Gastroesophageal leaks after antireflux operations.

A retrospective review of gastroesophageal leaks complicating antireflux operations was conducted to determine the incidence, predisposing factors, optimal treatment, and outcome in such patients. Twelve postoperative gastroesophageal leaks occurred in a series of 1,005 antireflux procedures (1.2%). Four of the 12 patients had undergone a previous hiatal operation, and this was a significant risk factor for postoperative leak (p < 0.001). Ten of the 12 patients had undergone "incomplete" wraps that involved suturing of the gastric fundus to the esophagus, and this was a significant risk factor for postoperative leak (p < 0.04). Five patients had peritoneal contamination and 7 had mediastinal or pleural soilage. Patients with peritoneal perforations were less likely to require intensive care unit admission than were patients with thoracic perforations (p < 0.05). Six of the 12 perforations were either well contained or well drained at the time of the diagnostic contrast study. All 6 of these patients responded to conservative treatment. The remaining 6 perforations were not contained at the time of diagnosis. Two of the affected patients initially received conservative treatment (1 death and 1 late empyema) and 4 were treated by operation (1 death). The mortality associated with gastroesophageal perforation was 17%. Contained perforations can be treated conservatively but noncontained perforations require early and aggressive surgical intervention.