First Documented Ivor Lewis Oesophagectomy for Oesophageal Squamous Cell Carcinoma in Somalia: A Case Report From a Resource-Limited Setting.

BACKGROUND: Oesophageal squamous cell carcinoma is associated with poor prognosis, particularly in resource-limited settings where access to advanced staging, multi-modal oncology treatment and complex surgical care is constrained. Ivor Lewis oesophagectomy is an established surgical approach for selected mid- and distal oesophageal tumours, but its implementation requires specialised surgical, anaesthetic and peri-operative support. To the best of our knowledge, this is the first documented report of Ivor Lewis oesophagectomy for oesophageal squamous cell carcinoma performed in Somalia.

CASE PRESENTATION: A 42-year-old female presented with a 3-month history of progressive dysphagia affecting both solid and liquid foods. Upper gastrointestinal endoscopy demonstrated a mid-oesophageal mass, and biopsy confirmed Grade 1 well-differentiated squamous cell carcinoma. Contrast-enhanced CT of the chest and abdomen showed a mid/subhilar oesophageal tumour with luminal narrowing and proximal oesophageal dilatation, without radiological evidence of distant metastasis. Because PET-CT and endoscopic ultrasound were unavailable, precise T and N staging could not be determined; therefore, the disease was clinically staged as cT2-T3 Nx M0 and considered resectable. Neoadjuvant chemoradiotherapy was considered, but timely access to standardised treatment was limited. Upfront curative-intent surgery was therefore selected after assessment of resectability, patient fitness and available local resources. The patient underwent open Ivor Lewis oesophagectomy with gastric conduit formation, limited lymphadenectomy, feeding jejunostomy placement and hand-sewn intra-thoracic oesophagogastric anastomosis. Operative time was 5 h, estimated blood loss was 800 mL and there were no intra-operative complications.

DISCUSSION: Post-operative CT demonstrated small bilateral pleural effusions, mild pneumothorax and pneumomediastinum, which were managed conservatively without reoperation or invasive intervention. A post-operative day-7 contrast swallow study showed no anastomotic leak or obstruction. The final histopathology confirmed Grade 1 well-differentiated squamous cell carcinoma with an R1 resection margin, indicating microscopic tumour involvement at the margin. The exact lymph node yield and number of metastatic lymph nodes were not clearly documented, limiting complete pathological nodal staging and assessment of lymphadenectomy adequacy. Intra-operative frozen-section margin assessment was not performed because this facility was not reliably available. At 7 weeks' follow-up, the patient was tolerating oral intake with no clinical evidence of anastomotic leak or stricture, and oncology review was arranged for consideration of adjuvant treatment and structured surveillance.

CONCLUSION: This case demonstrates the technical feasibility of open Ivor Lewis oesophagectomy for oesophageal squamous cell carcinoma in a resource-limited setting. However, the R1 margin, incomplete nodal assessment, limited staging modalities and short follow-up mean that this case should be interpreted as a technically successful, curative-intent procedure rather than evidence of complete oncological clearance. Long-term oncological follow-up remains ongoing.