Stage III signet-ring gastric cancer complicated by a life-threatening aortic fistula after treatment

What happened, in summary

A 67-year-old man underwent total gastrectomy with Roux-en-Y esophagojejunostomy in January 2019 for gastric cardia cancer. Pathology showed Stage III signet-ring cell carcinoma with a positive proximal margin. He therefore received adjuvant chemoradiotherapy.

Four months into surveillance, endoscopy showed an ulcer near the anastomosis but no local recurrence. Nine months after the original surgery he developed massive vomiting of blood and hemorrhagic shock. Angiography confirmed an aortoesophageal fistula at the esophagojejunal anastomosis. An emergency thoracic aortic stent initially controlled the bleeding, but infection and worsening fistula formation followed.

A multidisciplinary team then performed extensive staged surgery, removing the fistula together with involved aorta, esophagus, Roux limb and part of the transverse colon, followed by aortic graft reconstruction. Pathology showed inflammation and fistula formation without malignancy. After antibiotics, he was discharged following a 59-day hospitalization. One year later he underwent esophageal reconstruction using an ileocolon conduit. He recovered from the second operation, returned to independent living and continued regular follow-up without gastric-cancer recurrence.