Gastropleural Fistula: An Unusual Cause of Intractable

Postoperative Nausea and Vomiting

Iqbal H. Biswas, MD*, Chitra Raghavan, MDt, and Ludovit Sevcik, MDt
*Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, and tDepartment of Clinical Anesthesia, St. Agnes Hospital,
White Plains, New York
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astropleural fistula is an uncommon finding (1). On physical examination, her temperature was 38”C,
Gastropleural fistulae have been reported after heart rate 96 bpm, and arterial blood pressure 100/80 mm
pulmonary resection (l), perforated paraesoph- Hg. Breath sounds were decreased in the lower left lung
field. Pulse oximetry was 90%. White blood cell count was
ageal hernia (2), perforated malignant gastric ulcer at
16,000/mm3. Infiltrates and consolidation of the left lower
the fundus, and gastric bypass operation for morbid lobe were evident on chest radiograph (Fig. 2). Electro-
obesity. We present a case of gastropleural fistula that cardiogram, ventilation perfusion scan, and cardiac iso-
resulted acutely from intractable postoperative nausea enzymes were within normal limits. Bilateral lower ex-
and vomiting after ambulatory knee arthroscopic sur- tremity Doppler studies were normal. A presumptive
gery under general anesthesia. diagnosis of pneumonia was made, and treatment with
antibiotics was started.
The patient continued to have chest pain and fever, and
pulmonary consultation was requested. Contrast computed
axial tomography of the chest revealed massive pleural ef-
Case Report fusion with hydropneumothorax. Thoracocentesis revealed
A 67-yr-old female underwent arthroscopy of the right knee a turbid brownish acidic fluid with no odor and with many
and debridement of the right femoral condyle for chondro- white blood cells. A 32 Fr chest tube placed via the left sixth
malacia. Her past medical history was significant for left intercostal space drained 1.5 L of turbid fluid.
thoracotomy and segmental lung resection for multiple be- Antibiotic therapy was continued. The next day, i.e., the
nign lesions (hamartomas) 4 yr previously. She had also third postoperative day, a barium swallow study revealed a
smoked heavily until that time. Exercise tolerance was nor- perforated fundus of the stomach with a fistulous connec-
mal for her age and she had no residual signs or symptoms tion to the left pleural space (Fig. 3). Exploratory laparotomy
of pulmonary disease. Laboratory data including chest was performed. The perforated area of the gastric fundus
radiography (Fig. 1) and electrocardiogram were within nor- had incarcerated through a 3 X 3 cm hernia in the tendinous
mal limits. portion of the diaphragm. The diaphragmatic hernia was
Anesthesia was induced with thiopental 4 mg/kg, mi- repaired and the fundus and part of the stomach resected.
dazolam 1 mg, and fentanyl 2 ,ug/kg. Endotracheal intu- Histologic examination of the specimen showed the stomach
bation was facilitated by administration of atracurium with perforation, acute peritonitis, and acutely inflamed
0.4 mg/kg and was accomplished atraumatically. General granulation tissue. The remainder of the stomach showed
anesthesia was maintained with nitrous oxide, oxygen, marked mucosal and submucosal congestion and edema.
and isoflurane. Neuromuscular blockade was reversed The patient tolerated the procedure well. She was admitted
with 0.4 mg of atropine and 30 mg of edrophonium and to the intensive care unit postoperatively and recovered
tracheal extubation was performed smoothly. The proce- uneventfully. She was discharged home 7 days after
dure lasted less than 1 h. surgery.
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 Discussion
the same-day surgery unit to her home 6 h after the com- Markowitz and Herter (2) noted that gastropleural
pletion of surgery. That night she vomited violently several fistulae may arise from different pathologic condi-
times after drinking clear liquids. The vomiting subsided the
tions: perforation of the intrathoracic portion of the
next day but she developed a sudden pain in the midaxillary
line on the left side. The pain persisted, so she returned to stomach in an esophageal hiatal hernia, trauma result-
the emergency room on the second postoperative day. ing in immediate formation of a gastropleural fistula
or formation of a diaphragmatic hernia with a subse-
quent perforation of the intrathoracic portion of the
Accepted for publication March 20, 1996.
Address correspondence to Iqbal H. Biswas, MD, Critical Care stomach, and, lastly, erosion of an intraabdominal
Service, St. Mary’s Hospital, Alfred 4-440, Rochester, MN 55905. abscess through the diaphragm.

01996 by the International Anesthesia Research Society

186 Anesth Analg 1996;3:186-8 0003.2999/96/$5.00
ANESTH ANALG CASE REPORTS 187
1996;3:186-8

Figure 3. Barium swallow showing a perforated fundus of the

stomach with fistulous connection to the left pleural space.

Figure 1. The preoperative chest radiograph.

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 arthros-
copy under nitrous oxide, oxygen, and sufentanyl an-
esthesia compared to nitrous oxide, oxygen, and
isoflurane. There is an increased incidence of postop-
erative 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 nau-
sea 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
Figure 2. Infiltration and consolidation of left lower lobe of lung.
thus several factors that placed our patient at greater
risk of vomiting.
In conclusion, in a patient with a history of pulmo-
In our patient, there was no history of hiatal hernia nary resection, especially the lower lobe, esophageal
or trauma, nor were there any symptoms suggestive of surgery, gastric bypass operation or gastric ulcer, the
abdominal abscess or hiatal hernia. The only signifi- possibility of a diaphragmatic hernia or hiatal hernia
cant medical history was left thoracotomy and seg- should be considered. Measures should be taken to
mental lung resection for multiple hamartomas four avoid postoperative nausea and vomiting, especially if
years previously. Review of the operative report of the other risk factors for increased nausea and vomiting
above surgery showed that the patient had a small are present. Several drugs have been used to prevent
lesion at the junction of the diaphragm and the lower and treat postoperative nausea and vomiting. Newer anti-
lobe of the left lung which was excised and oversewn. emetics which selectively antagonize 5-hydroxytryptamine
This procedure may have created a weak area in the type 3 receptors, like ondansetron 4 mg IV (8) and
diaphragm contributing to the development of a granisetron 20 pg/kg IV (9) are effective and well
small, asymptomatic, diaphragmatic hernia. Episodes tolerated in the treatment and prevention of postop-
of postoperative retching may have contributed to erative nausea and vomiting. Also, if postoperative
herniation of the fundus of stomach through the pre- nausea and vomiting is prolonged and intractable in
existing diaphragmatic hernia and prolonged nausea spite of apparently adequate pharmacotherapy, other
and vomiting. The herniated portion of the stomach causes should be sought.
188 CASE REPORTS ANESTH ANALG
1996;3:186-8

5. Larson S, Lundberg D. A prospective survey of postoperative

The authors would like to thank Dr. Elizabeth A. M. Frost for her nausea and vomiting with special regard to incidence and rela-
editorial contribution and Mrs. Beverley Pipolo for her secretarial tions to patient characteristics, anesthetic routines and surgical
skills. procedures. Acta Anesthesiol Stand 1995;39:539-45.
6. Cardosa M, Rudkin GE, Osborne GA. Outcome from day-case
knee arthroscopy in a major teaching hospital. Arthroscopy
1994;10:624-9.
7. Carrol NV, Miederhoff I’, Cox FM, et al. Postoperative nausea
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