Only a handful of papers have been published reporting perforation in a paraesophageal hernia and most of the reports cover gastric ulcer perforations with a postulated mechanical cause of the ulcer [8–13]. The mortality in the case of a perforated gastric ulcer in the context of paraesophageal hernia is very high . To the best of our knowledge, only one former report exists concerning perforation of a peptic duodenal ulcer in combination with a paraesophageal hernia , and no report exits on a patient surviving this rare life threatening condition.
When not accidentally discovered, common presentations of paraesophageal hernias are postprandial discomfort, nausea, vomiting, hiccough, belching, dysphagia, reflux, chest gurgling, respiratory difficulties and cardiac type pain. Sub-acute or acute presentations of paraesophageal hernias, which may be life threatening, are gastrointestinal bleeding, gastric perforation, gastric or oesophageal obstruction, gastric volvulus or strangulation and thereby infarction of any herniated organ . The risk of serious complications has, since many years, rendered in recommendations of early treatment of paraesophageal hernias by many influential authors [15, 16]. In a recent study by Stylopoulos et al. , it is argued that this aggressive attitude should be modified since the pooled annual risk of developing acute symptoms from a paraesophageal hernia and thereby requiring emergency surgery is estimated to only about 1%. The lifetime risk of developing acute symptoms for a 65-year-old patient with a paraesophageal hernia is 18%, and the risk decreases exponentially with increasing age. Furthermore, in pooled data from the literature regarding emergency surgery in the situation of paraesophageal hernias, the mortality rate is calculated to 17%, which probably is an overestimation, since modern data base analysis has estimated the risk to 5.4% .
A perforated peptic ulcer requires, in most cases, immediate surgery and delay will increase the risk of death [18, 19]. Patients with an episode of obstruction caused by a paraesophageal hernia also call for urgent surgery. However, if the stomach is decompressed by a naso-gastric tube, surgery may be postponed until a surgical team with experience of surgery from both above and below the diaphragm is at hand. According to our experience, gastric decompression may lower the risk of strangulation and reduce mechanical causes of gastric perforation. Furthermore, the risk of aspiration is decreased.
In the presented case, the hernial sac was contaminated with duodenal content and had to be removed. Due to the risk of an existing or iatrogenic small defect in to the pleural space, and as the common surgical dogma of not leaving contaminated areas undrained, we chose to drain the mediastinal cavity by a chest tube to avoid the formation of a concealed and undrained infection.
In conclusion, we hereby present a case with successful outcome, on the extremely rare life threatening combination of a paraesophageal hernia with a perforated peptic duodenal ulcer.