|LETTER TO EDITOR
|Year : 2020 | Volume
| Issue : 2 | Page : 94-95
Gastrobronchial fistula following splenectomy for abscess
Arunashree Subbarayappa1, Biju Chandran2, Sunil Rajan1, Lakshmi Kumar1
1 Department of Anaesthesiology and Critical Care, Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India
2 Department of Gastro Surgery and Solid Organ Transplant, Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India
|Date of Submission||15-Apr-2020|
|Date of Acceptance||12-Jun-2020|
|Date of Web Publication||30-Aug-2020|
Dr. Lakshmi Kumar
Department of Anaesthesiology and Critical Care, Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Subbarayappa A, Chandran B, Rajan S, Kumar L. Gastrobronchial fistula following splenectomy for abscess. Airway 2020;3:94-5
|How to cite this URL:|
Subbarayappa A, Chandran B, Rajan S, Kumar L. Gastrobronchial fistula following splenectomy for abscess. Airway [serial online] 2020 [cited 2020 Oct 19];3:94-5. Available from: https://www.arwy.org/text.asp?2020/3/2/94/293957
A 44-year-old woman, a case of splenic abscess [Figure 1]a managed with frequent percutaneous drainage over 6 months, presented with fever and left hypochondrial pain. As percutaneous interventions had failed, she underwent splenectomy with distal pancreatectomy, ileostomy and resection of adherent diaphragm. The intraoperative period was uneventful, and she was discharged on the 6th postoperative day (POD). Five days later, she presented with fever, chills and persistent cough with minimal amounts of yellow-coloured expectoration. Computed tomography (CT) image revealed pockets of subdiaphragmatic collection with pleural effusion [Figure 1]b. In view of persistent cough with frequent expectoration of small amounts of thin yellow fluid along with desaturation (SpO285%) and hypotension, she was intubated 2 days later (13th POD). Placing the patient in head-up or lateral position did not reduce cough or expectoration. Rapid sequence intubation was performed with etomidate, fentanyl and suxamethonium, and the airway was secured with a single-lumen 7.5 mm ID endotracheal tube. Saturation improved to 97%, and a tidal volume of 360 mL was achieved with pressure-controlled ventilation (PCV) at a pressure setting of 25 cm H2O, positive end expiratory pressure (PEEP) of 10 cm H2O and FIO2 of 1.0. Arterial blood gas analysis showed pH of 7.28, PaO2 of 86 mm Hg and PaCO2 of 48 mm Hg. Flexible bronchoscopy showed continuous welling up of yellow fluid in the left lower segmental bronchus. PCV with application of PEEP reduced secretions and cough. CT image with oral contrast showed leakage of contrast into the left lower bronchus [Figure 2]. A diagnosis of gastrobronchial fistula (GBF) was made, and the patient was scheduled for emergency surgical repair within 2 h.
|Figure 1: (a) Preoperative computed tomography with large splenic abscess. (b) Pleural effusion and basal lung collapse after surgery|
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|Figure 2: Computed tomographic image with oral contrast 1. Oral contrast in gastric lumen, 2. Contrast in left bronchus suggestive of gastrobronchial fistula|
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Intraoperatively, there was no air leak through the fistula, and the patient was managed with PCV. Drainage of the abdominal collection, repair of the gastric wall erosion and closure of diaphragm were performed. Postoperatively, she was ventilated for 48 h and discharged from the hospital 2 weeks after the second surgery. She underwent ileostomy closure under general anaesthesia 3 months later and remains well.
Although GBF can occur following gastric or oesophageal surgery,, it appears rarely in association with splenic abscess.,, The major anaesthetic issue in our patient was establishing airway control in a coughing patient with significant desaturation. She was at a further risk for dissemination of infective material to the other lung. We believe that the fluid-filled cavity following splenectomy had eroded through the diaphragmatic rent and stomach wall and presented as GBF. Early intubation and administration of PEEP, along with an early decision for surgical intervention, prevented further soiling of lungs. As the decision to proceed with surgery was taken immediately after CT and as secretions had subsided with ventilation, we did not attempt to switch to a double-lumen tube for surgery. However, anticipating the possibility of the collected material at the time of laparotomy, we could have changed to a double-lumen tube to offer better airway protection. We wish to highlight the rare occurrence of a fistulous communication with the bronchus following surgery for splenic abscess. Persistent cough should alert the possibility of pleural and bronchial communication. Elective ventilation with PEEP and lung isolation with a double-lumen tube may prevent lung complications and allow early recovery.
Declaration of patient consent
The authors certify that they have obtained the appropriate patient consent form. In the form, the patient has given her consent for her images and clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]