Closure of a Gastropleural Fistula Using Advanced Endoscopy

Gastropleural fistulas (GPFs) are rare complications, which have been reported in the setting of trauma, bariatric surgery, hiatal hernia, and pulmonary resection.^1,2 The general management includes control of the thoracic contamination, antimicrobial agents, respiratory support, and parenteral nutrition. Majority of the case reports involve surgical management of the fistula consisting of fistula takedown, gastric resection and repair, diaphragmatic repair, and any other intervention depending on the underlying etiology. There are limited reports on the successful endoscopic repair of a GPF. To our knowledge, we represent a rare case of gastropleural fistula after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) that was successfully treated with advanced endoscopic intervention.

The patient is a 75-year-old woman with a history of recurrent pseudomyxoma peritonei secondary to ruptured low-grade appendiceal mucinous neoplasm status post CRS-HIPEC (total abdominal colectomy, subtotal gastrectomy with Billroth II reconstruction, bilateral partial diaphragmatic resection, and loop ileostomy) who presented to the ED with worsening of shortness of breath (SOB). She had a 1 month history of SOB, intermittent chest pain, abdominal pain, and dry cough. Patient was afebrile and all of her vital signs were stable. Her exam was notable for diminished left lung base breath sounds, shallow breathing, and the use of accessory muscles. Patient had a leukocytosis of 13.1. Computed tomography of the chest, abdomen, and pelvis demonstrated a loculated fluid collection with oral contrast in the left pleural space that was in continuity with the gastric lumen at the gastrojejunostomy. The patient was immediately made NPO, put on TPN, given empiric IV antibiotics and antifungals, and provided supplemental oxygen. Thoracic surgery was consulted, and on hospital day (HD) 3 a left chest tube was placed which initially had a brown-green output. Chest tube output gradually decreased through her hospital course. Cultures of the pleural fluid were positive for Enterococcus faecalis and Escherichia coli. On HD 4, gastroenterology conducted an EGD. A fistulous tract was noticed at the gastrojejunal anastomosis. The fistula was closed with an overstitch after local tissue was revitalized with argon plasma coagulation. On HD 7, CT of the chest and abdomen demonstrated a successful closure of the fistula given the lack of oral contrast in the left pleural space and the loculated pleural fluid collection had resolved. Through the remainder of the hospital stay, the patient was transitioned to a regular diet, TPN was weaned off, and her chest tube was removed. On HD 13, the patient was discharged home.

To our best knowledge, this is the first case in literature of a patient with CRS-HIPEC who had a gastropleural fistula. Furthermore, this is also the first case in which a gastropleural fistula has been successfully managed with advanced endoscopic techniques. Although there are a few reported cases of advanced endoscopic techniques being used for managing GPF, these patients ultimately require surgery. ¹

The common pathophysiology of gastropleural fistulas includes insults to the diaphragm and gastrointestinal tract. The insults can stem from traumatic injury, underly pathology contributing to a hiatal hernia, gastric perforation, iatrogenic injury after thoracic or bariatric surgeries, and inflammatory-mediated injury from various disease processes such as leaks after a sleeve gastrectomy or subphrenic abscesses.^1,2 Commonly, the presentation includes dyspnea, cough, abdominal pain, chest pain, and/or fever. The presentation can also include persistent respiratory issues and recurrent respiratory infections. Mortality and morbidity stem from gastric spillage into the pleural cavity which contributes to respiratory dysfunction, sepsis, and multiorgan failure.

Although gastropleural fistulas are rare and there are no guidelines for management, the limited case reports in the literature delineate key concepts. There are many modalities to diagnose gastropleural fistulas. Computed tomography scans and upper gastrointestinal series have been used in the majority of the cases. Upper endoscopy can also be used to confirm the diagnosis. Occasionally, patients will have a chest tube placed for an effusion and the fluid cultures will grow microbes consistent with gut flora and raise suspicion for a GPF. ¹ Conservative management includes broad spectrum empiric antimicrobials, TPN, and control of the pleural contamination with a chest tube. Surgical management generally includes gastric resection, fistula takedown, and diaphragmatic repair and can include other interventions such as hiatal hernia repair, decortication, pleurectomy, and others depending on the extent of disease in the abdomen and thoracic cavity. However, with advancements in endoscopic suturing, advanced endoscopy may be an option to fix fistulas. ³

Gastropleural fistula is a rare complication that patients can have after cytoreductive surgery and should be on the differential in patients with persistent respiratory symptoms. Currently, there is no recommended approach to managing GPFs. Majority of the published reports have implemented various surgical interventions to treat GPFs depending on the underlying cause of the fistula. The current case suggests it is possible to treat patients with advanced endoscopic procedures. Further investigation is warranted to improve advanced endoscopic management of gastropleural fistulas.