Case Report: Gastro-bronchial fistula complicating a sleeve gastrectomy: from a glimmer of hope to a plight

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Despite its benefits, howver, it may result in severe complications. One rare but serious postoperative issue is the development of a gastrobronchial fistula (GBF), a condition with a challenging diagnosis and management pathway due to its insidious nature. Case Presentation We report the case of a 36-year-old woman who underwent sleeve gastrectomy in 2015. The early postoperative course was complicated by a gastric fistula that was managed with double pigtail stents. Subsequently, the patient developed recurrent bronchopulmonary infections, and imaging in 2017 revealed a GBF connecting the gastric remnant to the bronchial tree. Initial endoscopic management with stenting failed because of migration. Definitive surgical management involved complex adhesiolysis and creation of tension-free fistula-jejunal anastomosis. Postoperative recovery was uneventful, and the patient remains asymptomatic. Discussion Gastrothoracic fistula post-bariatric surgery is a rare but potentially life-threatening complication. Their development is often linked to the insufficient treatment of early gastric leaks or collections. Diagnosis is frequently delayed owing to nonspecific respiratory symptoms. Endoscopic approaches have show limited success, and surgical management, often complex, is frequently necessary. Multidisciplinary strategies, including endoscopic and surgical options, are vital for achieving favorable outcomes. Conclusion Gastrobronchial fistulas represent a diagnostic and therapeutic challenge following sleeve gastrectomy. A high index of suspicion, long-term follow-up, and tailored multidisciplinary approach are essential for effective management and resolution. Awareness of this rare complication should prompt early detection and intervention to reduce the morbidity and mortality. 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F1000Research 2025, 14 :948 ( https://doi.org/10.12688/f1000research.169504.2 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Case Report Revised Case Report: Gastro-bronchial fistula complicating a sleeve gastrectomy: from a glimmer of hope to a plight [version 2; peer review: 1 approved, 2 approved with reservations] Adala Mourad 1 , Adala Ahmed 1 , Siala Rakia 2 , [...] Mseddi Mohamed Ali https://orcid.org/0000-0002-5107-2122 2 , Yaakoubi Chaima https://orcid.org/0000-0002-5174-2624 2 , Ben Radhia Bechir 1 , Amara Amal https://orcid.org/0009-0009-9090-7047 2 , Sallemi Karim 2 , Guizeni Rami https://orcid.org/0000-0001-6083-0880 2 , Ghariani Brahim 2 , Sassi Karim 2 , Ben Slima Mohamed 2 Adala Mourad 1 , Adala Ahmed 1 , [...] Siala Rakia 2 , Mseddi Mohamed Ali https://orcid.org/0000-0002-5107-2122 2 , Yaakoubi Chaima https://orcid.org/0000-0002-5174-2624 2 , Ben Radhia Bechir 1 , Amara Amal https://orcid.org/0009-0009-9090-7047 2 , Sallemi Karim 2 , Guizeni Rami https://orcid.org/0000-0001-6083-0880 2 , Ghariani Brahim 2 , Sassi Karim 2 , Ben Slima Mohamed 2 PUBLISHED 08 Dec 2025 Author details Author details 1 Tunis obesity and diabetes surgery center, Tunis, Tunisia 2 general surgery "B", Rabta Hospital, Tunis, Tunis, Tunisia Adala Mourad Roles: Data Curation, Validation Adala Ahmed Roles: Supervision Siala Rakia Roles: Supervision, Validation Mseddi Mohamed Ali Roles: Writing – Original Draft Preparation, Writing – Review & Editing Yaakoubi Chaima Roles: Validation Ben Radhia Bechir Roles: Supervision Amara Amal Roles: Supervision Sallemi Karim Roles: Supervision Guizeni Rami Roles: Supervision Ghariani Brahim Roles: Supervision Sassi Karim Roles: Supervision Ben Slima Mohamed Roles: Validation, Visualization OPEN PEER REVIEW DETAILS REVIEWER STATUS Abstract Background Bariatric surgery, particularly sleeve gastrectomy (SG), has emerged as an effective long-term treatment for morbid obesity. Despite its benefits, howver, it may result in severe complications. One rare but serious postoperative issue is the development of a gastrobronchial fistula (GBF), a condition with a challenging diagnosis and management pathway due to its insidious nature. Case Presentation We report the case of a 36-year-old woman who underwent sleeve gastrectomy in 2015. The early postoperative course was complicated by a gastric fistula that was managed with double pigtail stents. Subsequently, the patient developed recurrent bronchopulmonary infections, and imaging in 2017 revealed a GBF connecting the gastric remnant to the bronchial tree. Initial endoscopic management with stenting failed because of migration. Definitive surgical management involved complex adhesiolysis and creation of tension-free fistula-jejunal anastomosis. Postoperative recovery was uneventful, and the patient remains asymptomatic. Discussion Gastrothoracic fistula post-bariatric surgery is a rare but potentially life-threatening complication. Their development is often linked to the insufficient treatment of early gastric leaks or collections. Diagnosis is frequently delayed owing to nonspecific respiratory symptoms. Endoscopic approaches have show limited success, and surgical management, often complex, is frequently necessary. Multidisciplinary strategies, including endoscopic and surgical options, are vital for achieving favorable outcomes. Conclusion Gastrobronchial fistulas represent a diagnostic and therapeutic challenge following sleeve gastrectomy. A high index of suspicion, long-term follow-up, and tailored multidisciplinary approach are essential for effective management and resolution. Awareness of this rare complication should prompt early detection and intervention to reduce the morbidity and mortality. READ ALL READ LESS Keywords sleeve gastrectomy, gastrobronchiol fistula, bariatric surgery Corresponding Author(s) Mseddi Mohamed Ali ( [email protected] ) Close Corresponding author: Mseddi Mohamed Ali Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2025 Mourad A et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Mourad A, Ahmed A, Rakia S et al. Case Report: Gastro-bronchial fistula complicating a sleeve gastrectomy: from a glimmer of hope to a plight [version 2; peer review: 1 approved, 2 approved with reservations] . F1000Research 2025, 14 :948 ( https://doi.org/10.12688/f1000research.169504.2 ) First published: 19 Sep 2025, 14 :948 ( https://doi.org/10.12688/f1000research.169504.1 ) Latest published: 08 Dec 2025, 14 :948 ( https://doi.org/10.12688/f1000research.169504.2 ) Revised Amendments from Version 1 In the revised version of the manuscript, we have strengthened the causal explanation of fistula formation by detailing how an early proximal staple-line leak can evolve into a persistent subphrenic abscess whose chronic inflammatory and enzymatic activity progressively damages adjacent tissues, ultimately eroding the diaphragm and creating a trans-diaphragmatic tract that communicates with the bronchial tree; we have also clarified that distal sleeve stenosis or functional obstruction may exacerbate this sequence by sustaining the leak and preventing effective healing. In addition, we have incorporated a dedicated synthesis of learning points to enhance clinical applicability: persistent or unexplained respiratory symptoms after sleeve gastrectomy now explicitly prompt evaluation for a gastro-bronchial fistula; chronic subphrenic sepsis is highlighted as a mechanism capable of diaphragmatic erosion; the discussion defines a clear pivot point for transitioning from endoscopic management to surgical rescue when sepsis, fistula maturation, or distal stenosis preclude endoscopic success; and the rationale for selecting fistulo-jejunostomy is articulated, emphasizing its ability to divert gastric flow, exclude the diseased segment, and achieve definitive control of the leak and associated sepsis. We added labels to figures and abbrevation list and corrected wrong terms. In the revised version of the manuscript, we have strengthened the causal explanation of fistula formation by detailing how an early proximal staple-line leak can evolve into a persistent subphrenic abscess whose chronic inflammatory and enzymatic activity progressively damages adjacent tissues, ultimately eroding the diaphragm and creating a trans-diaphragmatic tract that communicates with the bronchial tree; we have also clarified that distal sleeve stenosis or functional obstruction may exacerbate this sequence by sustaining the leak and preventing effective healing. In addition, we have incorporated a dedicated synthesis of learning points to enhance clinical applicability: persistent or unexplained respiratory symptoms after sleeve gastrectomy now explicitly prompt evaluation for a gastro-bronchial fistula; chronic subphrenic sepsis is highlighted as a mechanism capable of diaphragmatic erosion; the discussion defines a clear pivot point for transitioning from endoscopic management to surgical rescue when sepsis, fistula maturation, or distal stenosis preclude endoscopic success; and the rationale for selecting fistulo-jejunostomy is articulated, emphasizing its ability to divert gastric flow, exclude the diseased segment, and achieve definitive control of the leak and associated sepsis. We added labels to figures and abbrevation list and corrected wrong terms. To read any peer review reports and author responses for this article, follow the "read" links in the Open Peer Review table. READ REVIEWER RESPONSES Introduction Obesity is common. It affected 1 in 8 persons wordwide, according to the World Health Organization, it affects one in eight persons wordwide in 2022. 1 A review of data from the Global Burden of Disease registry in 2021, showcased increased by 2,5 fold in death and disability-adjusted life years attributable to high weight. 2 There is great disparity in prevalence on an international scale. 3 The low to middle socio-demographic index experienced the highest annual percentage increase in age standardized deaths and disability-adjusted life-year rates caused by obesity. 2 A meta-analysis of two decades of World Health Organization reports concluded an association and a 14% increase in the chance of obesity with increasing economic status. 3 For these reasons, decision makers and the medical community have suggested bariatric surgery as a secure and durable cure for obesity in selected patients. 4 The American Society for Metabolic and Bariatric surgery estimated 279967 national inpatient surgeries by 2022. 5 This enthousiasm and rising trend in performing bariatric surgery is justified by 29%, 43%, and 72% of cardiovascular disease, cancer, and diabetes rates dropping after surgery. 6 Sleeve gastrectomy outnumbered other surgical and endoluminal interventions in the latest report by the International Federation for the Surgery of Obesity and Metabolic disorders in 2024. 7 However, bariatric surgery can be fraught with severe post-operative complications. The National Institute of Diabetes and Digestive and Kidney Diseases disclosed 0,2% mortality rate for laparoscopic gastric bypass. 8 With open procedures, deaths reached 2,1%. 8 The mortality rate following sleeve gastrectomy was 0,22%. 9 A large propensity-matched comparison of 30-day morbidity and mortality of sleeve gastrectomy, Roux-en-Y gastric bypass, and one-anastomosis gastric bypass showed no significant difference in 30-day morbidity and mortality. 10 Although nonsurgical causes are the main cause of death, 11 surgery-related complications can cause postoperative mortality or complications. Gastrobronchial fistula is an unseen post-sleeve gastrectomy complication. This poses both diagnostic and therapeutic challenges. It is insidious and can go unnoticed for several years, as was the case in our patient. We report a similar case that posed difficulties in its diagnosis and treatment. We aimed to shed light on its mechanisms to present a clear diagnosis and treatment plan. Case report Here, we report the case of a 36 year old woman with no relevant medical history. She had a BMI of 42 kg/m 2 and required sleeve gastrectomy in 2015 in another surgical department. She denied smoking or drug use. The postoperative course was fraught with a gastric fistula, on 13 th postoperative day (POD). This complication was successfully managed with double-pigtail stenting for 8 weeks. One year after the index surgery in 2016, she underwent cholecystectomy for de novo cholecystolithiasis. On the 6 th POD, purulent left subphrenic collection was diagnosed after she experienced left upper quadrant pain and fever. Percutaneous drainage was warranted with a good response. In 2017, she reported cough with recurrent bronchopneumonia. Her weight loss was stable and had a BMI of 22 kg/mm 2 . Given her worsening condition, a CT scan was ordered. It revealed a left subphrenic collection, atelectasis of the left lower pulmonary base, and a fistulous tract between the gastric remnant and the ronchial tree. On EGD, a large fistula measuring 10 mm was discovered in the cardia. Our patient had persistent stable respiratory status. The multidisciplinary decision was to stent the fistulous tract, which failed three weeks after prosthesis 3 weeks later. Surgery was then performed. After pneumoperitoneum was established using Hasson technique, dense adhesions between the gastric tube, the left hepatic lobe, and the left diaphragm were freed; using scissors to avoid energy related injuries. Peri-fistular fibrosclerosis made the dissection taut and hemorrhagic ( Figure 1 ). There was a fistulous tract on the anterior aspect of the gastric pouch measuring 1 cm in diameter with hardened edges. To achieve tension-free fistula-jejunal anastomosis, the intra thoracic esophagus was freed ( Figures 2 and 3 ). A jejunal loop, 60 cm from the ligament of Treitz, was raised and anastomosed manually in a termino-lateral fashion; with a running 4-0 vicryl thread ( Figures 4 and 5 ). Surgical intervention was completed by drainage of the hiatal orifice. Our patient was discharged on the 10 th POD and has remained well since then. Five years later, the patient did not report dysphagia or cough, and had a stable BMI. Figure 1. Adhesiolysis of peri fistular fibrous adhesions. Figure 2. Intra thoracic dissection of gastric pouch. Figure 3. Lowering the mediastinal esophagus. Figure 4. Operative view of the fistulous orifice within the gastric wall. Figure 5. Roux-en-y fistulo-jejunostomy. Discussion Gastrothoracic fistulas are serious complications that are relatively rarely described after bariatric surgery, for which there is no consensus on management. These have been described following sleeve gastrectomy or gastric bypass. A multicenter French cohort included 24 cases from 2007 to 2018, of which 21 underwent sleeve gastrectomy and 3 underwent gastric bypass. 12 Sometimes, it is not the result of a gastric fistula, but rather the aftermath of inappropriate treatment of the latter. According to a review of 76 patients with intra thoracic gastric fistula, a history of gastric fistula was made in 57,5% of cases. 13 And in 26,25% of the cases, patients were insufficiently treated for abdominal or mediastinal collection. 13 Inappropriate stent size, position, stenting duration, and persistence of low-grade inflammation could explain the reported case. 14 The development of the broncho-gastric fistula in our case can be understood as a sequential process in which an early proximal staple-line leak gave rise to a persistent subphrenic collection. Over time, this collection evolved into a true abscess whose inflammatory and enzymatic activity caused progressive damage to adjacent tissues. The diaphragm, lying directly above the infected cavity, became exposed to continuous inflammation, local sepsis and ischemic stress, ultimately leading to its erosion and to the creation of a trans-diaphragmatic tract that extended toward the bronchial tree, establishing a broncho-gastric communication. This mechanism may be further exacerbated when a distal sleeve stenosis or functional obstruction is present, as increased intraluminal pressure promotes ongoing leakage, prevents adequate healing of the staple line, and sustains the subphrenic suppuration, thereby accelerating the erosion process and facilitating fistula formation. In fact, pus can eventually erode through the ipsilateral diaphragm, creating a pathological communication between the stomach, bronchial tree, or pleura, causing a gastro-bronchial or gastro-pleural fistula. 15 Downstream stenosis should be considered as chronic fistulas that are related to increased intraluminal pressure in the newly sized stomach. 16 The presentation is usually insidious. In a systematic review of 26 studies, respiratory symptoms were the most reported signs, with pneumonia taking the lead, next to subphrenic collections. 17 This is always a consequence of an anterior fistula. 12 A French study of 11 OGF cases concluded that in the majority of cases, the fistulous tract rises at the proximal end of the suture line. 18 Its treatment is not consensual and different attitudes have been suggested. However, given its complex nature, healing requires a long period. Fistula tract closure was achieved at an average of 7 months. 12 In one case, the healing time reached 7 years. 17 Endoscopic treatment, including clip or stent placement, has resulted in poor results. In fact, in a cohort of 24 cases, despite an average endoscopic treatment of 5 essays, 83% of patients underwent surgical procedures. 12 In another multicenter study, endoscopic internal drainage using stents was performed in 30 cases of gastro-bronchial fistulas and 10 gastrocolic fistulas following SG. 19 Despite the absence of major adverse effects, success was recorded in 47,5% of the cases. 19 This highlights the safety of endoscopic treatment for these complications despite their average results. In certain cases, when no endoscopic or surgical salvage procedures are efficient, total gastrectomy is performed. 20 In addition, a combined thoracic and abdominal route is often necessary foradequate debridement. This complication is often the cause of subsequent denutrtion (79%) explaining the high mortality rate reported in the literature (42%). 12 Finally, given the intense adhesion state, surgery can be limited to simple debridement, as stated in a recent review. 13 Conclusion Bariatric surgical procedures are constantly evolving with the increased necessity of radical treatment for obesity. Laparoscopic sleeve gastrectomy is the most commonly performed surgery, owing to its reproducibility and safety. However, this can lead to serious adverse events (AEs). It is crucial for surgeons to be aware of common and rare postoperative complications. The onset of GBF is challenging. Surgeons should trace patients postoperatively because their occurrence is subtle. Persistent or otherwise unexplained respiratory symptoms after SG should raise early suspicion for a GBF and prompt appropriate imaging. Chronic subphrenic sepsis, even when initially subtle, has the potential to erode the diaphragm and facilitate fistulization into the thoracic cavity, underscoring the need for timely drainage and source control. The treatment incorporates both endoscopic and surgical methods. Closure of the fistulous tract is possible because of the different strategies available. The choice of salvage plan should be tailored to the patient’s condition and the center’s expertise. A clear pivot point must also be established between prolonged endoscopic therapy and escalation to surgical rescue, particularly when sepsis persists, a mature fistulous tract becomes evident, or distal sleeve stenosis prevents durable healing. In such situations, fistulo-jejunostomy offers a rational and effective surgical option, as it diverts gastric flow away from the fistula, excludes the diseased segment, and enables definitive control of both the leak and the associated sepsis. Declarations Ethical approval Not required. This work is a single case report, which is generally not considered “research” requiring formal review by an ethics committee. The case describes the clinical management of one patient without any experimental intervention or deviation from standard care. Consent Written informed consent for publication of their clinical details and clinical images was obtained from the patient. Availability of data and materials The project contains the following underlying data : 10.5281/zenodo.16941530 . Under the name: dataset for article “CARE checklist for manuscript 169504 ” 21 Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0). Acknowledgements None. References 1. Obesity and overweight.2025. Reference Source 2. Zhou XD, Chen QF, Yang W, et al. : Burden of disease attributable to high body mass index: an analysis of data from the Global Burden of Disease Study 2021. J Eclinm. 2024; 76 : 102848. PubMed Abstract | Publisher Full Text | Free Full Text 3. Islam ANMS, Sultana H, Nazmul Hassan Refat M, et al. : The global burden of overweight-obesity and its association with economic status, benefiting from STEPs survey of WHO member states: A meta-analysis. Prev. Med. Rep. 2024; 46 : 102882. PubMed Abstract | Publisher Full Text | Free Full Text 4. Robertson AGN, Wiggins T, Robertson FP, et al. : Perioperative mortality in bariatric surgery: meta-analysis. Br. J. Surg. 2021; 108 (8): 892–897. PubMed Abstract | Publisher Full Text 5. American Society for Metabolic and Bariatric Surgery: Estimate of Bariatric Surgery Numbers, 2011-2022.2022. Reference Source 6. Adams TD, Meeks H, Fraser A, et al. : Long-term all-cause and cause-specific mortality for four bariatric surgery procedures. Obesity. 2023; 31 (2): 574–585. PubMed Abstract | Publisher Full Text | Free Full Text 7. Angrisani L, Santonicola A, Iovino P, et al. : IFSO Worldwide Survey 2020–2021: Current Trends for Bariatric and Metabolic Procedures. Obes. Surg. 2024; 34 (4): 1075–1085. PubMed Abstract | Publisher Full Text | Free Full Text 8. National Institute of Diabetes and Digestive and Kidney Diseases: Long-term Study of Bariatric Surgery for Obesity: LABS - NIDDK.2025. Reference Source 9. El Masry MAMA, Rahman IA: Perioperative Morbidity and Mortality of Laparoscopic Sleeve Gastrectomy (LSG) in a Single-Surgeon Experience on 892 Patients Over 11 Years. World J. Surg. 2023; 47 (11): 2809–2815. PubMed Abstract | Publisher Full Text | Free Full Text 10. Singhal R, Cardoso VR, Wiggins T, et al. : 30-day morbidity and mortality of sleeve gastrectomy, Roux-en-Y gastric bypass and one anastomosis gastric bypass: a propensity score-matched analysis of the GENEVA data. Int. J. Obes. 2022; 46 (4): 750–757. PubMed Abstract | Publisher Full Text | Free Full Text 11. Rookes N, Al-Asadi O, Yeluri S, et al. : Causes of Death After Bariatric Surgery: Long-Term Study of 10 Years. Obes. Surg. 2025; 35 (1): 47–58. PubMed Abstract | Publisher Full Text | Free Full Text 12. Marie L: Enquête sur les fistules gastro-thoraciques après chirurgie bariatrique. Aix-Marseille Université - École de médecine; 2019. 13. Shoar S, Hosseini FS, Gulraiz A, et al. : Intrathoracic gastric fistula after bariatric surgery: a systematic review and pooled analysis. Surg. Obes. Relat. Dis. 2021; 17 (3): 630–643. PubMed Abstract | Publisher Full Text 14. Gkolfakis P, Bureau MA, Arvanitakis M, et al. : A Gastrobronchial Fistula Secondary to Endoscopic Internal Drainage of a Post-Sleeve Gastrectomy Fluid Collection. Clin Endosc. 2021; 55 (1): 141–145. PubMed Abstract | Publisher Full Text | Free Full Text 15. Belluzzi A, Sample JW, Marrero K, et al. : Rare Complications Following Laparoscopic Sleeve Gastrectomy. J. Clin. Med. 2024; 13 (15): 4456. PubMed Abstract | Publisher Full Text | Free Full Text 16. Papavramidis TS, Mantzoukis K, Michalopoulos N: Confronting gastrocutaneous fistulas. Ann. Gastroenterol. 2011; 24 (1): 16–19. PubMed Abstract | Free Full Text 17. Sakran N, Zakeri R, Madhok B, et al. : Gastric Fistula in the Chest After Sleeve Gastrectomy: a Systematic Review of Diagnostic and Treatment Options. Obes Surg. janv. 2021; 31 (1): 357–369. PubMed Abstract | Publisher Full Text 18. Bruzzi M, M’harzi L, El Batti S, et al. : Bases anatomiques des fistules œsogastro-bronchiques et/ou pleurales après sleeve gastrectomie. Morphologie. 2019; 103 (342): 109. Publisher Full Text 19. D’Alessandro A, Galasso G, Zito FP, et al. : Role of Endoscopic Internal Drainage in Treating Gastro-Bronchial and Gastro-Colic Fistula After Sleeve Gastrectomy. Obes. Surg. 2022; 32 (2): 342–348. PubMed Abstract | Publisher Full Text 20. Tabbara M, Polliand C, Barrat C: Fistule gastro-bronchique: complication rare des sleeves gastrectomies. J. Chir. Visc. 2015; 152 (6): 416–417. Publisher Full Text 21. Mseddi MA: CARE checklist for manuscript 169504. Zenodo. 2025. Publisher Full Text Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 19 Sep 2025 ADD YOUR COMMENT Comment Author details Author details 1 Tunis obesity and diabetes surgery center, Tunis, Tunisia 2 general surgery "B", Rabta Hospital, Tunis, Tunis, Tunisia Adala Mourad Roles: Data Curation, Validation Adala Ahmed Roles: Supervision Siala Rakia Roles: Supervision, Validation Mseddi Mohamed Ali Roles: Writing – Original Draft Preparation, Writing – Review & Editing Yaakoubi Chaima Roles: Validation Ben Radhia Bechir Roles: Supervision Amara Amal Roles: Supervision Sallemi Karim Roles: Supervision Guizeni Rami Roles: Supervision Ghariani Brahim Roles: Supervision Sassi Karim Roles: Supervision Ben Slima Mohamed Roles: Validation, Visualization Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (2) version 2 Revised Published: 08 Dec 2025, 14:948 https://doi.org/10.12688/f1000research.169504.2 version 1 Published: 19 Sep 2025, 14:948 https://doi.org/10.12688/f1000research.169504.1 Copyright © 2025 Mourad A et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Mourad A, Ahmed A, Rakia S et al. Case Report: Gastro-bronchial fistula complicating a sleeve gastrectomy: from a glimmer of hope to a plight [version 2; peer review: 1 approved, 2 approved with reservations] . F1000Research 2025, 14 :948 ( https://doi.org/10.12688/f1000research.169504.2 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 2 VERSION 2 PUBLISHED 08 Dec 2025 Revised Views 0 Cite How to cite this report: Hsu KF. Reviewer Report For: Case Report: Gastro-bronchial fistula complicating a sleeve gastrectomy: from a glimmer of hope to a plight [version 2; peer review: 1 approved, 2 approved with reservations] . F1000Research 2025, 14 :948 ( https://doi.org/10.5256/f1000research.192320.r442107 ) The direct URL for this report is: https://f1000research.com/articles/14-948/v2#referee-response-442107 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 30 Dec 2025 Kuo-Feng Hsu , National Defense Medical University, Taipei, Taiwan Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.192320.r442107 This manuscript presents a well-documented and clinically relevant case of a delayed gastro-bronchial fistula following sleeve gastrectomy. The authors describe the diagnostic challenge, failure of endoscopic management, and successful definitive surgical treatment with fistulo-jejunal anastomosis, achieving durable symptom resolution on ... Continue reading READ ALL This manuscript presents a well-documented and clinically relevant case of a delayed gastro-bronchial fistula following sleeve gastrectomy. The authors describe the diagnostic challenge, failure of endoscopic management, and successful definitive surgical treatment with fistulo-jejunal anastomosis, achieving durable symptom resolution on long-term follow-up. The topic is important for bariatric and upper gastrointestinal surgeons, and the manuscript adds educational value by illustrating a complex salvage strategy for a rare but severe complication. The revised version has substantially improved in terms of pathophysiological explanation, operative rationale, and clinical clarity. Only minor revisions are suggested to further enhance completeness and transparency. Minor Comments / Points for Clarification Clarification regarding total gastrectomy In the Discussion, the authors appropriately mention that total gastrectomy may be required in selected cases when endoscopic and surgical salvage procedures fail . Given this statement and the severity of the present case, it would be important to explicitly clarify: Whether total gastrectomy was considered at any stage in this patient’s management , and If so, why it was ultimately avoided in favor of fistulo-jejunostomy (e.g., preserved gastric remnant viability, controlled sepsis, patient nutritional status, or desire to avoid the morbidity of total gastrectomy). A brief sentence addressing this decision-making process would significantly strengthen the surgical reasoning and help readers understand the indications and thresholds for escalating to total gastrectomy in similar scenarios. Surgical decision-making hierarchy The authors may consider adding one short sentence in the Discussion summarizing their institutional or case-based algorithm (endoscopic → surgical diversion → total gastrectomy as last resort), reinforcing that fistulo-jejunostomy served as a definitive but organ-preserving alternative in this case. Minor language and formatting Only minor language polishing is still needed in a few sentences (spacing, punctuation, and consistency of terminology), but these do not affect scientific content. Overall Assessment This case report is scientifically sound, clinically instructive, and suitable for indexing after minor revision . Addressing the point regarding consideration of total gastrectomy will further improve the manuscript’s completeness and value for practicing surgeons. Is the background of the case’s history and progression described in sufficient detail? Yes Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Yes Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Yes Is the case presented with sufficient detail to be useful for other practitioners? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: BARIATRIC SURGERY I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Hsu KF. Reviewer Report For: Case Report: Gastro-bronchial fistula complicating a sleeve gastrectomy: from a glimmer of hope to a plight [version 2; peer review: 1 approved, 2 approved with reservations] . F1000Research 2025, 14 :948 ( https://doi.org/10.5256/f1000research.192320.r442107 ) The direct URL for this report is: https://f1000research.com/articles/14-948/v2#referee-response-442107 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Hany M. Reviewer Report For: Case Report: Gastro-bronchial fistula complicating a sleeve gastrectomy: from a glimmer of hope to a plight [version 2; peer review: 1 approved, 2 approved with reservations] . F1000Research 2025, 14 :948 ( https://doi.org/10.5256/f1000research.192320.r439637 ) The direct URL for this report is: https://f1000research.com/articles/14-948/v2#referee-response-439637 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 27 Dec 2025 Mohamed Hany , Alexandria University, Alexandria, Egypt Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.192320.r439637 Unaddressed Issues : 1. Echoing Reviewer 1, I stated that the “authors should clearly articulate what this case adds to existing knowledge beyond documenting another instance of a known complication.” I noted that “The current manuscript does not appear ... Continue reading READ ALL Unaddressed Issues : 1. Echoing Reviewer 1, I stated that the “authors should clearly articulate what this case adds to existing knowledge beyond documenting another instance of a known complication.” I noted that “The current manuscript does not appear to introduce a new diagnostic modality, a novel therapeutic technique, or a fundamentally different understanding of the pathophysiology of GBF.” As mentioned, the revised manuscript fails to provide a clear statement of its novel contributions. The case is presented as a clinical example, but there is no explicit discussion of what makes it unique or what new insights it provides to the field. . 2. I requested more detailed clinical information, noting that the report “does not provide details of the findings” from the CT scan and that information on “pulmonary function tests or the severity of the recurrent bronchopulmonary infections” would be beneficial. The reviewer also noted that “The report mentions a CT scan revealed the GBF, but it does not provide details of the findings. Including images or a more detailed description of the CT and endoscopic findings would be highly beneficial.” The revised manuscript mentions CT findings but does not provide detailed descriptions or images. The text states: “a CT scan was ordered. It revealed a left subphrenic collection, atelactasis of the left lower pulmonary base, and a fistula tract between the gastric remnant and the bronchial tree.” However, no CT images are included, and there is no information regarding the patient’s pulmonary function tests or the severity of the recurrent bronchopulmonary infections beyond the statement that the patient “reported cough with recurrent bronchopneumonia.” Basic CT findings are mentioned, but detailed descriptions, images, and pulmonary function information are absent. 3. I highlighted the need for objective follow-up data, including “absence of cough/aspiration, nutritional status (weight/BMI, albumin), need for PPIs, pulmonary function or imaging, and any recurrence or re-intervention at defined intervals (e.g., 3/6/12 months).” I specifically noted: ”‘Asymptomatic’ is insufficient for a fistula. Report objective outcomes: absence of cough/aspiration, nutritional status (weight/BMI, albumin), need for PPIs, pulmonary function or imaging, and any recurrence or re-intervention at defined intervals (e.g., 3/6/12 months).” The manuscript states, “Five years later, the patient did not report dysphagia or cough and had a stable BMI.” However, it provides no objective data on nutritional status beyond BMI, no information on PPI usage, no pulmonary imaging follow-up, and no detailed recurrence assessment. The follow-up duration is mentioned as five years, but there is no specification of formal follow-up intervals or objective clinical assessments at defined time points. - Follow-up duration (five years) and absence of dysphagia/cough are mentioned, but objective nutritional data, PPI usage, pulmonary imaging, and recurrence assessment are absent. 4. I recommended that the “CARE checklist items should be integrated into the manuscript (timeline; patient perspective; diagnostic challenges; rationale for decisions; follow-up).” I noted: “You reference a Zenodo item titled ‘CARE checklist for manuscript 169504.’ Please integrate key CARE items into the manuscript (timeline; patient perspective; diagnostic challenges; rationale for decisions; follow-up). Verify that the Zenodo link is functional and clearly labeled in Data availability.” The “Data availability” section mentions “The project contains the following underlying data: 10.5281/zenodo.16941530. Under the name: dataset for article ‘CARE checklist for manuscript 169504’” and Reference 21 is listed as “Mseddi MA: CARE checklist for manuscript 169504. Zenodo. 2025. Publisher Full Text.” However, the CARE checklist items (timeline, patient perspective, diagnostic challenges, rationale for decisions, follow-up) have not been explicitly integrated into the manuscript narrative. While the manuscript does provide some of this information scattered throughout, it is not organized according to the CARE checklist framework. The CARE checklist is referenced and available, but its items are not explicitly integrated into the manuscript structure as requested. 5. I found the cited “42% mortality in the literature” to be alarming and requested “careful citation, context (era, selection bias, septic shock cohorts), and comparison with more recent series.” I specifically stated: “The discussion mentions a 42% mortality in the literature; this is alarming and requires careful citation, context (era, selection bias, septic shock cohorts), and comparison with more recent series. Re-check the source and either justify or temper the claim.” The revised manuscript’s discussion section states: “This complication is often the cause of subsequent denutrtion (79%) explaining the high mortality rate reported in the literature (42%).” This statement is cited to Reference 12, which is Marie L’s 2019 thesis “Enquête sur les fistules gastro-thoraciques après chirurgie bariatrique.” While the reference is now properly cited, the manuscript does not provide the context requested by the reviewer. There is no discussion of the era from which this 42% mortality rate derives, no mention of potential selection bias, no discussion of whether this rate applies to septic shock cohorts specifically, and no comparison with more recent mortality data. The 42% mortality rate is now properly cited to Reference 12, but the contextual information and comparison with recent data are absent. 6. I pointed out several minor issues, including non-sequential figure numbering, the need for a clearer timeline of events, the presence of vague statements like “pus can eventually erode through the peripheral diaphragm,” and the need for consistent terminology. The figures in the manuscript are numbered 1 through 5 and appear to be sequential in the text. However, the timeline of events is presented in narrative form rather than in a structured table or chronological summary as suggested. The manuscript contains the statement “pus can eventually erode through the ipsilateral diaphragm, creating a pathological communication between the stomach, bronchial tree, or pleura, causing a gastro-bronchial or gastro-pleural fistula.” While this is slightly more precise than the original vague statement, it still lacks the scientific rigor expected in a medical manuscript. Terminology appears to be generally consistent, with “gastro-bronchial fistula (GBF)” being used throughout. Figure numbering appears correct, terminology is consistent, but the timeline remains in narrative form, and some statements could be more scientifically precise. Competing Interests: No competing interests were disclosed. Reviewer Expertise: MBS I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Hany M. Reviewer Report For: Case Report: Gastro-bronchial fistula complicating a sleeve gastrectomy: from a glimmer of hope to a plight [version 2; peer review: 1 approved, 2 approved with reservations] . F1000Research 2025, 14 :948 ( https://doi.org/10.5256/f1000research.192320.r439637 ) The direct URL for this report is: https://f1000research.com/articles/14-948/v2#referee-response-439637 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Aliyev V. Reviewer Report For: Case Report: Gastro-bronchial fistula complicating a sleeve gastrectomy: from a glimmer of hope to a plight [version 2; peer review: 1 approved, 2 approved with reservations] . F1000Research 2025, 14 :948 ( https://doi.org/10.5256/f1000research.192320.r439636 ) The direct URL for this report is: https://f1000research.com/articles/14-948/v2#referee-response-439636 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 27 Dec 2025 Vusal Aliyev , General Surgery, Alibey Hospital, Istanbul, Turkey Approved VIEWS 0 https://doi.org/10.5256/f1000research.192320.r439636 The changes ... Continue reading READ ALL The changes are acceptable. Competing Interests: No competing interests were disclosed. Reviewer Expertise: General Surgery I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Aliyev V. Reviewer Report For: Case Report: Gastro-bronchial fistula complicating a sleeve gastrectomy: from a glimmer of hope to a plight [version 2; peer review: 1 approved, 2 approved with reservations] . F1000Research 2025, 14 :948 ( https://doi.org/10.5256/f1000research.192320.r439636 ) The direct URL for this report is: https://f1000research.com/articles/14-948/v2#referee-response-439636 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Version 1 VERSION 1 PUBLISHED 19 Sep 2025 Views 0 Cite How to cite this report: Aliyev V. Reviewer Report For: Case Report: Gastro-bronchial fistula complicating a sleeve gastrectomy: from a glimmer of hope to a plight [version 2; peer review: 1 approved, 2 approved with reservations] . F1000Research 2025, 14 :948 ( https://doi.org/10.5256/f1000research.186852.r423300 ) The direct URL for this report is: https://f1000research.com/articles/14-948/v1#referee-response-423300 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 20 Nov 2025 Vusal Aliyev , General Surgery, Alibey Hospital, Istanbul, Turkey Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.186852.r423300 This case report presents a rare but clinically important complication following sleeve gastrectomy—gastro-bronchial fistula (GBF). The topic is relevant to bariatric and thoracic surgeons, and the authors describe a well-documented patient course. However, the manuscript would benefit from significant ... Continue reading READ ALL This case report presents a rare but clinically important complication following sleeve gastrectomy—gastro-bronchial fistula (GBF). The topic is relevant to bariatric and thoracic surgeons, and the authors describe a well-documented patient course. However, the manuscript would benefit from significant refinement in structure, detail, and language. There are repeated or redundant sentences, typographical inconsistencies, and limited novelty in presentation. Major Comments: The Introduction contains repeated and awkwardly phrased sentences, especially the opening statement: “Obesity is rare. It affected 1 in 8 persons worldwide... it affects one in eight persons worldwide in 2022.” This duplication should be corrected and revised to a scientifically accurate statement such as: “Obesity is a major global health issue affecting approximately one in eight people worldwide (WHO, 2022).” The paragraph mixes epidemiologic data, mortality rates, and surgical volume without clear flow. Consider restructuring to: Global burden of obesity Rationale for bariatric surgery Frequency and complications of sleeve gastrectomy Rarity of gastro-bronchial fistula Novelty and Significance GBF after sleeve gastrectomy has been documented in multiple systematic reviews and recent reports. The case offers no clearly novel diagnostic or therapeutic innovation. The authors should emphasize what differentiates this report — e.g., the combination of post-cholecystectomy abscess contributing to fistula formation or the long latency period. Case Description The surgical and diagnostic details are overly brief: Include imaging (CT, endoscopy) descriptions or figures with annotations. Specify the size, location, and relation of the fistulous tract. Clarify intraoperative findings and rationale for fistulo-jejunal anastomosis. Add follow-up duration (months/years) and outcomes such as pulmonary recovery or nutritional status. Correct inconsistent abbreviations: EGOD → EGD, “ronchial” → bronchial. Discussion Strengthen causal reasoning: explain how early leak and subphrenic abscess led to diaphragmatic erosion and GBF formation. The cited 42% mortality rate is likely from older literature; verify source and contextualize. Provide a schematic explanation or flow of pathogenesis (e.g., leak → abscess → erosion → communication). Language and Style The tone is sometimes overly dramatic (e.g., “from a glimmer of hope to a plight”). A more neutral scientific style is preferable. Numerous grammatical and typographical errors should be corrected (e.g., “howver,” “double-pig,” “foradequate”). Use consistent terminology: “gastro-bronchial fistula (GBF)” throughout. Figures Current intraoperative photos need labeling, arrows, and context. Add pre- and post-treatment imaging if possible. References Several references are incomplete or non-standard (e.g., “Obesity and overweight. 2025” is not a proper citation). Add recent key works such as: Sakran et al., Obes Surg 2021;31:357-369 Rogalski et al., Prz Gastroenterol 2020;15:356-362 Campos et al., Obes Surg 2011;21:1339-1345 Minor Comments Standardize decimals (0.22%, not 0,22%). Correct organization names (IFSO = International Federation for the Surgery of Obesity and Metabolic Disorders ). Define all abbreviations on first use (SG, GBF, BMI, etc.). Provide clear chronological timeline (2015–2025). Include “Learning points” at the end summarizing: Chronic cough after SG warrants GBF evaluation. Early leaks or abscesses may cause thoracic fistulae. Combined surgical and endoscopic management yields best outcomes. Is the background of the case’s history and progression described in sufficient detail? No Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? No Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? No Is the case presented with sufficient detail to be useful for other practitioners? No Competing Interests: No competing interests were disclosed. Reviewer Expertise: General Surgery I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Aliyev V. Reviewer Report For: Case Report: Gastro-bronchial fistula complicating a sleeve gastrectomy: from a glimmer of hope to a plight [version 2; peer review: 1 approved, 2 approved with reservations] . F1000Research 2025, 14 :948 ( https://doi.org/10.5256/f1000research.186852.r423300 ) The direct URL for this report is: https://f1000research.com/articles/14-948/v1#referee-response-423300 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Hany M. Reviewer Report For: Case Report: Gastro-bronchial fistula complicating a sleeve gastrectomy: from a glimmer of hope to a plight [version 2; peer review: 1 approved, 2 approved with reservations] . F1000Research 2025, 14 :948 ( https://doi.org/10.5256/f1000research.186852.r419810 ) The direct URL for this report is: https://f1000research.com/articles/14-948/v1#referee-response-419810 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 04 Nov 2025 Mohamed Hany , Alexandria University, Alexandria, Egypt Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.186852.r419810 The manuscript by Mourad et al. presents a case report of a 36-year-old woman who developed a gastro-bronchial fistula (GBF) as a rare and delayed complication of a sleeve gastrectomy performed in 2015. The authors describe the patient’s clinical course, ... Continue reading READ ALL The manuscript by Mourad et al. presents a case report of a 36-year-old woman who developed a gastro-bronchial fistula (GBF) as a rare and delayed complication of a sleeve gastrectomy performed in 2015. The authors describe the patient’s clinical course, including the initial management of a gastric leak, the subsequent development of recurrent respiratory infections, and the eventual diagnosis of a GBF in 2017. The report details the failure of endoscopic stenting and the successful definitive management with a complex surgical procedure involving adhesiolysis and a tension-free fistula-jejunal anastomosis. The authors conclude that GBF is a challenging complication that requires a high index of suspicion and a multidisciplinary approach for successful management. Major Issues The manuscript addresses an important and rare complication of bariatric surgery. However, several major issues need to be addressed to improve the quality and impact of this report. 1. The primary concern is the limited novelty of the case. While GBF is an uncommon complication, it is a well-documented phenomenon. A recent literature search reveals numerous case reports and systematic reviews on this topic. For instance, a comprehensive systematic review by Sakran et al. (2021), which the authors cite, has already analyzed 55 cases of gastric fistulas in the chest after sleeve gastrectomy, providing a thorough overview of diagnostic and treatment options [1]. More recent case reports from 2024 and 2025 also describe similar presentations and management strategies [2, 3]. The current manuscript does not appear to introduce a new diagnostic modality, a novel therapeutic technique, or a fundamentally different understanding of the pathophysiology of GBF. The authors should clearly articulate what this case adds to the existing body of knowledge beyond simply documenting another instance of a known complication. 2. The clinical details provided are insufficient for a thorough understanding of the case. Key information is missing, which limits the educational value of the report. Specifically: • The report mentions a CT scan revealed the GBF, but it does not provide details of the findings. Including images or a more detailed description of the CT and endoscopic findings would be highly beneficial. • There is no information on the patient’s pulmonary function tests or the severity of the recurrent bronchopulmonary infections. • The description of the definitive surgical procedure is too brief. A more detailed, step-by-step description of the operative technique, including the approach to adhesiolysis and the specifics of the fistula-jejunal anastomosis, would be valuable for other surgeons who may encounter this rare complication. • The report states the patient remained well since then,” but the duration of follow-up is not specified. This is a critical piece of information for assessing the long-term success of the surgical intervention. 3. CARE checklist & data availability You reference a Zenodo item titled “CARE checklist for manuscript 169504.” Please integrate key CARE items into the manuscript (timeline; patient perspective; diagnostic challenges; rationale for decisions; follow-up). Verify that the Zenodo link is functional and clearly labeled in Data availability. 4. The discussion mentions a 42% mortality in the literature; this is alarming and requires careful citation, context (era, selection bias, septic shock cohorts), and comparison with more recent series. Re-check the source and either justify or temper the claim. 5. “Asymptomatic” is insufficient for a late thoraco-abdominal fistula. Report objective outcomes : absence of cough/aspiration, nutritional status (weight/BMI, albumin), need for PPIs, pulmonary function or imaging, and any recurrence or re-intervention at defined intervals (e.g., 3/6/12 months) 6. Current intraoperative photos (pp. 4–5) would benefit from annotated arrows/labels (fistulous tract, diaphragm, pouch, jejunal limb) and consistent terminology in captions. Add scale/context where possible. Please complement intraop images with pre-/post-treatment imaging as above. 7. The discussion attributes GBF to “insufficient treatment of early leaks/collections,” yet the case also includes a post-cholecystectomy subphrenic abscess , which may have contributed to diaphragmatic erosion. Please strengthen the causal reasoning with a schematic model: proximal staple-line leak → subphrenic abscess → diaphragmatic erosion → broncho-gastric communication; and discuss the influence of downstream sleeve stenosis/pressure if present Minor Issues: Several minor issues detract from the manuscript's clarity and professionalism. • The figures are not sequentially numbered in the text, which can cause confusion for the reader. • Several abbreviations (e.g., GBF, CT, EGOD) are used without being defined on their first use. • The timeline of events could be presented more clearly. A simple table or a more structured narrative would improve readability. • VThe manuscript contains several vague statements, such as “pus can eventually erode through the peripheral diaphragm,” which lack scientific precision. Page 3 opens with “ Obesity is rare ,” which is incorrect and contradicts the following sentence; revise to “ Obesity is common … affects ~1 in 8 people worldwide.” Remove duplicated sentences and harmonize global burden statements. Standardize decimals to a period (0.22%, not 0,22%) and ensure percentages are evidence-based (mortality rates, case numbers). Correct numerous typographical errors (e.g., “howver,” “wordwide,” “double-pig” → double pigtail , “ronchial” → bronchial , “EGOD” → EGD , “taught” → taut , “foradequate” → for adequate ; “for the Surgery of Surgery” → International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) ). Define all acronyms at first use. N.B. Use the new name of IFSO Use past tense consistently; standardize procedure names; avoid ambiguous phrases (“prosthesis 3 weeks later”). Provide learning points : (i) persistent respiratory symptoms after SG warrant GBF work-up; (ii) chronic subphrenic sepsis can erode the diaphragm; (iii) define a pivot point from endoscopic to surgical rescue; (iv) rationale for fistulo-jejunostomy selection. Language and Style The manuscript would benefit from a thorough language and style revision. The tone is at times overly dramatic (e.g., “from a glimmer of hope to a plight”) for a scientific publication. There are also grammatical errors, including inconsistent tense usage and awkward phrasing (e.g., “Downstream stenosis should be considered as chronic fistulas”). Use metabolic and bariatric surgery (MBS) ; sleeve gastrectomy (SG) ; gastro-bronchial fistula (GBF) . Avoid inconsistent forms such as “gastrobronchiol fistula,” “gastrothoracic fistula,” or “gastrobronchiolitis fistula” unless defined. References The reference list requires significant attention. • Several references are incomplete. For example, Reference 1 (“Obesity and overweight. 2025”) is not a proper citation, and Reference 8 is listed only as “Reference Source.” • Verification: Not all references could be readily verified. For example, Reference 12 is a French thesis that may not be easily accessible to an international audience. • Missed Opportunities: The authors have missed the opportunity to include several highly relevant and highly cited articles that would have provided a stronger context for their case report. The discussion would be significantly strengthened by incorporating findings from these key papers. Additional Recommended References The following references should be reviewed by the authors and considered for inclusion in their discussion: refer to 1,2,3,4 References refer to 5,6,7 Is the background of the case’s history and progression described in sufficient detail? Partly Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Partly Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Partly Is the case presented with sufficient detail to be useful for other practitioners? No References 1. Rogalski P, et al. (2020). Endoscopic management of leaks and fistulas after bariatric surgery. Prz Gastroenterol. 2020;15(4):356-362. 2. Campos JM, et al. (2011). Gastrobronchial fistula after sleeve gastrectomy and gastric bypass: endoscopic management and prevention. Obes Surg. 2011;21(9):1339-1345. 3. Silva LB, et al. (2015). Gastrobronchial fistula in sleeve gastrectomy and Roux-en-Y gastric bypass—a systematic review. Obes Surg. 2015;25(10):1927-1932. 4. Hany M, et al. (2025). Combined Laparoscopic and Thoracoscopic Management of Gastrobronchial Fistula Developed Early After Laparoscopic Sleeve Gastrectomy: A Video Presentation. Obes Surg. 2025;35(9):3952. 5. Hany M, Megahed A, Elraey A, Youssef M, et al.: Combined Laparoscopic and Thoracoscopic Management of Gastrobronchial Fistula Developed Early After Laparoscopic Sleeve Gastrectomy: A Video Presentation. Obesity Surgery . 2025; 35 (9): 3949-3951 Publisher Full Text 6. On behalf of the Global Bariatric Research Collaborative, Sakran N, Zakeri R, Madhok B, et al.: Gastric Fistula in the Chest After Sleeve Gastrectomy: a Systematic Review of Diagnostic and Treatment Options. Obesity Surgery . 2021; 31 (1): 357-369 Publisher Full Text 7. Mahapatra S, et al. S4034 Successful Closure of a Gastro-Bronchial Fistula… Am J Gastroenterol. 2024;119(10S):pS2425. doi:10.14309/01.ajg.0000959487.33333.f3. Competing Interests: No competing interests were disclosed. Reviewer Expertise: MBS I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Hany M. Reviewer Report For: Case Report: Gastro-bronchial fistula complicating a sleeve gastrectomy: from a glimmer of hope to a plight [version 2; peer review: 1 approved, 2 approved with reservations] . F1000Research 2025, 14 :948 ( https://doi.org/10.5256/f1000research.186852.r419810 ) The direct URL for this report is: https://f1000research.com/articles/14-948/v1#referee-response-419810 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 19 Sep 2025 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 3 Version 2 (revision) 08 Dec 25 read read read Version 1 19 Sep 25 read read Mohamed Hany , Alexandria University, Alexandria, Egypt Vusal Aliyev , Alibey Hospital, Istanbul, Turkey Kuo-Feng Hsu , National Defense Medical University, Taipei, Taiwan Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2026 Hsu K. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 30 Dec 2025 | for Version 2 Kuo-Feng Hsu , National Defense Medical University, Taipei, Taiwan 0 Views copyright © 2026 Hsu K. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions This manuscript presents a well-documented and clinically relevant case of a delayed gastro-bronchial fistula following sleeve gastrectomy. The authors describe the diagnostic challenge, failure of endoscopic management, and successful definitive surgical treatment with fistulo-jejunal anastomosis, achieving durable symptom resolution on long-term follow-up. The topic is important for bariatric and upper gastrointestinal surgeons, and the manuscript adds educational value by illustrating a complex salvage strategy for a rare but severe complication. The revised version has substantially improved in terms of pathophysiological explanation, operative rationale, and clinical clarity. Only minor revisions are suggested to further enhance completeness and transparency. Minor Comments / Points for Clarification Clarification regarding total gastrectomy In the Discussion, the authors appropriately mention that total gastrectomy may be required in selected cases when endoscopic and surgical salvage procedures fail . Given this statement and the severity of the present case, it would be important to explicitly clarify: Whether total gastrectomy was considered at any stage in this patient’s management , and If so, why it was ultimately avoided in favor of fistulo-jejunostomy (e.g., preserved gastric remnant viability, controlled sepsis, patient nutritional status, or desire to avoid the morbidity of total gastrectomy). A brief sentence addressing this decision-making process would significantly strengthen the surgical reasoning and help readers understand the indications and thresholds for escalating to total gastrectomy in similar scenarios. Surgical decision-making hierarchy The authors may consider adding one short sentence in the Discussion summarizing their institutional or case-based algorithm (endoscopic → surgical diversion → total gastrectomy as last resort), reinforcing that fistulo-jejunostomy served as a definitive but organ-preserving alternative in this case. Minor language and formatting Only minor language polishing is still needed in a few sentences (spacing, punctuation, and consistency of terminology), but these do not affect scientific content. Overall Assessment This case report is scientifically sound, clinically instructive, and suitable for indexing after minor revision . Addressing the point regarding consideration of total gastrectomy will further improve the manuscript’s completeness and value for practicing surgeons. Is the background of the case’s history and progression described in sufficient detail? Yes Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Yes Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Yes Is the case presented with sufficient detail to be useful for other practitioners? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise BARIATRIC SURGERY I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (0) Hsu KF. Peer Review Report For: Case Report: Gastro-bronchial fistula complicating a sleeve gastrectomy: from a glimmer of hope to a plight [version 2; peer review: 1 approved, 2 approved with reservations] . F1000Research 2025, 14 :948 ( https://doi.org/10.5256/f1000research.192320.r442107) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-948/v2#referee-response-442107 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Hany M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 27 Dec 2025 | for Version 2 Mohamed Hany , Alexandria University, Alexandria, Egypt 0 Views copyright © 2025 Hany M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Unaddressed Issues : 1. Echoing Reviewer 1, I stated that the “authors should clearly articulate what this case adds to existing knowledge beyond documenting another instance of a known complication.” I noted that “The current manuscript does not appear to introduce a new diagnostic modality, a novel therapeutic technique, or a fundamentally different understanding of the pathophysiology of GBF.” As mentioned, the revised manuscript fails to provide a clear statement of its novel contributions. The case is presented as a clinical example, but there is no explicit discussion of what makes it unique or what new insights it provides to the field. . 2. I requested more detailed clinical information, noting that the report “does not provide details of the findings” from the CT scan and that information on “pulmonary function tests or the severity of the recurrent bronchopulmonary infections” would be beneficial. The reviewer also noted that “The report mentions a CT scan revealed the GBF, but it does not provide details of the findings. Including images or a more detailed description of the CT and endoscopic findings would be highly beneficial.” The revised manuscript mentions CT findings but does not provide detailed descriptions or images. The text states: “a CT scan was ordered. It revealed a left subphrenic collection, atelactasis of the left lower pulmonary base, and a fistula tract between the gastric remnant and the bronchial tree.” However, no CT images are included, and there is no information regarding the patient’s pulmonary function tests or the severity of the recurrent bronchopulmonary infections beyond the statement that the patient “reported cough with recurrent bronchopneumonia.” Basic CT findings are mentioned, but detailed descriptions, images, and pulmonary function information are absent. 3. I highlighted the need for objective follow-up data, including “absence of cough/aspiration, nutritional status (weight/BMI, albumin), need for PPIs, pulmonary function or imaging, and any recurrence or re-intervention at defined intervals (e.g., 3/6/12 months).” I specifically noted: ”‘Asymptomatic’ is insufficient for a fistula. Report objective outcomes: absence of cough/aspiration, nutritional status (weight/BMI, albumin), need for PPIs, pulmonary function or imaging, and any recurrence or re-intervention at defined intervals (e.g., 3/6/12 months).” The manuscript states, “Five years later, the patient did not report dysphagia or cough and had a stable BMI.” However, it provides no objective data on nutritional status beyond BMI, no information on PPI usage, no pulmonary imaging follow-up, and no detailed recurrence assessment. The follow-up duration is mentioned as five years, but there is no specification of formal follow-up intervals or objective clinical assessments at defined time points. - Follow-up duration (five years) and absence of dysphagia/cough are mentioned, but objective nutritional data, PPI usage, pulmonary imaging, and recurrence assessment are absent. 4. I recommended that the “CARE checklist items should be integrated into the manuscript (timeline; patient perspective; diagnostic challenges; rationale for decisions; follow-up).” I noted: “You reference a Zenodo item titled ‘CARE checklist for manuscript 169504.’ Please integrate key CARE items into the manuscript (timeline; patient perspective; diagnostic challenges; rationale for decisions; follow-up). Verify that the Zenodo link is functional and clearly labeled in Data availability.” The “Data availability” section mentions “The project contains the following underlying data: 10.5281/zenodo.16941530. Under the name: dataset for article ‘CARE checklist for manuscript 169504’” and Reference 21 is listed as “Mseddi MA: CARE checklist for manuscript 169504. Zenodo. 2025. Publisher Full Text.” However, the CARE checklist items (timeline, patient perspective, diagnostic challenges, rationale for decisions, follow-up) have not been explicitly integrated into the manuscript narrative. While the manuscript does provide some of this information scattered throughout, it is not organized according to the CARE checklist framework. The CARE checklist is referenced and available, but its items are not explicitly integrated into the manuscript structure as requested. 5. I found the cited “42% mortality in the literature” to be alarming and requested “careful citation, context (era, selection bias, septic shock cohorts), and comparison with more recent series.” I specifically stated: “The discussion mentions a 42% mortality in the literature; this is alarming and requires careful citation, context (era, selection bias, septic shock cohorts), and comparison with more recent series. Re-check the source and either justify or temper the claim.” The revised manuscript’s discussion section states: “This complication is often the cause of subsequent denutrtion (79%) explaining the high mortality rate reported in the literature (42%).” This statement is cited to Reference 12, which is Marie L’s 2019 thesis “Enquête sur les fistules gastro-thoraciques après chirurgie bariatrique.” While the reference is now properly cited, the manuscript does not provide the context requested by the reviewer. There is no discussion of the era from which this 42% mortality rate derives, no mention of potential selection bias, no discussion of whether this rate applies to septic shock cohorts specifically, and no comparison with more recent mortality data. The 42% mortality rate is now properly cited to Reference 12, but the contextual information and comparison with recent data are absent. 6. I pointed out several minor issues, including non-sequential figure numbering, the need for a clearer timeline of events, the presence of vague statements like “pus can eventually erode through the peripheral diaphragm,” and the need for consistent terminology. The figures in the manuscript are numbered 1 through 5 and appear to be sequential in the text. However, the timeline of events is presented in narrative form rather than in a structured table or chronological summary as suggested. The manuscript contains the statement “pus can eventually erode through the ipsilateral diaphragm, creating a pathological communication between the stomach, bronchial tree, or pleura, causing a gastro-bronchial or gastro-pleural fistula.” While this is slightly more precise than the original vague statement, it still lacks the scientific rigor expected in a medical manuscript. Terminology appears to be generally consistent, with “gastro-bronchial fistula (GBF)” being used throughout. Figure numbering appears correct, terminology is consistent, but the timeline remains in narrative form, and some statements could be more scientifically precise. Competing Interests No competing interests were disclosed. Reviewer Expertise MBS I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (0) Hany M. Peer Review Report For: Case Report: Gastro-bronchial fistula complicating a sleeve gastrectomy: from a glimmer of hope to a plight [version 2; peer review: 1 approved, 2 approved with reservations] . F1000Research 2025, 14 :948 ( https://doi.org/10.5256/f1000research.192320.r439637) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-948/v2#referee-response-439637 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Aliyev V. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 27 Dec 2025 | for Version 2 Vusal Aliyev , General Surgery, Alibey Hospital, Istanbul, Turkey 0 Views copyright © 2025 Aliyev V. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions The changes are acceptable. Competing Interests No competing interests were disclosed. Reviewer Expertise General Surgery I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Aliyev V. Peer Review Report For: Case Report: Gastro-bronchial fistula complicating a sleeve gastrectomy: from a glimmer of hope to a plight [version 2; peer review: 1 approved, 2 approved with reservations] . F1000Research 2025, 14 :948 ( https://doi.org/10.5256/f1000research.192320.r439636) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-948/v2#referee-response-439636 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Aliyev V. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 20 Nov 2025 | for Version 1 Vusal Aliyev , General Surgery, Alibey Hospital, Istanbul, Turkey 0 Views copyright © 2025 Aliyev V. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions This case report presents a rare but clinically important complication following sleeve gastrectomy—gastro-bronchial fistula (GBF). The topic is relevant to bariatric and thoracic surgeons, and the authors describe a well-documented patient course. However, the manuscript would benefit from significant refinement in structure, detail, and language. There are repeated or redundant sentences, typographical inconsistencies, and limited novelty in presentation. Major Comments: The Introduction contains repeated and awkwardly phrased sentences, especially the opening statement: “Obesity is rare. It affected 1 in 8 persons worldwide... it affects one in eight persons worldwide in 2022.” This duplication should be corrected and revised to a scientifically accurate statement such as: “Obesity is a major global health issue affecting approximately one in eight people worldwide (WHO, 2022).” The paragraph mixes epidemiologic data, mortality rates, and surgical volume without clear flow. Consider restructuring to: Global burden of obesity Rationale for bariatric surgery Frequency and complications of sleeve gastrectomy Rarity of gastro-bronchial fistula Novelty and Significance GBF after sleeve gastrectomy has been documented in multiple systematic reviews and recent reports. The case offers no clearly novel diagnostic or therapeutic innovation. The authors should emphasize what differentiates this report — e.g., the combination of post-cholecystectomy abscess contributing to fistula formation or the long latency period. Case Description The surgical and diagnostic details are overly brief: Include imaging (CT, endoscopy) descriptions or figures with annotations. Specify the size, location, and relation of the fistulous tract. Clarify intraoperative findings and rationale for fistulo-jejunal anastomosis. Add follow-up duration (months/years) and outcomes such as pulmonary recovery or nutritional status. Correct inconsistent abbreviations: EGOD → EGD, “ronchial” → bronchial. Discussion Strengthen causal reasoning: explain how early leak and subphrenic abscess led to diaphragmatic erosion and GBF formation. The cited 42% mortality rate is likely from older literature; verify source and contextualize. Provide a schematic explanation or flow of pathogenesis (e.g., leak → abscess → erosion → communication). Language and Style The tone is sometimes overly dramatic (e.g., “from a glimmer of hope to a plight”). A more neutral scientific style is preferable. Numerous grammatical and typographical errors should be corrected (e.g., “howver,” “double-pig,” “foradequate”). Use consistent terminology: “gastro-bronchial fistula (GBF)” throughout. Figures Current intraoperative photos need labeling, arrows, and context. Add pre- and post-treatment imaging if possible. References Several references are incomplete or non-standard (e.g., “Obesity and overweight. 2025” is not a proper citation). Add recent key works such as: Sakran et al., Obes Surg 2021;31:357-369 Rogalski et al., Prz Gastroenterol 2020;15:356-362 Campos et al., Obes Surg 2011;21:1339-1345 Minor Comments Standardize decimals (0.22%, not 0,22%). Correct organization names (IFSO = International Federation for the Surgery of Obesity and Metabolic Disorders ). Define all abbreviations on first use (SG, GBF, BMI, etc.). Provide clear chronological timeline (2015–2025). Include “Learning points” at the end summarizing: Chronic cough after SG warrants GBF evaluation. Early leaks or abscesses may cause thoracic fistulae. Combined surgical and endoscopic management yields best outcomes. Is the background of the case’s history and progression described in sufficient detail? No Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? No Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? No Is the case presented with sufficient detail to be useful for other practitioners? No Competing Interests No competing interests were disclosed. Reviewer Expertise General Surgery I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (0) Aliyev V. Peer Review Report For: Case Report: Gastro-bronchial fistula complicating a sleeve gastrectomy: from a glimmer of hope to a plight [version 2; peer review: 1 approved, 2 approved with reservations] . F1000Research 2025, 14 :948 ( https://doi.org/10.5256/f1000research.186852.r423300) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-948/v1#referee-response-423300 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Hany M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 04 Nov 2025 | for Version 1 Mohamed Hany , Alexandria University, Alexandria, Egypt 0 Views copyright © 2025 Hany M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions The manuscript by Mourad et al. presents a case report of a 36-year-old woman who developed a gastro-bronchial fistula (GBF) as a rare and delayed complication of a sleeve gastrectomy performed in 2015. The authors describe the patient’s clinical course, including the initial management of a gastric leak, the subsequent development of recurrent respiratory infections, and the eventual diagnosis of a GBF in 2017. The report details the failure of endoscopic stenting and the successful definitive management with a complex surgical procedure involving adhesiolysis and a tension-free fistula-jejunal anastomosis. The authors conclude that GBF is a challenging complication that requires a high index of suspicion and a multidisciplinary approach for successful management. Major Issues The manuscript addresses an important and rare complication of bariatric surgery. However, several major issues need to be addressed to improve the quality and impact of this report. 1. The primary concern is the limited novelty of the case. While GBF is an uncommon complication, it is a well-documented phenomenon. A recent literature search reveals numerous case reports and systematic reviews on this topic. For instance, a comprehensive systematic review by Sakran et al. (2021), which the authors cite, has already analyzed 55 cases of gastric fistulas in the chest after sleeve gastrectomy, providing a thorough overview of diagnostic and treatment options [1]. More recent case reports from 2024 and 2025 also describe similar presentations and management strategies [2, 3]. The current manuscript does not appear to introduce a new diagnostic modality, a novel therapeutic technique, or a fundamentally different understanding of the pathophysiology of GBF. The authors should clearly articulate what this case adds to the existing body of knowledge beyond simply documenting another instance of a known complication. 2. The clinical details provided are insufficient for a thorough understanding of the case. Key information is missing, which limits the educational value of the report. Specifically: • The report mentions a CT scan revealed the GBF, but it does not provide details of the findings. Including images or a more detailed description of the CT and endoscopic findings would be highly beneficial. • There is no information on the patient’s pulmonary function tests or the severity of the recurrent bronchopulmonary infections. • The description of the definitive surgical procedure is too brief. A more detailed, step-by-step description of the operative technique, including the approach to adhesiolysis and the specifics of the fistula-jejunal anastomosis, would be valuable for other surgeons who may encounter this rare complication. • The report states the patient remained well since then,” but the duration of follow-up is not specified. This is a critical piece of information for assessing the long-term success of the surgical intervention. 3. CARE checklist & data availability You reference a Zenodo item titled “CARE checklist for manuscript 169504.” Please integrate key CARE items into the manuscript (timeline; patient perspective; diagnostic challenges; rationale for decisions; follow-up). Verify that the Zenodo link is functional and clearly labeled in Data availability. 4. The discussion mentions a 42% mortality in the literature; this is alarming and requires careful citation, context (era, selection bias, septic shock cohorts), and comparison with more recent series. Re-check the source and either justify or temper the claim. 5. “Asymptomatic” is insufficient for a late thoraco-abdominal fistula. Report objective outcomes : absence of cough/aspiration, nutritional status (weight/BMI, albumin), need for PPIs, pulmonary function or imaging, and any recurrence or re-intervention at defined intervals (e.g., 3/6/12 months) 6. Current intraoperative photos (pp. 4–5) would benefit from annotated arrows/labels (fistulous tract, diaphragm, pouch, jejunal limb) and consistent terminology in captions. Add scale/context where possible. Please complement intraop images with pre-/post-treatment imaging as above. 7. The discussion attributes GBF to “insufficient treatment of early leaks/collections,” yet the case also includes a post-cholecystectomy subphrenic abscess , which may have contributed to diaphragmatic erosion. Please strengthen the causal reasoning with a schematic model: proximal staple-line leak → subphrenic abscess → diaphragmatic erosion → broncho-gastric communication; and discuss the influence of downstream sleeve stenosis/pressure if present Minor Issues: Several minor issues detract from the manuscript's clarity and professionalism. • The figures are not sequentially numbered in the text, which can cause confusion for the reader. • Several abbreviations (e.g., GBF, CT, EGOD) are used without being defined on their first use. • The timeline of events could be presented more clearly. A simple table or a more structured narrative would improve readability. • VThe manuscript contains several vague statements, such as “pus can eventually erode through the peripheral diaphragm,” which lack scientific precision. Page 3 opens with “ Obesity is rare ,” which is incorrect and contradicts the following sentence; revise to “ Obesity is common … affects ~1 in 8 people worldwide.” Remove duplicated sentences and harmonize global burden statements. Standardize decimals to a period (0.22%, not 0,22%) and ensure percentages are evidence-based (mortality rates, case numbers). Correct numerous typographical errors (e.g., “howver,” “wordwide,” “double-pig” → double pigtail , “ronchial” → bronchial , “EGOD” → EGD , “taught” → taut , “foradequate” → for adequate ; “for the Surgery of Surgery” → International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) ). Define all acronyms at first use. N.B. Use the new name of IFSO Use past tense consistently; standardize procedure names; avoid ambiguous phrases (“prosthesis 3 weeks later”). Provide learning points : (i) persistent respiratory symptoms after SG warrant GBF work-up; (ii) chronic subphrenic sepsis can erode the diaphragm; (iii) define a pivot point from endoscopic to surgical rescue; (iv) rationale for fistulo-jejunostomy selection. Language and Style The manuscript would benefit from a thorough language and style revision. The tone is at times overly dramatic (e.g., “from a glimmer of hope to a plight”) for a scientific publication. There are also grammatical errors, including inconsistent tense usage and awkward phrasing (e.g., “Downstream stenosis should be considered as chronic fistulas”). Use metabolic and bariatric surgery (MBS) ; sleeve gastrectomy (SG) ; gastro-bronchial fistula (GBF) . Avoid inconsistent forms such as “gastrobronchiol fistula,” “gastrothoracic fistula,” or “gastrobronchiolitis fistula” unless defined. References The reference list requires significant attention. • Several references are incomplete. For example, Reference 1 (“Obesity and overweight. 2025”) is not a proper citation, and Reference 8 is listed only as “Reference Source.” • Verification: Not all references could be readily verified. For example, Reference 12 is a French thesis that may not be easily accessible to an international audience. • Missed Opportunities: The authors have missed the opportunity to include several highly relevant and highly cited articles that would have provided a stronger context for their case report. The discussion would be significantly strengthened by incorporating findings from these key papers. Additional Recommended References The following references should be reviewed by the authors and considered for inclusion in their discussion: refer to 1,2,3,4 References refer to 5,6,7 Is the background of the case’s history and progression described in sufficient detail? Partly Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Partly Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Partly Is the case presented with sufficient detail to be useful for other practitioners? No References 1. Rogalski P, et al. (2020). Endoscopic management of leaks and fistulas after bariatric surgery. Prz Gastroenterol. 2020;15(4):356-362. 2. Campos JM, et al. (2011). Gastrobronchial fistula after sleeve gastrectomy and gastric bypass: endoscopic management and prevention. Obes Surg. 2011;21(9):1339-1345. 3. Silva LB, et al. (2015). Gastrobronchial fistula in sleeve gastrectomy and Roux-en-Y gastric bypass—a systematic review. Obes Surg. 2015;25(10):1927-1932. 4. Hany M, et al. (2025). Combined Laparoscopic and Thoracoscopic Management of Gastrobronchial Fistula Developed Early After Laparoscopic Sleeve Gastrectomy: A Video Presentation. Obes Surg. 2025;35(9):3952. 5. Hany M, Megahed A, Elraey A, Youssef M, et al.: Combined Laparoscopic and Thoracoscopic Management of Gastrobronchial Fistula Developed Early After Laparoscopic Sleeve Gastrectomy: A Video Presentation. Obesity Surgery . 2025; 35 (9): 3949-3951 Publisher Full Text 6. On behalf of the Global Bariatric Research Collaborative, Sakran N, Zakeri R, Madhok B, et al.: Gastric Fistula in the Chest After Sleeve Gastrectomy: a Systematic Review of Diagnostic and Treatment Options. Obesity Surgery . 2021; 31 (1): 357-369 Publisher Full Text 7. Mahapatra S, et al. S4034 Successful Closure of a Gastro-Bronchial Fistula… Am J Gastroenterol. 2024;119(10S):pS2425. doi:10.14309/01.ajg.0000959487.33333.f3. Competing Interests No competing interests were disclosed. Reviewer Expertise MBS I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (0) Hany M. Peer Review Report For: Case Report: Gastro-bronchial fistula complicating a sleeve gastrectomy: from a glimmer of hope to a plight [version 2; peer review: 1 approved, 2 approved with reservations] . F1000Research 2025, 14 :948 ( https://doi.org/10.5256/f1000research.186852.r419810) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. 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