LAUSR

A 67-year-old man sustained an out-of-hospital cardiac arrest. Cardiopulmonary resuscitation (CPR) was commenced by bystanders and six shocks were delivered by an automatic external defibrillator before return of spontaneous circulation. The patient was transferred to hospital for further management. On arrival, the patient had a respiratory rate of 30 and oxygen saturation of 88% on room air. A computed tomography (CT) pulmonary angiogram was performed, looking for causes of arrest, which demonstrated a right-sided pneumothorax with associated rib fractures but no pulmonary emboli. Incidentally, pneumoperitoneum was also identified. On questioning, the patient denied having abdominal pain prior to, or after, his cardiac arrest. He did not have a history of peptic ulcer disease and had not recently taken any non-steroidal antiinflammatory drugs. His co-morbidities included ischaemic heart disease with previous coronary artery bypass grafting and hypertension. On examination, his abdomen was distended but non-tender. Abdominal and pelvic CT scan demonstrated a defect in the medial wall of the upper stomach with contrast extravasation (Fig. 1). A nasogastric tube was inserted and the patient was commenced on intravenous antibiotics and a pantoprazole infusion. The patient underwent a laparoscopic repair of gastric perforation. Optical entry was performed with a 12-mm port at Palmer’s point. Three 5-mm ports were inserted under direct vision. A Nathanson’s retractor was used to retract the liver. Findings included a 1-cm perforation at the upper lesser curve of the anterior stomach, which was identified with methylene blue dye (Fig. 2). There was very little contamination. The defect was repaired with 3-0 polydioxanone suture and patched with fat from the lesser omentum (Fig. 3). A 19-Fr Blake drain was placed near the lesser curve. The patient’s post-operative course was uneventful. Oral intake was upgraded until the patient was tolerating diet. The drain tube was removed on the sixth post-operative day. The patient was given prophylactic Helicobacter pylori eradication treatment and was discharged from the care of the surgical team on the eighth postoperative day, with a plan for outpatient follow-up. Other medical issues included (i) insertion of an automatic implantable cardioverter defibrillator; (ii) analgesia for the management of multiple rib fractures; and (iii) resolution of the right-sided pneumothorax with insertion of an intercostal catheter. The most common cause of gastric perforation is peptic ulcer disease. Risk factors for peptic ulcer disease include smoking, use of