title: Incidence, mechanisms, and outcomes of esophageal and gastric perforation during laparoscopic foregut surgery: a retrospective review of 1,223 foregut cases.
abstract: BACKGROUND
  Intraoperative perforation is a potentially major complication of laparoscopic (lap) foregut surgery. This study analyzed the incidence, mechanism, and outcomes of intraoperative perforations during these procedures in a large institutional experience.
  
  
  METHODS
  All patients who underwent lap foregut surgery including laparoscopic antireflux surgery (LARS), paraesophageal hernia (PEH) repair, Heller myotomy, and reoperative hiatal hernia (redo HH) repair at the authors' institution from August 2004 to September 2012 were reviewed retrospectively. Perforation events and postoperative outcomes were analyzed, and complications were graded by the modified Clavien system. All data are expressed as means ± standard deviations or as medians. Statistical analysis was performed using Fisher's exact test and the Mann-Whitney U test.
  
  
  RESULTS
  In this study, the repairs for 1,223 patients were analyzed (381 LARS procedures, 379 PEH repairs, 313 Heller myotomies, 150 redo HH repairs). Overall, 51 patients (4.2 %) had 56 perforations resulting from LARS (n = 4, 1 %), PEH repair (n = 7, 1.8 %), Heller myotomy (n = 18, 5.8 %), and redo HH repair (n = 22, 14.6 %). Redo HH was significantly more likely to result in perforations than LARS or PEH repair (p < 0.001). The locations of the perforations were esophageal in 13 patients (23.6 %), gastric in 40 patients (72.7 %), and indeterminate in 2 patients (3.6 %). The most common mechanisms of perforations were suture placement for LARS (75 %) and traction for PEH repair (43 %) and for Heller myotomy during the myotomy (72 %). The most redo HH perforations resulted from dissection/wrap takedown (73 %) and traction (14 %). Perforations were recognized and repaired intraoperatively in 43 cases (84 %) and postoperatively in eight cases (16 %). Perforations discovered postoperatively were more likely to require reoperation (75 vs 2 %; p < 0.001), to require more gastrointestinal and radiologic interventions (50 vs 2 %; p = 0.004), and to have higher morbidity (88 vs 26 %; p = 0.004) than perforations recognized intraoperatively.
  
  
  CONCLUSIONS
  In a high-volume center, intraoperative perforations are the most frequent with reoperative HH repair. If perforations are recognized and repaired intraoperatively, they require minimal postoperative intervention. Unrecognized perforations usually require reoperation and result in significantly greater morbidity.
authors.affiliation: Section of Minimally Invasive Surgery, Department of Surgery, Washington University School of Medicine, 660 S Euclid Avenue, Box 8109, St. Louis, MO, 63110, USA, lindapzhang@gmail.com.
authors.forename: Linda P
authors.initials: LP
authors.lastname: Zhang
authors.forename: Ronald
authors.initials: R
authors.lastname: Chang
authors.forename: Brent D
authors.initials: BD
authors.lastname: Matthews
authors.forename: Michael
authors.initials: M
authors.lastname: Awad
authors.forename: Bryan
authors.initials: B
authors.lastname: Meyers
authors.forename: J Chris
authors.initials: JC
authors.lastname: Eagon
authors.forename: L Michael
authors.initials: LM
authors.lastname: Brunt
mesh_terms: D000328:Adult; D000369:Aged, 80 and over; D003422:Critical Care / Q000706:statistics & numerical data; D004939:Esophageal Perforation / Q000453:epidemiology* / Q000209:etiology; D005260:Female; D006551:Hernia, Hiatal / Q000601:surgery; D059685:Herniorrhaphy / Q000009:adverse effects / Q000706:statistics & numerical data; D006801:Humans; D007049:Iatrogenic Disease / Q000453:epidemiology; D015994:Incidence; D010535:Laparoscopy / Q000009:adverse effects* / Q000706:statistics & numerical data*; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D008923:Missouri; D012086:Reoperation; D012189:Retrospective Studies; D013270:Stomach / Q000293:injuries*; D013272:Stomach Diseases / Q000601:surgery; D016896:Treatment Outcome; D014950:Wounds, Penetrating / Q000453:epidemiology* / Q000209:etiology