Malignant esophageal perforation with pleural empyema: a successful robotic esophagectomy with primary reconstruction – a case report

Introduction and importance: Esophageal perforation, particularly when associated with malignancy, is a rare and life-threatening condition with a high mortality rate. Evidence regarding optimal management remains limited, with treatment options ranging from conservative measures to surgery, including staged repair or primary anastomosis. Further data are needed to guide the best practices for these complex cases. Case presentation: A 69-year-old man developed a malignant esophageal perforation following stent placement during neoadjuvant chemotherapy. The course was complicated by sepsis, pleural empyema, and mediastinitis. A single-stage robotic-assisted esophagectomy with primary reconstruction and simultaneous decortication, and lavage of the empyema was performed. The anastomosis was protected using EsoSPONGE ® . The patient’s recovery was uneventful, allowing early oral intake. At follow-up, the patient remained cancer-free and was fully orally nourished. Clinical discussion: The optimal treatment strategy for malignant esophageal perforations remains unclear. In this case, resection with a direct anastomosis was feasible and prevented the patient from requiring further surgery. A high-volume center with specialized expertise and an interdisciplinary approach, involving intensive care, endoscopy, oncology, nutritional medicine, and surgery, was essential in achieving the best possible outcome. Conclusion: Primary anastomosis following resection in malignant esophageal perforations, complicated by sepsis and pleural empyema, is a feasible treatment option.