Emergency VATS Esophagectomy for T4 Esophageal Cancer With Massive Hematemesis in an Elderly Patient

Objective:  

The authors present a challenging case of emergency esophagectomy in an 80-year-old female with locally advanced (T4) esophageal squamous cell carcinoma complicated by massive hematemesis. 

Methods: 

 An 80-year-old female with chronic obstructive pulmonary disease presented with nausea and vomiting. An endoscopy revealed a middle and upper esophageal mass, confirmed as squamous cell carcinoma. CT and PET-MR scans staged the tumor as T3-4N1. Before initiating the planned neoadjuvant chemoradiation, the patient experienced massive hematemesis, necessitating emergency surgery. A four-port VATS esophagectomy was performed. 

Results:  

Intraoperatively, the tumor was found to have invaded the thoracic duct, azygous vein, and mediastinal pleura. The azygous vein invasion was identified as the likely source of hematemesis. An en bloc resection of the esophageal tumor with the azygous vein was performed. The tumor had invaded only the outer membrane of the aorta, allowing for complete resection. Meticulous dissection of mediastinal structures, including lymph nodes along the right recurrent laryngeal nerve and in the subcarinal region, was performed. Special attention was given to preserving the recurrent laryngeal nerve and the membranous part of the bronchus. 

Conclusions:  

This case demonstrates the feasibility and safety of emergency minimally invasive esophagectomy in elderly patients with locally advanced esophageal cancer complicated by life-threatening bleeding. It highlights the importance of careful preoperative evaluation, meticulous surgical technique, and adaptability to unexpected findings during surgery. The successful management of this complex case underscores the potential of VATS esophagectomy as a viable option in emergency situations, even for T4 tumors with invasion of adjacent structures. 

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