Use of a plastic endoprosthesis to successfully treat esophageal perforation following radiofrequency ablation of Barrett’s esophagus

Introduction

Barrett’s esophagus is a condition defined by the transformation of normal esophageal squamous epithelium to columnar epithelium containing goblet cells, known as intestinal metaplasia [1]. Barrett’s esophagus is a known precursor to esophageal adenocarcinoma, a condition with increasing incidence [2] [3]. Abnormal histologic changes in nondysplastic intestinal metaplasia may develop progressively, resulting in low grade dysplasia (LGD) or high grade dysplasia (HGD), prior to transforming into adenocarcinoma [4] [5]. The progression to cancer is higher with HGD as opposed to nondysplastic Barrett’s esophagus or LGD [6]. As a result, this population has been targeted for endoscopic therapy in attempts to minimize the risk of cancer. Traditionally, treatment of these patients has been esophagectomy with reported risk of mortality estimated between 3 % and 4 %, even in experienced centers [7]. As such, less invasive endoscopic eradication therapies (EETs) have become increasingly popular, particularly for patients who are not good surgical candidates due to significant co-morbities, and more frequently as an alternative treatment for those who want to avoid esophagectomy. One such modality is endoscopic radiofrequency ablation (RFA), which has been shown to be effective in eradicating dysplastic changes in Barrett’s esophagus [8]. Unfortunately, serious adverse outcomes of endoscopic therapy include bleeding, esophageal stricture and, less frequently, perforation [9]. However, if identified early, these events can be managed successfully during endoscopy. We present a case of esophageal perforation following EET.

References

• 1 Spechler S J. Barrett’s esophagus.  N Engl J Med. 2002;  346 836-842
• 2 Drewitz D J, Sampliner R E, Garewal H S. The incidence of adenocarcinoma in Barrett"s esophagus: a prospective study of 170 patients followed 4.8 years.  Am J Gastroenterol. 1997;  92 212-215
• 3 Pohl H, Welch H G. The role of overdiagnosis and reclassification in the marked increase of esophageal adenocarcinoma incidence.  J Natl Cancer Inst. 2005;  97 142-146
• 4 Reid B J, Sánchez C A, Blount P L et al. Barrett’s esophagus: cell cycle abnormalities in advancing stages of neoplastic progression.  Gastroenterology. 1993;  105 119-129
• 5 Rastogi A, Puli S, El-Serag H B et al. Incidence of esophageal adenocarcinoma in patients with Barrett’s esophagus and high-grade dysplasia: a meta-analysis.  Gastrointest Endosc. 2008;  67 394-398
• 6 Sharma P, Falk G W, Weston A P et al. Dysplasia and cancer in a large multicenter cohort of patients with Barrett’s esophagus.  Clin Gastroenterol Hepatol. 2006;  4 566-572
• 7 Swisher S G, Deford L, Merriman K W et al. Effect of operative volume on morbidity, mortality, and hospital use after esophagectomy for cancer.  J Thorac Cardiovasc Surg. 2000;  119 1126-1132
• 8 Shaheen N J, Sharma P, Overholt B F et al. Radiofrequency ablation in Barrett’s esophagus with dysplasia.  N Engl J Med. 2009;  360 2277-2288
• 9 Schembre D B, Huang J L, Lin O S et al. Treatment of Barrett’s esophagus with early neoplasia: a comparison of endoscopic therapy and esophagectomy.  Gastrointest Endosc. 2008;  67 602-603
• 10 Sharma P, Dent J, Armstrong D et al. The development and validation of an endoscopic grading system for Barrett’s esophagus: the Prague C & M criteria.  Gastroenterology. 2006;  131 1392-1399
• 11 Reid B J, Levine D S, Longton G et al. Predictors of progression to cancer in Barrett’s esophagus: baseline histology and flow cytometry identifying low- and high-risk patient subsets.  Am J Gastroenterol. 2000;  95 1669-1676
• 12 Pech O, Behrens A, May A et al. Long term results and risk factor analysis for recurrence after curative endoscopic therapies in 349 patients with high-grade intraepithelial neoplasia and mucosal adenocarcinoma in Barrett’s oesophagus.  Gut. 2008;  57 1200-1206
• 13 US Food and Drug Administration MAUDE database .Available at: http://www.fda.gov/default.htm. MDR report keys 983732 and 95694931. Accessed: August 2009
• 14 Wang K, Sampliner R. Updated guidelines 2008 for the diagnosis, surveillance and therapy of Barrett’s esophagus.  Am J Gastroenterol. 2008;  103 788-797