The Accuracy of Gastric Insufflation in Testing for Gastroesophageal Perforations during Laparoscopic Nissen Fundoplication, Flum DR et al. However, delay in the diagnosis of GE injuries results in peritonitis, sepsis and a high mortality rate. In one series of patients undergoing laparoscopic Nissen fundoplica- tion, delayed detection of GE injury resulted in 17% mor- tality.2 Because of the dramatic differences in outcome based on early identification of GE injuries, we have attempted to develop a technique for intraoperative detection of GE injuries. The standard technique of laparoscopic Nissen fundopli- cation does not include an effective survey for GE injuries. Many GE injuries occur during passage of the bougie dilator2,3 and are obvious at the time of injury. However, others are the result of improper dissection of the posterior GE window or from graspers placed on the stomach. Dissector and grasper injuries may easily go undetected because of their innocuous appearance adja- cent to a surgical dissection. Although some practition- ers rely on routine postoperative radiologie studies to evaluate for injury, this technique does not allow for repair during the initial operative setting. Instillation of méthylène blue into the stomach via the nasogastric tube has been used by others to detect injury.3 Infusions of méthylène blue into the stomach require large volumes to conclusively exclude injury and put the patient at risk for aspiration. As well, volume infusions will only effective- ly detect injuries in the dependent wall unless the GE vol- ume is completely filled. Routine endoscopy at the com- pletion of the procedure may not reliably identify small- er defects. We developed a gastric insufflation technique (GIT) for this purpose and have applied it in patients undergoing laparoscopic Nissen fundoplication. Gastric insufflation technique involves occlusion of the stomach with a non- crushing bowel clamp while insufflating the submerged stomach and esophagus with air. Gastric insufflation technique appears to effectively evaluate the integrity of the GE wall; however, we have detected no injuries while using the technique. This animal study was designed to confirm our clinical experience and to assess the utility of GIT. METHODS Five, female Yorkshire pigs (mean weight, 40.4 kg) were anesthetized following a 24-hour fast. After routine establishment of pneumoperitoneum (15 mm Hg), laparoscopic mobilization of the stomach and GE junc- tion was completed through five 11 mm ports. To com- plete the procedure, all short gastric vessels were rou- tinely divided using the Ultracision® harmonic scalpel (Ethicon Endo-Surgery, Cincinnati, Ohio). In four ani- mals, a variety of GE junction injuries were intentionally created using endoscopie dissectors and shears. Injuries were created by dissecting into the lumen of the esoph- agus to the point of nasogastric tube (NGT)visualization (3-5 mm distraction-type wall injuries). After creating injuries in the distal esophagus and GE junction, the pylorus was occluded using an endoscopie bowel clamp (Ethicon Endo-Surgery, Cincinnati, Ohio). The stomach and the esophagus were evaluated for injuries using the gastric insufflation technique. Gastric Insufflation Technique (GIT) Gastric insufflation technique was performed by insuf- flating the submerged stomach and esophagus with room air using a modified 18F nasogastric tube. The Salem® sump nasogastric tube (NGT) was modified by attaching a pressure "ball" with a one-way valve to the drainage port. A manometer was attached to the blue port to determine intragastric pressure during insufflation. Intragastric pressures were reported uncorrected for intra-abdominal pressure of 15 mm Hg. While inflating the stomach during pyloric occlusion, the luminal integri- ty of the stomach and esophagus were assessed by care- fully checking for air leakage. The NGT was then pulled back to the esophagus, and the proximal stomach was occluded during insufflation. The esophagus was then closely examined for air leakage. In all cases, an injury was considered detectable if rising air bubbles were noted from the submerged GE junction or stomach. Maximal luminal pressures needed to detect injuries were recorded. Laparoscopic Nissen fundoplication was completed in two of five animals, after which GIT was repeated with pyloric occlusion. In the fifth animal, the stomach and GE junction were mobilized, and the pylorus was occlud- ed laparoscopically while calibrated injuries were creat- ed on the anterior stomach wall and esophagus. Injuries were created using 23, 20, 18 and 16-gauge needles along with a #11 scalpel. To generate maximal gastric pressures, these maneuvers were repeated with the abdomen open. The animals were euthanized at the ter- mination of the procedure. All animals were cared for in accordance with National Institute of Health (NIH) pro- tocol. 268 JSLS (1999)3:267-271