Discussion:
GPF is a rare, pathological communication between the stomach and the
pleural cavity 1. It was first described by Markowitz
and Herter in 1960 as a complication of hiatal hernia rupture3. Since then, it has been reported secondary to
trauma, peptic ulcer disease, malignancy (lymphoma and gastric tumors),
and due to the spread of infection from adjacent structures such as
subdiaphragmatic abscess, empyema, or invasive fungal infection in
immunocompromised patients. Recently, with the emerging of obesity
related bariatric surgeries, GPF has been documented as a complication
of such surgeries in adult patients4. One of those
surgeries is SG which has been utilized in pediatric patients to a
lesser extent 2. Our patient had SG which was
unfortunately complicated by GPF.
GPF has a latency in presentation, presenting months to years after the
SG 1. The symptoms range from chronic cough to
recurrent respiratory infections, both of which were seen in our case1. Other respiratory symptoms include chest pain and
hemoptysis 5. Patients might exhibit gastrointestinal
symptoms such as hematemesis or abdominal pain 16. GPF
can be complicated by sepsis, hydropneumothorax, or tension
pneumothorax. Chest tube drainage containing food particles or bile has
also been reported 4.
Diagnosis of GPF requires a high index of suspicion and thorough
investigations 4. Initial workup includes CXR, which
may demonstrate pneumothorax, pleural effusion, or hydropneumothorax4. Upper GI series, preferably with water‐soluble
contrast, might show contrast extravasation to the pleural cavity6. CT with oral contrast may reveal contrast leakage
into the pleural space or delineate the fistula
tract4. Moreover, upper GI endoscopy may identify the
site of the fistula and can be utilized for therapeutic purposes7. Occasionally, GPF is diagnosed intraoperatively8.
There are no standardized treatment protocols for GPF7. Initial steps of management consist of treating the
GPF complications and providing an alternative to oral feeding
(parenteral nutrition or jejunostomy feeding tube)7,5. Meanwhile, the closure of the fistula can be done
endoscopically or surgically. Various endoscopic interventions have been
used including endoscopic clips stents, suturing, and fistula plug
application 7,9,10. Our patient was managed
conservatively and the fistula was closed endoscopically with an OTSC.
OTSC is a relatively new endoscopic intervention that has been used for
chronic fistulas with variable success rate, ranging from 30% to 100%,
and a low complication rate. Other indications for OTSC include
gastrointestinal hemorrhage and perforation 11. Our
patient failed surgical management, (i.e. trial of fistula closure
laparoscopically). Other surgical options include partial gastric
resection, diaphragmatic repair, and washout and drainage of the chest4. Roux-en-Y esophagojejunostomy for chronic GPF has
also been used for chronic fistula 5. In conclusion,
pediatric GPF has been reported due to various causes (table1). Our
patient is the first report of pediatric GPF secondary to SG. SG is not
without its complications and it must be reserved for morbidly obese
patients who fail conservative management. In our case, endoscopic
intervention with an OTSC had better results when compared to the
invasive surgical closure.
Authors contribution:
Author 1: literature review, discussion writing
Author 2: writing case description, discussion writing
Author 3: literature review, discussion writing
Author 4: editing and reviewing case description and discussion
Author 5: writing case description
Author 6: editing and reviewing case description and discussion
Conflict of interest:
None declared
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Figure 1: This figure shows the improvement in radiological findings.
Pre-endoscopic chest x ray (A) and CT scan (C) which shows a contrast
leak and loculated encysted fluid (Star). And post-endoscopic CXR (B)
and CT scan with oral contrast (D) which shows a regression of the
loculated fluid and no more leak from the fistula.
Figure 2: Endoscopic application of OVESCO
Table 1: Reported GPF in pediatric population