Gastropleural Fistula

Gastropleural fistula is an uncommon finding [1]. Gastropleural fistulae have been reported after pulmonary resection [1], perforated paraesophageal hernia [2], perforated malignant gastric ulcer at the fundus, and gastric bypass operation for morbid obesity. We present a case of gastropleural fistula that resulted acutely from intractable postoperative nausea and vomiting after ambulatory knee arthroscopic surgery under general anesthesia. Case Report A 67-yr-old female underwent arthroscopy of the right knee and debridement of the right femoral condyle for chondromalacia. Her past medical history was significant for left thoracotomy and segmental lung resection for multiple benign lesions (hamartomas) 4 yr previously. She had also smoked heavily until that time. Exercise tolerance was normal for her age and she had no residual signs or symptoms of pulmonary disease. Laboratory data including chest radiography Figure 1 and electrocardiogram were within normal limits.Figure 1: The preoperative chest radiograph.Anesthesia was induced with thiopental 4 mg/kg, midazolam 1 mg, and fentanyl 2 micro gram/kg. Endotracheal intubation was facilitated by administration of atracurium 0.4 mg/kg and was accomplished atraumatically. General anesthesia was maintained with nitrous oxide, oxygen, and isoflurane. Neuromuscular blockade was reversed with 0.4 mg of atropine and 30 mg of edrophonium and tracheal extubation was performed smoothly. The procedure lasted less than 1 h. Postoperatively the patient complained of nausea. She was medicated with prochlorperazine 5 mg intravenously (IV). Nausea and vomiting persisted but IV ondansetron 8 mg brought satisfactory relief. The patient was discharged from the same-day surgery unit to her home 6 h after the completion of surgery. That night she vomited violently several times after drinking clear liquids. The vomiting subsided the next day but she developed a sudden pain in the midaxillary line on the left side. The pain persisted, so she returned to the emergency room on the second postoperative day. On physical examination, her temperature was 38 degrees C, heart rate 96 bpm, and arterial blood pressure 100/80 mm Hg. Breath sounds were decreased in the lower left lung field. Pulse oximetry was 90%. White blood cell count was 16,000/mm (3). Infiltrates and consolidation of the left lower lobe were evident on chest radiograph Figure 2. Electrocardiogram, ventilation perfusion scan, and cardiac isoenzymes were within normal limits. Bilateral lower extremity Doppler studies were normal. A presumptive diagnosis of pneumonia was made, and treatment with antibiotics was started.Figure 2: Infiltration and consolidation of left lower lobe of lung.The patient continued to have chest pain and fever, and pulmonary consultation was requested. Contrast computed axial tomography of the chest revealed massive pleural effusion with hydropneumothorax. Thoracocentesis revealed a turbid brownish acidic fluid with no odor and with many white blood cells. A 32 Fr chest tube placed via the left sixth intercostal space drained 1.5 L of turbid fluid. Antibiotic therapy was continued. The next day, i.e., the third postoperative day, a barium swallow study revealed a perforated fundus of the stomach with a fistulous connection to the left pleural space Figure 3. Exploratory laparotomy was performed. The perforated area of the gastric fundus had incarcerated through a 3 times 3 cm hernia in the tendinous portion of the diaphragm. The diaphragmatic hernia was repaired and the fundus and part of the stomach resected. Histologic examination of the specimen showed the stomach with perforation, acute peritonitis, and acutely inflamed granulation tissue. The remainder of the stomach showed marked mucosal and submucosal congestion and edema. The patient tolerated the procedure well. She was admitted to the intensive care unit postoperatively and recovered uneventfully. She was discharged home 7 days after surgery.Figure 3: Barium swallow showing a perforated fundus of the stomach with fistulous connection to the left pleural space.Discussion Markowitz and Herter [2] noted that gastropleural fistulae may arise from different pathologic conditions: perforation of the intrathoracic portion of the stomach in an esophageal hiatal hernia, trauma resulting in immediate formation of a gastropleural fistula or formation of a diaphragmatic hernia with a subsequent perforation of the intrathoracic portion of the stomach, and, lastly, erosion of an intraabdominal abscess through the diaphragm. In our patient, there was no history of hiatal hernia or trauma, nor were there any symptoms suggestive of abdominal abscess or hiatal hernia. The only significant medical history was left thoracotomy and segmental lung resection for multiple hamartomas four years previously. Review of the operative report of the above surgery showed that the patient had a small lesion at the junction of the diaphragm and the lower lobe of the left lung which was excised and oversewn. This procedure may have created a weak area in the diaphragm contributing to the development of a small, asymptomatic, diaphragmatic hernia. Episodes of postoperative retching may have contributed to herniation of the fundus of stomach through the preexisting diaphragmatic hernia and prolonged nausea and vomiting. The herniated portion of the stomach may later have incarcerated and perforated resulting in the development of a gastropleural fistula. Nausea and vomiting is a common postoperative complication [3]. Zuurmond and VanLeeuwen [4] found an increased incidence of postoperative nausea and vomiting in patients undergoing knee arthroscopy under nitrous oxide, oxygen, and sufentanyl anesthesia compared to nitrous oxide, oxygen, and isoflurane. There is an increased incidence of postoperative nausea and vomiting in female patients after abdominal and orthopedic surgeries, under balanced anesthesia, and during long procedures [5]. Cardosa et al. [6] found an 11.5% incidence of postoperative nausea and vomiting after knee arthroscopy performed under general anesthesia. Same-day surgical patients may experience postoperative nausea and vomiting for as long as 1.7 days after discharge [7]. There were thus several factors that placed our patient at greater risk of vomiting. In conclusion, in a patient with a history of pulmonary resection, especially the lower lobe, esophageal surgery, gastric bypass operation or gastric ulcer, the possibility of a diaphragmatic hernia or hiatal hernia should be considered. Measures should be taken to avoid postoperative nausea and vomiting, especially if other risk factors for increased nausea and vomiting are present. Several drugs have been used to prevent and treat postoperative nausea and vomiting. Newer antiemetics which selectively antagonize 5-hydroxytryptamine type 3 receptors, like ondansetron 4 mg IV [8] and granisetron 20 micro gram/kg IV [9] are effective and well tolerated in the treatment and prevention of postoperative nausea and vomiting. Also, if postoperative nausea and vomiting is prolonged and intractable in spite of apparently adequate pharmacotherapy, other causes should be sought. The authors would like to thank Dr. Elizabeth A. M. Frost for her editorial contribution and Mrs. Beverley Pipolo for her secretarial skills.