Incidence, mechanisms, and outcomes of esophageal and gastric perforation during laparoscopic foregut surgery: A retrospective review of 1223 cases

Linda P Zhang, MD, Ronald Chang, BA, Brent D Matthews, MD, Michael Awad, MD, Bryan Meyers, MD, J. Chris Eagon, MD, L. Michael Brunt, MD

Washington University

INTRODUCTION: Intraoperative perforation is a potentially major complication of laparoscopic (lap) foregut surgery. We 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 lap antireflux surgery (LARS), paraesophageal hernia (PEH) repair, Heller myotomy, and reoperative hiatal hernia (redo HH) repair at our institution from August 2004 to September 2012 were reviewed retrospectively. Perforation events and postoperative outcomes were analyzed and complications were graded by modified Clavien system. All data are mean SD (or median) as specified. Statistical analysis was by Fisher exact and Mann Whitney U tests.

RESULTS: A total of 1223 patients were analyzed (381 LARS, 379 PEH repair, 313 Heller myotomy, 150 redo HH). Overall, 51 patients (4.2%) had 55 perforations. The perforation incidence was 1.0% for LARS (N=4), 1.8% for PEH repair (N=7), 5.8% for Heller myotomy (N=18, 5 of which were redo myotomies), and 14.7% for redo HH. Redo HH were significantly more likely to have perforations than primary LARS and PEH repairs (p<0.001). Location of perforations were esophageal in 13 (24%), gastric in 39 (71%), and indeterminate in 3 (5%). Mechanism of perforations for primary LARS were during suture placement (N=3) and bougie insertion (N=1), and in lap PEH repair, traction (N=3), suture placement (N=1), thermal (N=1), and bougie (N=2). Most lap Heller myotomy perforations (N=14, 77%) occurred during the myotomy. Redo HH perforations (N=23) were due to dissection/wrap takedown in 83% (N=19) and traction injury in 17% (N=4). None of the perforations in any group were related to the retroesophageal dissection. Perforations were recognized and repaired intraoperatively in 43 cases (84%), and postoperatively in 8 patients (16%). Compared to patients with perforations repaired intraoperatively, those discovered postoperatively were more likely to require reoperation (75% vs 2%, p<0.001), had more GI and radiologic interventions (50% vs 2%, p=0.004), and longer total length of stay (median 11.5 vs 4 days, p=0.01). Perforations discovered postoperatively also had higher 30-day perioperative morbidity (88% vs. 30%, p=0.004), and with higher Clavien grade (≥Grade III: 75% vs 9%, p=NS) One patient in the LARS group whose perforation was recognized intraoperatively died at postoperative day 2 from a pulmonary embolism (2% mortality in perforated patients).

CONCLUSIONS: In a high volume center, intraoperative perforations are uncommon during first time LARS or PEH repair, and are highest with reoperative HH repair. If recognized and repaired intraoperatively, most perforations require minimal postoperative intervention. Unrecognized perforations usually require reoperation, and result in more GI and radiologic interventions, extended hospital stays, and significantly greater morbidity.

Session: Podium Presentation

Program Number: S067

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