LB062 - FROM SLEEVE TO FISTULA : NAVIGATING THE CHALLENGES IN MANAGING BRONCHO-ESOPHAGEAL COMMUNICATION AFTER BARIATRIC SURGERY

LB062

"FROM SLEEVE TO FISTULA : NAVIGATING THE CHALLENGES IN MANAGING BRONCHO-ESOPHAGEAL COMMUNICATION AFTER BARIATRIC SURGERY"

H. L. Ab Halim^1,* on behalf of Abdul Hannan Bin Ghazali, Nor Azlin Binti Dahlan

¹Department of Anaesthesiology and Intensive Care, Institut Kanser Negara, Putrajaya, Malaysia

 

Rationale: This case is reported due to the rarity of broncho-esophageal fistula as a postoperative complication of sleeve gastrectomy, highlighting the anaesthetic challenges and the multidisciplinary approach required for successful management.

Methods: Broncho-esophageal fistula is a rare but potentially fatal complication following sleeve gastrectomy. Effective multidisciplinary collaboration is essential to determine the optimal surgical and anesthetic strategies,particularly during thoracotomy and single-lung ventilation to prevent further catastrophic outcomes.

 

Case presentation: A 48-year-old woman presented with persistent vomiting and clinical signs of sepsis approximately one month after undergoing laparoscopic sleeve gastrectomy at a private hospital. A thoracic CT scan revealed a right bronchial tear and an associated esophageal perforation, necessitating urgent surgical intervention. A multidisciplinary team comprising general surgeons, anesthesiologists, cardiothoracic surgeons, and respiratory specialists was convened to determine the safest and most effective approach for both anesthesia and surgical management. Following detailed evaluation, a decision was made to proceed with a right thoracotomy, left thoracoabdominal approach, and distal esophageal repair. Intraoperatively, single-lung ventilation using a bronchial blocker (Fuji System Uniblocker) proved advantageous. Despite the presence of a right bronchial perforation, the technique provided adequate oxygenation and offered the necessary flexibility to manage the challenging airway anatomy. The patient’s initial postoperative course was uneventful. She was transferred to the general ward on postoperative day 2. However, by postoperative day 4, she required readmission to the ICU due to complications, including lung empyema and persistent pneumothorax. Owing to prolonged mechanical ventilation, a tracheostomy was performed. Over the following weeks, the patient gradually stabilized and was successfully weaned to tracheal mask oxygenation after a 3-week ICU stay. With the aid of physiotherapy and supportive care, she showed continuous improvement and was eventually discharged 1.5 months after surgery.

 

Results: Right bronchial defects pose significant risks during one-lung ventilation due to potential failure to maintain adequate oxygenation. While small perforations (<2 cm) are often managed conservatively, the need for prolonged mechanical ventilation and risk of further respiratory compromise may necessitate surgical intervention.In managing such complex airway cases, bronchial blockers offer several advantages over double-lumen endotracheal tubes. Their flexibility, ease of positioning, and reduced risk of mucosal trauma make them particularly valuable in situations involving distorted or compromised bronchial anatomy, as seen in this case. Additionally, bronchial blockers allow selective lung isolation with a less invasive approach, which can be critical in maintaining oxygenation when a major airway injury is present.

 

Conclusion: Management of concurrent esophageal and bronchial injuries following bariatric surgery presents significant challenges to both surgical and anesthetic teams. Preoperative planning must include multidisciplinary input and shared decision-making with the patient and their family. Thorough preparation and teamwork are critical for anticipating and managing intraoperative and postoperative complications

References:  

1. Haaverstad, R., Ovrebo, K., Sandvik, L. et al. Multi-disciplinary treatment of broncho-esophageal fistula in a high-risk single-lung patient. J Cardiothorac Surg 20, 61 (2025). https://doi.org/10.1186/s13019-024-03287-5

2. Singh S, Garg A, Lamba N, Vishal. Anaesthetic management of intraoperative tracheo-bronchial injury. Respir Med Case Rep. 2019 Nov 18;29:100970. doi: 10.1016/j.rmcr.2019.100970. PMID: 31828009; PMCID: PMC6889322.

3. Chang S, Cistulli D, Harden M. Iatrogenic tracheal rupture in the elderly: a case report and review of tracheobronchial repair techniques. J Surg Case Rep. 2024 Aug 28;2024(8):rjae550. doi: 10.1093/jscr/rjae550. PMID: 39211364; PMCID: PMC11358051.

4. Munasinghe BM, Karunatileke CT. Management of an intraoperative tracheal injury during a Mckeown oesophagectomy: A case report. Int J Surg Case Rep. 2023 Apr;105:108010. doi: 10.1016/j.ijscr.2023.108010. Epub 2023 Mar 21. PMID: 36958145; PMCID: PMC10053374.

5. Ginesu GC, Feo CF, Cossu ML, Ruiu F, Addis F, Fancellu A, et al. Thoracoscopic treatment of a broncho-esophageal fistula: a case report. Int J Surg Case Rep. 2016;28:74–7. 

Disclosure of Interest: None declared