The Accuracy of Gastric Insufflation in Testing for Gastroesophageal Perforations during Laparoscopic Nissen Fundoplication

BACKGROUND Laparoscopic Nissen fundoplication is an effective technique for the symptomatic relief of the manifestations of gastroesophageal reflux disorder but is associated with a 0.8-1% rate of gastroesophageal perforation. Early detection and repair of these injuries is critical to patient outcome, but occult injuries occur and may be missed. Gastric insufflation technique evaluates the integrity of the gastroesophageal wall after laparoscopic Nissen fundoplication. Gastric insufflation technique involves occlusion of the proximal stomach with a noncrushing bowel clamp while insufflating the submerged gastroesophageal junction. We conducted an animal study to assess the utility of gastric insufflation technique. METHODS Five pigs (mean weight, 40.4 kg) underwent testing of laparoscopic gastric insufflation technique. In four animals, laparoscopic Nissen fundoplication was performed and then gastroesophageal junction injuries were created (3-5 mm distraction-type wall injuries). Non-crushing bowel clamps provided occlusion of the pylorus and then the proximal stomach during gastroesophageal insufflation. The gastroesophageal junction was then submerged. In the fifth animal, gastric insufflation technique was repeated while calibrated injuries were created to determine the smallest detectable injury. An injury was considered detectable if rising air bubbles were noted from the submerged gastroesophageal structures. Maximal luminal pressures needed to detect injuries were recorded with an in-line manometer. RESULTS In all animals, 5-7 mm injuries of the gastroesophageal junction were easily detected using gastric insufflation technique when the proximal stomach was occluded. When the pylorus alone was occluded, detection of gastroesophageal injuries was inconsistent. Small injuries (<3 mm) of the esophagus were difficult to visualize with pyloric occlusion alone but were consistently detectable with proximal stomach occlusion at pressures less than 20 mm Hg. When the pylorus alone was occluded, the smallest detectable stomach perforation was a 16-gauge needle puncture while applying maximal gastric pressure (40-60 mm Hg) and a 2.5 mm linear injury when generating lower pressures (20 mm Hg). CONCLUSION Proximal stomach occlusion and insufflation appears to effectively detect esophageal injuries of likely clinical importance (>2.5 mm). Pyloric occlusion and insufflation reliably evaluates the anterior stomach for injury. Gastric insufflation technique is a useful method for detecting gastroesophageal injury after laparoscopic Nissen fundoplication.