-induced gastropleural fistula. It is the first description of laparoscopy to repair this particular fistula in children. Furthermore, this is the first report of tissue plasminogen activator (TPA) to treat empyema caused by gastric contents. ^{4 –15}

Materials and Methods:

The patient is a nonverbal 15-year-old girl with a complicated medical history. She was transferred from another facility with a 5-day history of high fever and increased work of breathing. She also had a recent episode of repeated vomiting after swallowing a hair tie. A chest X-ray suggested the presence of left lower lobe pneumonia. A CT scan revealed extensive left-sided pleural disease and a small pneumothorax. There was fluid around the distal esophagus, and the esophageal lumen appeared irregular. We placed a Fuhrman catheter into the left chest, and the catheter evacuated enteric-appearing contents. We then proceeded with esophagram to evaluate for Boerhaave's syndrome. The esophagus was unremarkable. However, contrast filled the stomach and then opacified a tubular structure extending from the stomach into the left pleural space. We looked back at the CT scan, and again confirmed a fistula tract extending from the stomach to the left pleural space. The patient was taken to the operating room. We began with upper endoscopy and found a straw traversing the fundus of the stomach—hence, the cause of the fistula. We then performed diagnostic laparoscopy and identified omentum adhered to the stomach and diaphragm. We used the ligasure and blunt dissection to define the gastric aspect of the fistula. The stomach was dissected off the diaphragm to take down the fistula. An Endo GIA (Ethicon) stapler closed off the stomach. Three 0-Ethibond sutures were laparoscopically placed to close the diaphragm. After the diaphragm and stomach were repaired, we performed upper endoscopy and could not find the straw. We placed a camera in the left chest and thoracoscopically removed the straw. There was a significant amount of fibrinopurulent disease throughout the chest—we suctioned any free fluid but left the rind and Fuhrman catheter in place.

Results and Conclusions:

The patient was septic immediately postop. The cultures from the Fuhrman catheter grew multiple organisms. The patient's white blood cell count and C-reactive protein continued to rise, meanwhile chest X-rays showed layering pleural effusion. We initiated TPA postop day 2. The patient underwent two 3-day courses of TPA. The patient's blood counts and chest X-rays improved thereafter. She was discharged home at 2 weeks postop. This case report demonstrates that laparoscopic repair of a gastropleural fistula is safe in the pediatric surgery population. Furthermore, TPA is an effective treatment for empyema resulting from gastric etiology, and may obviate the need for additional surgical intervention.

No competing financial interests exist.

Runtime of video: 5 mins 1 sec