If an intramural hematoma or a non-full thickness laceration in abscence of gastric content spilling, occurs, no invasive procedures or major surgery are needed; draining the stomach by positioning a large bore nasogastric tube and close observation may be enough in most cases.

Once a lesion with spilling of gastric content has been detected, adequate debridement of the transected gastric margins is necessary prior to repair, especially for injuries due to stabs and low-velocity firearm.

In most cases, repair of the stomach with two-layer inverting closure is the treatment of choice for either blunt or penetrating injury, also to prevent bleeding from the suture line. Absorbable sutures such as polyglactin, polyglycolic acid, and polydioxanone are preferable as a running suture because they are relatively acid resistant.

In high-velocity bullet injuries, an extensive injury to the stomach that is not immediately apparent to the surgeon can occur. This type of injury may require wide debridement or partial gastrectomy. If such high-velocity injury is suspected but not immediately evaluable, a repeated laparotomy should be planned to look for subsequent demarcation of viable from nonviable tissue. Postoperative decompression with a nasogastric tube is recommended

Great care should be taken when repairing injuries to the narrow proximal and distal ends of the stomach, such as the esophagogastric junction and the pylorus, to avoid postoperative narrowing. This injury, when it occurs, should be repaired primarily.

If the injury occurs in the area of the gastroesophageal junction and it is not directly suturable, it may be necessary to perform a total gastrectomy.

In case of lesions of the pylorus, in order to prevent narrow and avoid excessive pressure to the sutured line, a pyloroplasty may be considered.

At the end of the procedure, the air test is useful for assessing the integrity of the repair and searching for any untreated perforation.

Large loss of tissue with devascularization of a large part of the stomach is rare and usually requires subtotal or total gastrectomy. Billroth 1 repair after partial gastrectomy has been practiced by most surgeons as it represents a fast operation, but in situations in which there is an associated duodenal injury requiring bypass, a gastrojejunostomy (Billroth 2) is appropriate.

In case of critically ill or hemodynamically unstable patients, when damage control strategy is performed, the definitive surgery for reconstruction after gastrectomy should be delayed, and a temporary closure should be obtained by stapling both proximal and distal margin of resection.

Even if intraoperative lavage and antibiotics are no guarantee against abscess formation, thorough and adequate peritoneal lavage is recommended. To the purpose, an extensive mechanical irrigation with large amount of a diluted solution of Betadine can be performed.

A gastric drainage procedure is another alternative either when the vagal nerves are damaged or when, for the general condition of the patient, it seems to be advisable. It can be obtained by placing a gastrostomy tube for decompression of the stomach.

A jejunostomy feeding tube to allow early enteral feeds while the foregut healed is indicated for those patients (pediatric, for instance) who require early nutrition (Table 12.2).