S6345 A Rare Case of Gastrobronchial Fistula Presenting Post Gastric Transposition

Introduction: After an esophagectomy a gastric transposition, also known as a gastric pull up, is a procedure where the stomach is moved upwards into the chest and connected to the remaining healthy esophagus. This procedure restores the continuity of the gastrointestinal (GI) tract to allow for swallowing and digestion of food. Literature to date reporting complications in gastric transposition is in children. Adult complications are not well elucidated. We illustrate a case of an adult patient, who developed an ulcer at the site of gastric transposition leading to a gastrobronchial fistula and subsequent aspiration. Case Description/Methods: A 56-year-old man with a history of esophageal cancer status post radiation therapy + esophagectomy w/ gastric transposition in 2002 presented from his clinic due to low oxygen saturation to 89%. Subjectively he reported 6 months of generalized weakness, decreased PO, weight loss, and frequent falls. Physical examination revealed a cachectic man with ecchymosis on the left chest wall and shoulder. Computed tomography (CT) chest was significant for multiple acute-subacute rib fractures on the left side and a large left sided empyema with internal gas locules which was thought to be secondary to bacterial seeding from the rib fractures. After drainage of the empyema and initial improvement, his course was complicated by severe acute hypoxemic respiratory failure requiring intubation. During mechanical ventilation it was noted he had an air leak on the ventilator. Computed tomography (CT) with intravenous contrast revealed a possible diverticulum in the conduit with proximity to the right mainstem bronchus. Bronchoscopy displayed air bubbles during expiration concerning for a tracheoesophageal fistula. A bedside esophagogastroduodenoscopy (EGD) displayed a 20 mm ulcer in the gastric pull up, within the ulcer base was a small fistula opening consistent with a gastrobronchial fistula. Additionally, a large amount of food residue was found within the pull up. Discussion: A gastrobronchial fistula is a rare complication post gastric pull up. Most described cases have been post Nissen fundoplication or post laparoscopic sleeve gastrectomy. Post gastric transposition has only be described in pediatric cases, this is the first such case reported in an adult. Contrast study of the upper GI tract is widely used for diagnosis and 1 study found that 21 out of 25 reported cases were identified using contrast studies. In our patient contrast study was negative possibly due to his severe kyphosis limiting his ability to lie supine.