Missed Gastroesophageal Injuries During Antireflux Surgery: Infrequent but Catastrophic Complications

<b>Background</b>: Laparoscopic antireflux surgery (LARS) is widely used to treat gastroesophageal reflux disease (GERD). Iatrogenic gastroesophageal injuries, when recognized intraoperatively, can be managed without major consequences, whereas undetected injuries presenting as postoperative leaks are associated with high morbidity and mortality. Despite their complexity, research on post-LARS leaks is scant. We aim to describe the diagnosis and management of such injuries at a tertiary referral center. <b>Methods</b>: We describe a single-center case series of patients referred for gastroesophageal perforations after LARS. Patients were identified through the personal records of surgeons at our institution. A narrative literature review was conducted to summarize publications on the topic. <b>Results</b>: Five patients (four female [80%]; median age, 73 years [IQR, 67-74]) were included. The median time between LARS and clinical presentation was 2 (IQR, 1-8) days (range 1-15 days). The most frequent symptoms were shortness of breath (all five patients) and pain (three [60%] patients). All patients presented with hypoxia, and four (80%) patients presented with sepsis. Two (40%) patients underwent primary repair, and three (60%) required limited esophagogastrectomy without immediate reconstruction. All patients required both thoracic and abdominal exploration, and all of them experienced significant postoperative complications (Clavien-Dindo ≥ 3). The median hospital stay was 58 days (IQR, 34-59). At a median follow-up of 14 months (IQR, 6-28), all patients were alive. <b>Conclusions</b>: Although infrequent, gastroesophageal perforation after LARS often requires complex surgical interventions and prolonged hospital stays. Additional efforts should focus on prevention and early recognition.