Repair Of Gastric Perforation Research Articles

Comparison of the curative effect of laparoscopy and laparotomy in surgical repair of gastric perforation

Objective To compare the the curative effect of laparoscopy and open operation in surgical repair of gastric perforation. Methods The clinical data of 68 patients with gastric perforation were analyzed.According to different operation method, the patients were diviede into laparoscopic group and laparotomy group, 34 cases in each group.The patients in the two groups were given laparoscopy or laparotomy, respectively. Results The operation time between the two groups had no statistically significant difference (P>0.05). The intraoperative blood loss, postoperative exhaust time, length of hospital stay in the laparoscopic group were (24.9±7.3)mL, (31.9±10.5)h, (7.4±2.9)d, respectively, which were significantly less than those in the laparotomy group, the differences were statistically significant (t=9.953, 5.226, 7.441, all P<0.05). The incidence rate of postoperative complications of the laparotomy group was 32.35%, which was significantly higher than 8.82% of the laparoscopic group, the difference was statistically significant(χ2=5.757, P=0.016). Conclusion The curative effect of laparoscopic downward gastric perforation repair is superior to laparotomy, patients have rapid recovery, less complications, it is worthy of clinical popularization and application. Key words: Laparoscopy; Peptic ulcer perforation; Stomach

Role of health education in improving the prognosis of patients with laparoscopic gastric perforation repair

目的 探讨健康教育在改善腹腔镜下胃穿孔修补术患者预后中的作用。 方法 选择行腹腔镜下胃穿孔修补术患者96例，按随机数字表法分为两组，对照组48例患者，行常规护理干预，观察组48例患者，在常规护理基础上实施健康教育，采用问卷调查的形式，了解患者对疾病知识掌握情况，并比较两组治疗依从性及术后相关并发症发生情况。 结果 观察组对疾病相关知识知晓率95.83%，明显高于对照组的72.92%，差异有统计学意义(χ2＝19.906，P<0.05)，观察组治疗依从率93.75%，显著高于对照组的79.17%，差异有统计学意义(χ2＝9.079，P<0.05)，观察组术后并发症发生率4.17%，显著低于对照组的16.67%，差异有统计学意义(χ2＝8.370，P<0.05)。 结论 在腹腔镜下胃穿孔修补术中开展健康教育，能提高患者知识掌握度，同时能降低术后相关并发症发生。

The first clinical use of domestically produced Chinese minimally invasive surgical robot system "Micro Hand S".

Robot-assisted minimally invasive surgery (MIS) has shown tremendous advances over the traditional technique. However, current commercialized systems are complicated and huge, which vastly raises system cost and requirements for operation room. Central South University in collaboration with Tianjin University developed one domestically produced Chinese minimally invasive surgical (MIS) robot system "Micro Hand S" in 2013. Recently, our center launched the first clinical trials of the robot, including one case of robotic gastric perforation repair and two cases of robotic appendectomy. In march 2014, one patient with gastric perforation and two patients with acute appendicitis who underwent robotic perforation repair and robotic appendectomy respectively. In these procedures, we firstly use "Micro Hand S" robot system. All of the patients were followed for 3 months, Total robotic operation time, Intra-operative blood loss and pre- and postoperative changes in routine blood test, liver function test, renal function test and major complications were recorded. "Micro Hand S" succeeded in accomplishing operations. No intraoperative complications or technical problems were encountered. At a three-month follow-up, patients were found to be progressing well, without evidence of adverse reactions. The domestic surgical robot system which was verified as safe and effective through these trials. The proposed design method is an effective way to solve some of drawbacks that exist in the former generations of the da Vinci surgical system.

Application of operating room workflow schedule in repair of idiopathic gastric perforation

Objective To develop the operating room workflow schedule (ORWS)on idiopathic gastric perforation repair (IGPR) and observe application effect of ORWS. Methods A total of 56 patients with IGPR were averagely divided into experimental group and control group by random number table from March 2013 to March 2014. The circuit nurses did operation cooperation with ORWS in the experimental group while nurses of control group did cooperation by themselves. We compared the length of operative time, amount of bleed during operation, each nursing indicator, and doctors and patients′ satisfaction for circuit nurses. Results The pass rate of operative items preparation, nurse reign rate and nurse′s work accuracy rate were 97.8%, 100.0%, 92.2%, which were higher than these of the control group (χ2=5.714, 6.207, 4.808; P<0.05). The satisfaction of patients to nurses was 95.6% in the experimental group, which was higher than that of the control group, but surgeons and anaesthetists′ satisfaction to circuit nurses had no statistical significance (χ2=5.262, P<0.05). Conclusions Application of ORWS in patients with IGPR can effectively shorten the operation time, improve the quality of care and satisfaction of patients and the surgeon for the nursing job. Key words: Operating room; Nursing workflow schedule; Idiopathic gastric perforation repair

A novel method for endoscopic perforation management by using abdominal exploration and full-thickness sutured closure

Perforation of the GI tract during endoscopy can result in significant morbidity and mortality. Early recognition and immediate management of endoscopic perforation are essential to optimize outcome. Larger perforations, defects with complex geometry, and those complicated by leakage of luminal contents have traditionally required surgical management. To assess the feasibility of a new method for managing complex perforations that incorporates abdominal exploration and endoscopic sutured closure. Case series. Tertiary care center. Two patients with large, complicated perforations and peritoneal contamination. Endoscopic exploration of abdomen with angiocatheter placement under direct visualization, management of leaked luminal contents, and full-thickness sutured defect closure. Endoscopic abdominal exploration through the perforation site allowed safe placement of an angiocatheter for management of pneumoperitoneum, inspection for injury that may warrant surgical management, and removal of leaked luminal contents. Endoscopic sutured closure allowed safe and robust perforation management. Repair of gastrojejunal anastomotic perforation required 2 sutures and 63 minutes. Repair of gastric perforation required 4 sutures and 48 minutes. Patients had successful endoscopic defect closure confirmed by an upper GI series and were discharged 1 day later. Report of a new method in 2 patients performed at tertiary care center. We demonstrate successful management of complex perforations with peritoneal contamination by incorporating endoscopic exploration and sutured closure with standard treatment measures. Traditional practice would have directed these patients to surgical management, which introduces additional morbidity and cost. A means for safe and broad implementation of these techniques should be evaluated.

Carcinoma gallbladder in a patient with choledochal cyst, cysto-hepatolithiasis, and simple liver cyst

Hepatobiliary malignancies are seen in 10 % to 30 % of cases with choledochal cyst (CDC), specifically in types I and IV [1]. This image illustrates the case of an 87-year-old female with cholangitis who had a thick-walled acalculous gallbladder, hepatolithiasis, choledocholithiasis, and a large simple liver cyst (Fig. 1). She had gastric perforation during endoscopic retrograde cholangiopancreatography. She underwent emergency surgery with deroofing of the cyst, gastric perforation repair, simple cholecystectomy, and choledocholithotomywith primary closure over a plastic biliary stent. The common bile duct was grossly dilated and packed with stones (Fig. 2) along with bilateral hepatolithiasis suggesting a type IV CDC. Histopathology

Adjustable loop-based purse-string technique in NOTES gastrotomy closure

Objective To assess the feasibility and safety of adjustable loop-based purse-string technique in gastrotomy closure of natural orifice translumenal endoscopic surgery （NOTES）.Methods Ten healthy female dogs were used in this study.Transgastric NOTES peritoneal exploration was performed in 5 groups （2 dogs in each） via various sites of the stomach （ greater curvature of the antrum; greater and lesser curvature of the body; anterior and posterior wall of the body）.The gastric incision was then closed by using loop-based purse-string technique.Healing of the incision and intra-peritoneal infection were checked by endoscopy,necropsy,bacterial culture and histological examination 2 weeks later.Results The performance of NOTES peritoneal exploration and closure with purse-string technique was successful in ten dogs without significant complications.The mean operation time of closure was 7.3 ± 1.8 min.Minor bleeding occurred in 2 dogs （20%） during the incision of greater curvature of the antrum and body,which was controlled by electrocoagulation.Culture of the ascitic fluid and necropsy revealed no sign of abdominal infection or other complications except for adhesion in 1 dog （ 10% ）.The intact incision was confirmed by endoscopic,postmortem and histological examination,which suggested complete healing of the incision.Conclusion It is easy and safe to use loop-based purse-string technique for closure of multi-regional NOTES gastrotomy.This technology may be used for the repair of gastric ulcer perforation theoretically. Key words: Models,animal; Stomach; Incision; Nylons; Suture techniques

To compare the effection of the treatment of gastric perforation repair between traditional way and using the laparoscopic way

Objective Comparing gastric perforation repair with traditional contrast,to explore the feasibility and superiority of the laparoscopic gastric perforation repair.Methods 68 cases were randomly divided into two groups for laparoscopic gastric perforation repair and traditional repair,then compared two groups of treatment.Results Both operations were successful ( including laparoscopic repair in 34 cases) and surgery time,blood loss,postoperative drainage,length of stay,and cosmetic results of the comparison.Conclusion Compared with the traditional open surgery,the laparoscopic surgery had less trauma,leas pain,faster recovery,shorter hospital stay,high efficacy and good cosmetic results and other advantages. Key words: Duodenal diseases; Reconstructive surgical procedures; Laparoscopes

A Rare Cause of Gastric Perforation-Candida Infection: A Case Report and Review of the Literature

Fungal microorganisms as a cause of gastric perforation, is very rare. Most of the cases of gastric perforation are seen as the complications of peptic ulcer disease, the intake of NSAIDs (Non Steroidal Anti-Inflammatory Drugs), neoplastic diseases, etc. We are reporting a case of a 50 year old male who presented with a sudden onset of abdominal pain and shock and was diagnosed as acute peritonitis which was caused by a gastrointestinal perforation. An emergency exploratory laporotomy was performed and a gastric perforation repair with omentoplexy was done. However, the patient died in the post operative period due to a sudden cardiac arrest. A gastric perforation edge biopsy revealed the presence of fungal hyphae. The peritoneal fluid culture revealed Candida albicans colonies.

Gastric perforation after corrosive ingestion

To describe a series of children with gastric perforation (GP) after corrosive ingestion. Case notes of children treated for GP complicating corrosive ingestion between May 2001 and April 2010 were retrospectively reviewed. Seventy-six children with corrosive ingestion were treated during the study period of which 5 (6.6%) developed GP. This complication was evident on admission in one case and developed within 48 h in the others. The major clinical findings were abdominal pain, tenderness, and distension with radiologic evidence of pneumoperitoneum. Associated pathology included necrosis of the abdominal esophagus in one case and duodenal perforation in another. Two cases have died during surgery while three survived with free of complications related to GP repair. Two patients developed gastric outlet obstruction (one with an esophageal stricture) on follow-up. GP is a rare but major complication of corrosive ingestion. Children who swallow corrosives should be closely monitored and pediatric surgeons should be aware of this potential early complication. The possibility of associated pathology should be considered when undertaking surgical repair.

Notes Omental Patch Repair of Gastric Perforation Is Comparable to Laparoscopic Repair in a Porcine Model

Background: Perforation accounts for over 70% of deaths associated with peptic ulcer disease. Post-interventional complications contribute to short-term patient outcome. Reduction of procedural impact may decrease morbidity and mortality. A natural orifice translumenal approach may decrease surgical physiologic impact. Hypothesis: NOTES omental patch repair of full thickness gastrotomy is feasible with decreased physiologic impact compared to laparoscopy. Design: Randomized, dual arm, porcine 2-week survival trial. Setting: IACUC approved study with 28 swine. Methods: Twenty-eight swine were randomized to laparoscopic (n=14) or NOTES repair (n=14) of a 1 cm anterior wall gastrotomy. Gastrotomy was created laparoscopically followed by four hours wait (soilage) time. After peritoneal cavity irrigation, repair proceeded with laparoscopic omental patch (Lap) or NOTES approach. For NOTES repair, an endoscope was advanced into the stomach and through the perforation. Omentum was grasped with endoscopic biopsy forceps, pulled into the gastric lumen, and fixed with metallic clips. Procedure and clinical parameters including necropsy were recorded. Serum samples were collected for WBC count and TNF-α analysis using dual-sandwich ELISA. T -test, Wilcoxon Rank sum test, and Levene's test were used for statistical analysis Results: NOTES repair failed in one animal (unable to exit perforation); this was repaired laparoscopically, data were analyzed as intention to treat. Twenty-four of 28 animals thrived to study completion. Two NOTES, 1 Lap swine succumbed to airway compromise in recovery; 1 NOTES animal failed to thrive on POD 7. No intra-abdominal cause for these deaths was found. At necropsy, all repairs were intact. Mean NOTES repair time was comparable to laparoscopy (NOTES: 28 min vs. Lap: 33 min, p=0.5). WBC counts from both groups were comparable on POD 1 (NOTES: 18.1 vs. Lap: 17.5, p=0.44). Mean TNF-α serum levels in the NOTES group on POD1 were not significantly different from laparoscopy (NOTES: 25.3 pg/nL vs. Lap: 51.5 pg/nL, p=0.12); a significant difference in TNF-α variation from baseline at procedure conclusion (p<0.01) and POD 1(p=0.044) was noted between NOTES and Lap animals. Conclusion: Endoscopic perforated hollow viscus repair was technically feasible in this experimental model and may be slightly less invasive. Early results appear encouraging and warrant further evaluation.

Seven Cases of Gastric Perforation in Roux-en-Y Gastric Bypass Patients: What Lessons Can We Learn?

Patients undergoing Roux-en-Y gastric bypass for the resolution of morbid obesity have significant medical sequelae related to their weight. One of the most common comorbid conditions is joint pain requiring the use of non-steroidal anti-inflammatory medications (NSAIDs). In addition to NSAIDs, patients may engage in behaviors such as smoking and alcohol misuse that increase the risk of long-term postoperative complications to include gastric perforation. Data on 1,690 patients undergoing gastric bypass surgery were collected prospectively and reviewed retrospectively. We identified seven patients who presented to an emergency room and subsequently required emergent surgical intervention for repair of gastric perforation. Six of the seven cases involved use or abuse of NSAIDs. Important characteristics were identified including the use of NSAIDs, alcohol use, and non-compliance with routine long-term postoperative follow-up. Identifying those patients at high risk may decrease the incidence of this potentially life-threatening complication.

Surgical management of diaphragmatic injuries

Traumatic diaphragmatic lesions have variable presentations and need a high index of suspicion to be diagnosed in the acute phase. Delayed diagnosis is frequently associated with considerable comorbidity. The present retrospective study aims to evaluate the radiological findings and discuss the surgical approach for the repair of the injured diaphragm. This study includes fifteen cases with diaphragmatic injuries, which were surgically managed between 1994 and 2005. Injuries resulted from violent blunt trauma in twelve patients and three patients had penetrating injuries. Patients presented with hypotension, respiratory insufficiency, acute abdomen and hemothorax. Preoperative diagnosis was established in 12/15 (80%) patients depending on the clinical and the chest skiagram findings. Intra-operative diagnosis was made in the rest. Injuries were more common on the left side (11/15, 73.33%). All these patients underwent repair of the defect by direct closure in double layer using monofilament polypropylene suture. In addition, laparotomy was performed in four patients who had liver and spleen injury. Concomitant procedures included lobectomy, segmentectomy, repair of lung laceration, spleenectomy, spleenorraphy, repair of gastric perforation, intestinal perforation and mesenteric tear. One patient died (1/15, 6.66%) of associated injuries. Two patients with major liver injuries had prolonged drainage and repeated subdiaphragmatic collections. Associated lesions particularly influence the outcome after traumatic lesions of the diaphragm. Surgical exploration is mandatory whenever diaphragmatic injuries are suspected. Right-sided injuries are best exposed and managed through the right thoracotomy. Direct suture is effective in preventing future specific complications.

Gastrotomy closure using bioabsorbable plugs in a canine model

The repair of gastric perforation commonly involves simple suture closure using an open or laparoscopic approach. An endolumenal approach using prosthetic materials may be beneficial. The role of bioprosthetics in this instance has not been thoroughly investigated, thus the authors evaluated the feasibility of gastric perforation repair using a bioabsorbable device and quantified gross and histological changes at the injury site. Twelve canines were anesthetized and underwent open gastrotomy. A 1-cm-diameter perforation was created in the anterior wall of the stomach and plugged with a bioabsorbable device. Intralumenal pH was recorded. Canines were sacrificed at one, four, six, eight, and 12 weeks. The stomach was explanted followed by gross and histological examination. The injury site was examined. The relative ability of the device to seal the perforation was recorded, as were postoperative changes. Tissue samples were analyzed for gross and microscopic tissue growth and compared to normal gastric tissue in the same animal as an internal control. A scoring system of -2 to +2 was used to measure injury site healing (-2= leak, -1= no leak and minimal ingrowth, 0= physiologic healing, +1= mild hypertrophic tissue, +2= severe hypertrophic tissue). In all canines, the bioprosthesis successfully sealed the perforation without leak under ex vivo insufflation. At one week, the device maintained its integrity but there was no tissue ingrowth. Histological healing score was -1. At 4-12 weeks, gross examination revealed a healed injury site in all animals. The lumenal portion of the plug was completely absorbed. The gross and histological healing score ranged from -1 to +1. The application of a bioabsorbable device results in durable closure of gastric perforation with physiologic healing of the injury site. This method of gastrotomy closure may aid in the evolution of advanced endoscopic approaches to perforation closure of hollow viscera.

Coeliac Axis Thrombosis After Surgical Correction of Spinal Deformity in Type VI Ehlers-Danlos Syndrome

An unusual case of postoperative thrombosis of celiac artery in a patient of Type VI Ehlers-Danlos syndrome (EDS) with severe kyphotic deformity is reported. To describe an unusual complication of celiac artery thrombosis following surgical correction of kyphotic deformity in Type VI EDS. Neurologic deficit following surgical correction for kyphoscoliotic deformities in patients with Type VI has been reported in 4 cases previously. There has been no previous report of combined celiac artery thrombosis leading to infarction of major abdominal organs along with quadriparesis below C7-C8. Case report and literature review. Subsequent to a 2-stage surgical correction with posterior instrumentation and fusion of spine, this patient with Type VI EDS developed celiac artery thrombosis leading to infarction of major abdominal organs. At laparotomy, he required hemihepatectomy, splenectomy, cholecystectomy, and a repair of gastric perforation. Following his abdominal catastrophe, he developed quadriparesis possibly due to anterior spinal artery ischemia. Spine surgeons treating Type VI EDS with progressive kyphoscoliosis should be aware of such an unusual complication of celiac artery occlusion in late postoperative period. Preoperative antithrombotic medication should be monitored carefully to avoid such catastrophic complication. The prognosis remains poor following anterior spinal artery ischemia due to infarction or thrombosis.

Laparoscopic repair of neonatal gastric perforation

Background Gastric perforation is a rare, life-threatening condition in neonates. To avoid deterioration, prompt surgical treatment is mandatory. Patients We report on 2 neonates (1 and 8 days old) with feeding tube associated gastric perforation managed laparoscopically by single layer suture repair. Both children suffered from severe peritonitis. Operative time was 60 minutes in both cases. Oral feeding was started on postoperative day 3 and 7, respectively. No complications regarding the gastric perforation were encountered on follow-up (11 and 8 months, respectively) in both cases. Conclusions We recommend laparoscopic suture repair as a safe and feasible method for surgical treatment of gastric perforation in neonates. These appear to be the first reported cases using this procedure for treatment of neonatal gastric perforation.

3471 Guideline for gastric perforation endoscopic repair using metallic clips.

Introduction- Perforation of the digestive tract wall is one of the most feared complications in endoscopic resections of epithelial or subepithelial lesions. Aims - Evaluation of an experimental endoscopic closure of gastric perforations on pigs and establishment of guidelines for endoscopic closing sutures. Method-Ten pigs of races Landrace and Large-White were submitted to general anesthesia and upper GI endoscopy. Initially a standardized gastric wall perforation was performed. The opening was made by aspiration of the gastric wall with an end adapter used for rubber band ligation. The resection of the adapter content was performed with a polypectomy snare introduced through a plastic tube attached to the endoscope. As a next step, a metallic endoscopic clip (Hemoclip® - Olympus America Inc., Miami FL ) was placed on the edge of the opening, grasping firmly the muscular layer. After having trapped the clip, the polypectomy snare was pulled through the mouth so as to bring the wound to a spindleshaped form. The closure was achieved by clips placed one by one. Where the muscular layer could not be seen, the closure was made with the mucosa, aiming to catch the wall as deeply as possible. The pneumoperitoneum was emptied with a Verres needle. The animals were sacrificed after 15 days and had their stomach removed for macro and microscopical study. At the same time, the abdominal cavity was evaluated. Results - The suture was performed in all animals, but in only seven (7) of them was the muscular layer clearly attached to both sides of the wound. Nine (9) pigs showed the opening edges firmly coapted and five (5) had an ulcer at the site of the wound. Three pigs appeared to be ill in the postoperative course and showed localized or generalized peritonitis. One (1) died on the 13th day. Conclusions - The endoscopic repair of gastric perforation using clips seems to be feasible and easy. It seems useful to establish some guidelines. After aspiration of gastric contents, the first step would be to work the wound into the shape of a mouth. This strategy will make it easy to clip the edges. It is very important to make the suture grasp the muscular layer. More studies are needed before this technique is used routinely in patients.

2216 Endoscopic gastric perforation repair with omental patch, using endoscopic clips.

INTRODUCTION - Perforation of the digestive tract wall is a complication of some therapeutic procedures. In such an event, the endoscopic repair is less invasive and its performance has been reported in several cases. On the other hand, the idea of using an omental patch for such repairs has been applied for a long time to the surgical treatment of gastroduodenal ulcer perforation. This study shows the results of combining both techniques and allows to establish a guideline for this kind of repair. METHOD -Ten threecross Large White, Landrace and Pietan pigs were submitted to a standardized gastric perforation procedure by aspiration and cutting, for which a polypectomy snare and an end adapter for endoscopic esophageal varices ligation were used. The omentum (OM) was pulled to the gastric cavity in most cases by aspiration with the endoscope) and then caught with the metallic snare and fixed to the muscular layer of the stomach by endoscopic metallic clips. By changing the position of the snare it was possible to place the clips in any convenient position. This procedure was carried out under general anesthesia. The animals received food on the first day after the operation. They were sacrificed on the 15th postoperative day. RESULTS - Nine animals had a normal postoperative course. In all of them, an ulcer could be seen at the repaired site. On the external side of the wall, the OM was adherent. No other alterations were observed in the peritoneal cavity. The gastric wall histology showed a moderate inflammatory process in these pigs. In one animal whose muscular layer could not be seen during the procedure, the clips attached the OM to the mucosa. This animal died on the 11th postoperative day. Examination of the peritoneal cavity at sacrifice revealed intense peritonitis. The perforation was not repaired in this animal. CONCLUSION - This seems to be a simple and easy technique for EGPR, as safe as the conventional surgery.With the use of antibiotics, the risk of infection could be considered acceptable, especially in view of the advantages offered by a less invasive procedure. It seems to be important to attach the omentum to the muscular layer. The EGPR with a patch of OM seems to be an interesting option to be confirmed by further studies.

A Physiologic Approach to Laparoscopic Fundoplication for Gastroesophageal Reflux Disease

The authors examined indications, evaluations, and outcomes after laparoscopic fundoplication in patients with gastroesophageal reflux through this single-institution study. Laparoscopic fundoplication has been performed for less than 5 years, yet the early and intermediate results suggest that this operation is safe and equivalent in efficacy to open techniques of antireflux surgery. Over a 4-year period, 300 patients underwent laparoscopic Nissen fundoplication (252) or laparoscopic Toupet fundoplication (48) for gastroesophageal reflux refractory to medical therapy or requiring daily therapy with omeprazole or high-dose H2 antagonists. Preoperative evaluation included symptom assessment, esophagogastroduodenoscopy, 24-hour pH evaluation, and esophageal motility study. Physiologic follow-up included 24-hour pH study and esophageal motility study performed 6 weeks and 1 to 3 years after operation. The most frequent indication for surgery was the presence of residual typical and atypical gastroesophageal reflux symptoms (64%) despite standard doses of proton pump inhibitors. At preoperative evaluation, 51% of patients had erosive esophagitis, stricture, or Barrett's metaplasia. Ninety-eight percent of patients had an abnormal 24-hour pH study. Seventeen percent had impaired esophageal motility and 2% had aperistalsis. There were four conversions to open fundoplication (adhesions, three; large liver, one). Intraoperative technical difficulties occurred in 19(6%) patients and were dealt with intraoperatively in all but 1 patient (bleeding from enlarged left liver lobe). Minor complications occurred in 6% and major complications in 2%. There was no mortality. Median follow-up was 17 months. One year after operation, heartburn was absent in 93%. Four percent took occasional H2 antagonists, and 3% were back on daily therapy. Atypical reflux symptoms (e.g., asthma, hoarseness, chest pain, or cough) were eliminated or improved in 87% and no better in 13%. Overall patient satisfaction was 97%. Four patients have subsequently undergone laparotomy for repair of gastric perforation (1 year after operation), severe dumping, "slipped" Nissen, and repair of acute paraesophageal herniation. Two patients had laparoscopic revision of herniated fundoplications. Results of follow-up 24-hour pH studies were normal in 91% of patients more than 1 year after operation. In patients with poor esophageal motility, esophageal body pressure improved 1 year after operation in 75% and worsened in 10%. Although long-term efficacy data are lacking, intermediate follow-up shows laparoscopic fundoplication to be safe and effective. A physiologic approach to evaluation and follow-up of patients with gastroesophageal disease allows the surgeon to tailor antireflux surgery to esophageal body function and follow the function of the fundoplication and esophagus after operation.

Laparoscopic repair of full-thickness stomach injury

A case of laparoscopic repair of gastric perforation caused by a trocar is reported. Suturing was carried out by the apposition of clips. The potential advantages of this approach are that the treatment is performed at the time of the complication, the duration of the operation is reduced, and the discharge of the patient from hospital is accelerated.