Ann Thorac Surg 2004;78:339-341
© 2004 The Society of Thoracic Surgeons
Case report
Spontaneous biliopneumothorax (thoracobilia) following gastropleural fistula due to stomach perforation by nasogastric tube
Alessandro Bini, MDa,
Manuele Grazia, MDa,
Francesco Petrella, MD*a,
Franco Stella, MDa,
Ruggero Bazzocchi, MDa
a Department of General and Thoracic Surgery, "S. Orsola— Malpighi" Hospital, University of Bologna, Bologna, Italy
Accepted for publication June 13, 2003.
* Address reprint requests to Dr Petrella, Department of General and Thoracic Surgery, "S. Orsola—Malpighi" Hospital, University of Bologna, Via Massarenti 9, Bologna, Italy, Bologna, Bologna, Italy Italy
e-mail: fpetrella{at}libero.it
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Abstract
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Gastropleural fistula may occur after pulmonary resection, perforated paraesophageal hernia, perforated malignant gastric ulcer at the fundus, or gastric bypass surgery for morbid obesity. We describe a case of gastropleural fistula after stomach perforation by a nasogastric tube in a patient who underwent Billroth II gastric resection for adenocarcinoma. Left biliopneumothorax occurred and was treated by thoracic drainage with –20 cm H2O aspiration. As gastropleural fistula persisted, laparotomy was repeated and gastric and diaphragmatic perforations were sutured. Gastropleural fistula is rare and, to our knowledge, this is the first reported case of gastropleural fistula and biliopneumothorax caused by gastric and diaphragmatic perforation by a nasogastric tube.
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Introduction
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Gastropleural fistula is a rare condition first described by Markowitz and Herter in 1960. They observed how a gastropleural fistula may arise from perforation of the intrathoracic portion of the stomach in an esophageal hiatal hernia, from posttraumatic diaphragmatic hernia with subsequent perforation of the intrathoracic portion of the stomach, or from the erosion of an intra-abdominal abscess through the diaphragm [1]. Other causes of gastropleural fistula have been subsequently described as complications of pulmonary and esophageal surgery [2, 3]. We describe the first case of biliopneumothorax after gastropleural fistula due to stomach perforation by a nasogastric tube in a patient who underwent Billroth II gastric resection for adenocarcinoma.
A 73-year-old man was admitted to our department for treatment of gastric adenocarcinoma. Admission tests were normal and the patient was in good general condition; the patient had no history of diabetes mellitus or cardiovascular diseases and was not taking immunosuppressive drugs. Computed tomography showed a large solid mass (8 x 7 cm) in the lower part of the body of the stomach, with perigastric lymphoadenomegalies. Esophagogastroscopy showed a large ulcerated mass with vegetation arising from the lesser curvature of the stomach, involving the fundus and antrum; endoscopic biopsy suggested adenocarcinoma.
The patient underwent laparotomy, revealing a large mass arising from the stomach, infiltrating the middle colic artery. Subtotal gastric resection, transverse colon, and mesocolon were resected with lymphoadenectomy, colocolic anastomosis, and gastrojejunum shunting. The greater omentum was also resected and a nasogastric tube was inserted with the distal edge in the gastric fundus, near the afferent intestinal loop. No technical problems occurred during intraoperative positioning of the traditional polyvinyl chloride nasogastric tube.
Histologic examination showed scarcely differentiated gastric adenocarcinoma, infiltrating the whole gastric wall, omentum, and gastrocolic ligament to the colic wall. Nine of 10 resected lymph nodes contained metastases; the resection margin was free from neoplastic cells.
Postoperatively, the nasogastric tube was placed on gravity drainage without continuous suction. Seven days after surgery, the patient had left chest pain and dyspnea. Chest x-ray showed hydropneumothorax (Fig 1);
esophagogram showed gastropleural fistula (Fig 2).
The patient underwent left percutaneous tube thoracostomy; 800 mL of biliary liquid was drained. Microbiologic examination showed Stenotrophomonas (Xantomonas) maltophilia. Biochemical tests included: bilirubin, 1.68 mg/dL; amylase, 62,900 u/L; and lipase, 47,600 u/L. Chest x-ray after percutaneous tube thoracostomy showed a major decrease in hydropneumothorax, but gastropleural fistula persisted. The patient underwent a repeat laparotomy, which showed a strong adhesion between the gastric stump and diaphragm. After adhesiolysis, a small (0.5 cm) gastric and diaphragmatic perforation from the distal edge of the nasogastric tube was found and sutured. Protective enteroenteric anastomoses were made between afferent and efferent loops. No gastroenteric anastomotic dehiscence was observed. The patient was discharged in good clinical condition 13 days after repeat laparotomy.
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Comment
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Gastropleural fistula is a rare pathologic communication between the stomach and the pleural space, with or without diaphragmatic fistula. Gastropleural fistula may be caused by perforation of the intrathoracic portion of the stomach in an esophageal hiatal hernia, by trauma, or by erosion of an intra-abdominal abscess through the diaphragm [4].
Gastropleural fistula may also be a complication of major pulmonary and esophageal resections [2, 3]. The diagnosis of gastropleural fistula is usually made with contrast radiology, at upper gastrointestinal endoscopy, or at surgery. Use of methylene blue as a marker and testing the pleural fluid for pH or bile salts can be useful [5].
Pneumothorax may occur as a secondary complication of empyema as a result of inflammatory erosion of the pleura after pneumonia or pulmonary abscess formation, but may also result from visceral perforation [6].
The presence of bile and gastric juice in the pleural space after gastropleural fistula has an erosive action on visceral pleura, resulting in biliopneumothorax, as occurred our patient.
The resection margin was free from neoplastic cells after surgery in our patient, and no gastroenteric anastomotic dehiscence was observed at repeat laparotomy.
The pathophysiology of the gastropleural fistula and biliopneumothorax could be that after subtotal gastrectomy, which was performed after small gastric curve mobilization and short gastric vessel preservation, the gastric stump migrated into the left hypochondrium, under the left hemidiaphragm, facing the spleen, where hemidiaphragm excursion transmitted the movement to the gastric stump. However, a more likely hypothesis is nasogastric tube displacement in the gastric fundus stump where diaphragm excursion perforated the gastric wall: the gastric wall probably adhered to the hemidiaphragm resulting in gastropleural transdiaphragmatic fistula, facilitated by the corrosive action of the gastric juices.
To our knowledge, this is the first case of biliopneumothorax after gastropleural fistula due to stomach perforation by a nasogastric tube.
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References
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- Markowitz A.M., Hetrer F.P. Gastropleural fistula as a complication of esophageal hiatus hernia. Ann Surg 1960;152:129-134.[Medline]
- O'Keefe P.A., Goldstraw P. Gastropleural fistula following pulmonary resection. Thorax 1993;48:1278-1279.[Abstract/Free Full Text]
- Jha KP, Deiraniya A, Keeling-Roberts C, Das SR. Gastrobronchial fistula—a recent series. Interactive Cardiovascular and Thoracic Surgery—Eur J Cardiothorac Surg (in press)
- Biswas I.H., Raghavan C., Sevick L. Gastropleural fistula: an unusual cause of intractable postoperative nausea and vomiting. Anesth Analg 1996;83:186-188.[Abstract]
- Warburton C.J., Calverley P.M.A. Gastropleural fistula due to gastric lymphoma presenting as tension pneumothorax and empyema. Eur Respir J 1997;10:1678-1679.[Abstract]
- Roberts C.M., Gelder C.M., Goldstraw P., Spiro S.G. Tension pneumothorax and empyema as a consequence of gastro-pleural fistulae. Respir Med 1990;84:253-254.[Medline]
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Abstract
Introduction
