Squamous cell carcinoma-induced gastric conduit-thoracic aorta fistula presenting with massive hematemesis 4 years after radical esophagectomy: a CARE guidelines-compliant case report.

INTRODUCTION

Gastric squamous cell carcinoma (GSCC) arising within a gastric conduit is an exceedingly rare phenomenon, and its presentation as a gastro-aortic fistula has never been documented. This case highlights the diagnostic challenges and life-threatening potential of delayed aortoenteric complications after esophagectomy, and underscores the evolving role of endovascular therapy in emergent hemorrhage control.

PATIENT CONCERNS AND CLINICAL FINDINGS: A 75-year-old male presented with 6 h of recurrent, high-volume hematemesis and presyncope. On arrival, he was hypotensive (74/50 mmHg), tachycardic, and profoundly anemic (hemoglobin 64 g/L). Physical examination revealed marked conjunctival pallor but a soft, non-tender abdomen without signs of portal hypertension.

DIAGNOSIS INTERVENTIONS AND OUTCOMES: Emergent computed tomography angiography demonstrated contrast extravasation from the posterior wall of the gastric conduit into the descending thoracic aorta. Digital subtraction angiography confirmed a focal gastro-aortic fistula at the T6 level. Under angiographic guidance, thoracic endovascular aortic repair (TEVAR) was performed using a COOK ZTEG-2PT-30-200 covered stent graft, achieving immediate hemostasis. The patient received massive transfusion support (22 units packed red cells, 8 units cryoprecipitate, 2,000 ml fresh frozen plasma) alongside proton pump inhibitors and somatostatin. Two days post-repair, endoscopic biopsy of the conduit ulcer edge confirmed squamous cell carcinoma. The patient recovered without further bleeding and was discharged day 10 in stable condition. A multidisciplinary tumor board recommended adjuvant chemoradiotherapy. The patient and family opted for palliative care following oncologic consultation due to the advanced disease stage and overall clinical context.

CONCLUSION

In late post-esophagectomy patients presenting with massive upper gastrointestinal bleeding, high clinical suspicion for arterioenteric fistula is warranted. Computed tomography angiography and DSA should precede endoscopy in hemodynamically unstable patients. TEVAR offers a minimally invasive, rapid means of hemorrhage control, serving as a critical bridge to definitive cancer management.