The Accuracy of Gastric Insufflation in Testing for Gastroesophageal Perforations during Laparoscopic Nissen Fundoplication, Flum DR et al. 17 gastric and esophageal perforations after LNF, three mechanisms accounted for all injuries. Ten injuries were from improper retroesophageal dissection (nine resulted from dissection in an improper operative plane). One occurred as a result of an inappropriately limited retroe- sophageal window causing a tear of the fundus during fundoplication. Five other injuries occurred during pas- sage of the bougie (n=4) or NGT (n=1). Two injuries occurred after suture pull through of "full-thickness" stomach sutures. The estimated size of injuries was 0.5- 2 cm (mean 1.1 cm). Contributing findings among patients with injuries included obesity, hiatal hernia, excessive fatty tissue in the periesophageal area and blood staining of the operative field.2 Of these injuries,2 most (n=11) were recognized at the time of the surgery. Four injuries were repaired through the laparoscope, five through laparotomy, and one through thoracotomy. Six cases (35%) were identified after surgery. Presenting findings in this group included persistent abdominal pain, peritonitis and respiratory dis- tress. On average, these injuries were identified 1-6 days after surgery with the principal presenting sign of increased abdominal pain in 67%. At least one patient had a documented GE injury despite a reassuring barium study of the GE junction. Outcomes after injury detection and repair vary signifi- cantly based on the time of discovery. Those injuries identified at the time of perforation were associated with a 0% mortality rate, no postoperative leaks and mean hospital stay of 4.5 days. Of those six patients with delayed discovery of injuries, one died (17%), abscess was noted in two, and pleural effusions, fistula, or vagus nerve injury were also noted. In the delayed diagnosis group, the mean hospital stay was 14 days.2 Intraoperative detection of GE injuries is clearly beneficial to the patient; yet, routine inspection for unsuspected injury is not a current component of standard foregut surgery. We have developed a gastric insufflation tech- nique to facilitate intraoperative detection of such injuries. GIT is a simple, reproducible and low-cost tech- nique for the detection of GE injury during LNF. The technique requires little modification of the common operation and few additional instruments. By routinely applying GIT, the surgeon can be better assured of the integrity of the GE junction with minimal delay and with little risk to the patient. In our clinical practice, GIT is applied after the stomach and esophagus have been completely mobilized and just before fundoplication. Prior to introducing the bougie, the distal stomach is occluded with a laparoscopic, non- crushing bowel clamp, and the stomach is insufflated to maximal volume. Insufflation of the stomach can be greatly facilitated by attaching a pressure ball with a one- way valve (the type routinely found on sphygmo- manometers or pressure bags) to the suction port of the nasogastric tube. The blue "sumping" port is clamped during insufflation. A manometer is not necessary once the surgeon is comfortable assessing maximal gastric dilatation. The patient is then placed in Trendelenberg position and irrigation is placed in the upper quadrant of the abdomen. Air bubbling signifies a break in the GE luminal integrity and requires further investigation and repair. The NGT should then be partially withdrawn to the esophagus and the proximal stomach occluded while the insufflation is repeated. The bougie is then advanced under direct visualization while appropriately manipulat- ing the stomach.2 If there is a question of occult GE injury after bougie placement, GIT can be performed after the fundoplication is completed. It should not be routinely necessary to perform GIT more than once, and it is expected that this will add three to five minutes to the total procedure time. Although GIT appears to be a useful technique, there are several limitations to using an animal model to evaluate the question of its utility in humans. The porcine esoph- agus is much more pliable and muscular than that found in humans. Indeed, despite multiple attempts at angu- lating the GE junction, we were unable to perforate the porcine esophagus with either a nasogastric tube or 40F bougie. This appears to be because the porcine esoph- agus has a more developed muscular lining. Conversely, it has been demonstrated that the human esophagus can be easily perforated with an improperly placed bougie or operative dissection. This suggests that GIT may be even more sensitive in humans than in the animal model. The less muscular human esophagus might be more likely to leak air bubbles when submerged. Our results suggest that it is more difficult than expected to identify small esophageal injuries with pyloric occlu- sion alone. However, proximal stomach occlusion rou- tinely detects esophageal and GE junction injuries. While it is intuitive that clamping of the distal stomach and insufflation will identify meaningful breaks in the GE wall, we found that pyloric occlusion alone is not a suf- 270 JSLS (1999)3:267-271