Catastrophic Hydropneumothorax as a Presentation of Esophageal Anastomotic Leak: A Case Report

Background: Anastomotic leakage (AL) is one of the most serious complications following esophagectomy, with an incidence of up to 10% and significant associated morbidity and mortality. AL can lead to pleural contamination, empyema, hydropneumothorax, sepsis, and death if not identified promptly. For emergency clinicians, recognizing the early signs of AL in post-esophagectomy patients is critical for timely intervention and improved outcomes. Case Presentation: We describe a 59-year-old male who presented to the Emergency Department seven days after partial esophago-gastrectomy with acute respiratory distress, severe right-sided chest pain, and hypoxia. Chest radiography revealed a right-sided hydropneumothorax, and emergent tube thoracostomy drained purulent fluid. Pleural fluid analysis confirmed empyema, and contrast-enhanced CT demonstrated an esophageal anastomotic leak. The patient required endotracheal intubation, intensive care admission, and broad-spectrum antibiotics. Definitive management included endoscopic stenting and endoluminal vacuum therapy, resulting in clinical stabilization. Conclusion: This case highlights the importance of maintaining a high index of suspicion for AL in post-esophagectomy patients presenting with pleural collections or respiratory compromise. In the Emergency Department, early recognition, prompt drainage, and resuscitative measures are lifesaving and should precede definitive diagnostic confirmation. A multidisciplinary approach, incorporating minimally invasive therapies such as endoscopic stenting and endoluminal vacuum therapy, offers promising outcomes. For frontline emergency clinicians, vigilance and early intervention remain central to reducing morbidity and mortality from this devastating complication.