Perforation of Barrett's ulcer: a challenge in esophageal surgery

Esophageal Ulcer as a Cause of Death: A Population-Based Study. Mortality of Esophageal Ulcer Disease

BACKGROUND

This study aimed at defining the mortality and the nature of fatal complications that arise out of esophageal ulcer for one clearly defined geographical area.

METHODS

In this national, population-based study, the occurrence of fatal esophageal ulcer or ulcer requiring hospital treatment between January 1987 and December 2000 was assessed by the use of Finland's administrative databases. Medical records provided etiology of fatal ulcer and agonal symptoms.

RESULTS

Due to an esophageal ulcer, 2,242 patients received treatment in Finnish hospitals, at an annual frequency of 3.2/100,000. Ulcer with hemorrhage (53.5%), perforation (38.4%), or aspiration pneumonia (2.3%) was the cause of death in 86 patients for an annual mortality of 0.12/100,000. Based on the number of ulcers treated, 3.8% cases ended fatally. Gastroesophageal reflux disease (GERD) seemed to be the etiologic factor for ulcer in 68 (79.0%) patients. The most common agonal symptoms were hematemesis (41.8%), abdominal pain (25.6%), melaena (22.1%), and dyspnea (17.4%). Twenty (23.3%) patients were found dead at home.

CONCLUSION

The rarity of the disease, related disorders, and the diversity of symptoms make the complicated esophageal ulcer a diagnostic challenge. Effective monitored treatment for severe GERD may be an important step to prevent fatal outcome.

Thoracoscopic esophageal repair of a spontaneous Barrett's ulcer perforation

Spontaneous esophageal perforation of a Barrett's ulcer is a rare condition that is associated with high morbidity and mortality. It occurs as a result of a missed diagnosis of underlying Barrett's esophagus or because of unresponsiveness to medical management. Owing to the life-threatening nature of this disease, emergency surgical intervention is indicated. Here, we report the first case of spontaneous Barrett's esophageal perforation that has been managed using a thoracoscopic approach. This case highlights the feasibility of minimally invasive methodology for emergent esophageal disorders. It also demonstrates the altered esophageal wall properties of Barrett's esophagus through musculofibrous thickening and muscularis mucosae duplication that may contribute to the technical outcomes of esophageal surgical management.

Right hemothorax: An unusual presentation of a Barrett's ulcer perforation

INTRODUCTION

Despite improvements in detection and surgical techniques perforation of the esophagus are lifethreatening. In this case report a rare presentation esophageal perforation due to Barrett's ulceration into an aortic vessel is described.

PRESENTATION OF CASE

We report a 42 year old man with known Barrett's esophagus presenting with abdominal pain. Further investigations showed an active intrathoracal hemorrhage due to esophageal perforation at exactly the same site of the known Barret's ulcer one year before. Thoracotomy with evacuation of blood was performed and an aortic branch as bleeding focus was found.

DISCUSSION

Hemothorax due to esophageal perforation of a benign Barrett's ulcer is rare. The diagnosis of aortoesophageal fistula's can be complicated and its presentation is frequently unspecific and is simply confused with other disorders. Acute thoracotomy is necessary and choice of closure depends on the cause and size of the perforation.

CONCLUSION

This case illustrates the need for maintaining a wide-ranging view of potential casus of hemothorax. The key to survival in patients with aorto-esophageal fistula is maintaining awareness of the condition to allow early diagnosis and operative management of this treatable lesion.

How to treat esophageal perforations when determinants and predictors of mortality are considered

BACKGROUND

Published lethality rates of esophageal perforation (EP) vary depending on patient- and disease-related factors. This study was designed to evaluate how these factors impact death. Furthermore, we calculated the predictive accuracy of the Mortality Prediction Model (MPM II) and the Simplified Acute Physiology Score (SAPS II) for in-hospital death. Conclusions about treatment decisions were drawn based on our data and analysis of recent literature.

METHODS

Every patient who was treated for EP at our department from December 2001 to July 2008 is included in this study. Logistic regression analyses of various risk factors, such as etiology, time interval, size, comorbidities, localization, type of treatment, and preexisting pathologies of the esophagus on death, were performed.

RESULTS

Of the 41 patients diagnosed with EP, nine died (21%). The most important risk factor concerning death was cirrhosis of the liver (0 vs. 89% mortality; odds ratio, 208; P<0.001). Accuracy for lethality risk prediction was calculated with MPM II and SAPS II on admission, and afterward the characteristic increase that occurred was evaluated by using receiver operator characteristic curves. Optimal results were achieved by using a characteristic SAPS II increase (AUC 0.86; P: 0.009) after the patient was admitted to the intensive care unit.

CONCLUSIONS

Our study was the first to demonstrate that a rapid or continuous increase more than 40 of the daily SAPS II clearly indicates that a high risk of death is imminent. This should be used as a reevaluation factor when choosing a treatment strategy.

Esophageal perforation: principles of diagnosis and surgical management

PURPOSE

Esophageal perforation (EP) is still associated with a high mortality rate, even after surgical repair. We reviewed 17 cases of EP to evaluate the management of this major surgical problem.

METHODS

We reviewed the medical records of all patients treated for EP in our department between November 2001 and November 2004. Therapy was based on various patient-related factors.

RESULTS

Seventeen patients, with a mean age of 63 years, presented with EP mostly caused by iatrogenic incidents (11/17). In nine patients, the perforation was located in the thoracic segment, with a mean size of 2.5 +/- 0.6 cm. Thoracic computed tomography (CT) was performed in all patients to assess the periesophageal inflammation precisely. More than 50% showed signs of systemic inflammation indicative of sepsis, reflected by a dramatic increase in serum C-reactive protein and leukocytosis. Treatment consisted of debridement and drainage (n = 3), primary repair (n = 3), reinforced repair (n = 4), esophageal resection (n = 5), and conservative measures (n = 2). All patients, except for three with pre-existing liver dysfunction and other comorbidities, survived, representing a mortality rate of 17.6% (14/17). An analysis of the literature (2000-2005) revealed an overall mortality rate of 19.7% (101/521), ranging from 3% to 67%.

CONCLUSION

Our data support the individualized surgical management of EP, based on careful evaluation of various patient-related factors, including CT findings.

Aortoesophageal fistula of uncommon origin: perforation of a Barrett's ulcer

Aortoesophageal fistulas are life-threatening conditions of which over half are secondary to thoracic aortic aneurysms. Four cases related to perforation of a Barrett's ulcer have been described so far, accounting for less than 1% of published aortoesophageal fistulas. We report a fifth case, which presented with severe hypotension, anemia and hematemesis. The patient underwent emergency esophagectomy and aortic closure but postoperatively required aortic endoprosthesis for residual bleeding. This case highlights the great diagnostic and therapeutic challenge associated with perforated Barrett's ulcer.

Perforating Barrett's ulcer resulting in a life-threatening esophagobronchial fistula

Perforating benign ulcer is a very rare complication of Barrett's esophagus. This report presents the management of a patient with a Barrett's ulcer that penetrated into the left mainstem bronchus resulting in a life-threatening bronchial esophageal fistula. This rare complication was successfully managed by using a staged surgical approach, which combined the principles used for treating benign esophagorespiratory fistulas and perforating Barrett's ulcers.