A 59-year-old man with a background of adenocarcinoma of the gastroesophageal junction presented to the Emergency Department with severe right-sided chest pain, uneasiness, and acute shortness of breath. He had undergone partial esophago-gastrectomy through a lateral thoraco-abdominal approach 7 days earlier, and had been discharged from the same hospital a day prior to presentation. The post-operative period had been uneventful.

On examination, the patient appeared toxic and unwell. His vital signs were notable for a pulse rate of 166 beats per minute, respiratory rate of 38 breaths per minute, blood pressure of 180/90 mm Hg, and oxygen saturation of 88% on supplemental oxygen via a facemask at 6 liters per minute. His exam was remarkable for a grossly reduced air entry over the right side of the chest. A bedside radiograph ( Figure 1 ) of the chest showed a right-sided pneumothorax, with haziness over the lower and middle zones, suggestive of a moderate hydropneumothorax.

An emergent tube thoracostomy was performed in the Emergency Department, and 800 ml of thick, milky, off-white pleural fluid was drained ( Figure 2 ).

In view of persistent respiratory distress and progressive encephalopathy, a decision was made to electively intubate and mechanically ventilate him, before transferring to the Intensive Care Unit. A central venous catheter was placed in the right internal jugular vein ( Figure 3 ).

At this juncture, there were two potential considerations which might have explained the pleural collection; acute empyema, or chylothorax.

Initial laboratory analysis revealed: haemoglobin 11.4 g/dl, white cell count 19,750/L, absolute neutrophil count 16,471 g/dl, and platelet count 440/L. C-reactive protein 136 mg/L, Procalcitonin 1.61 ng/ml. Pleural fluid analysis confirmed pus growing Escherichia coli. A computed tomography (CT) scan with enteral contrast via a nasogastric tube showed an anastomotic leak in the lower esophagus. The pleural drain was replaced by a pigtail catheter, resulting in complete evacuation of residual pleural collection. Though the pleural drainage dropped to virtually nil over 72 hours, resulting in the decision to subsequently remove the pigtail catheter, his follow-up contrast scan still showed a persistent leak. Sepsis profile and physiologic parameters had stabilized, with an overall improvement in his clinical condition, seemingly responding to a combination of Meropenem and Teicoplanin.

He was finally taken up for endoscopic esophageal stenting and endoluminal vacuum therapy.

The pathogenesis of AL involves ischemia at the anastomotic site, technical factors, tension on the anastomosis, and impaired healing due to malnutrition or comorbidities . It is pertinent to note, that our patient did not exhibit obvious risk factors like malnutrition, obesity, or diabetes for predisposition to a leak. In terms of anastomotic site, our patient had a gastro-esophageal anastomosis, once again making this occurrence rare, considering that cervical anastomoses are more prone to leaks. Once leakage occurs, contamination of the pleural or mediastinal space may lead to empyema, systemic inflammatory response, and septic shock . The risk is greater for intrathoracic anastomoses, although cervical leaks are more common overall [3] . Clinically, early warning signs include tachycardia, fever, respiratory distress, and leucocytosis . Radiographically, a new pleural effusion or infiltrate adjacent to the anastomosis is often the first sign of AL . In our case, the presence of a large hydropneumothorax with purulent drainage was the diagnostic clue.

Early diagnosis remains challenging, as there is no single gold-standard test [2] . Imaging modalities include contrast-enhanced computed tomography (CT), contrast esophagography, and endoscopy. CT with oral or enteral contrast is particularly sensitive, allowing visualization of extravasation and associated collections [4] [6] . In our patient, CT confirmed the leak and guided further intervention. Bedside clinical suspicion, however, remains paramount — particularly in the ED where delays can worsen outcomes.

The management of AL depends on the severity of leakage, clinical status, and available expertise. Initial priorities are resuscitation, broad-spectrum antibiotics, and adequate drainage of pleural or mediastinal collections [2] [5] . Tube thoracostomy, as performed in our patient, is lifesaving in cases of large empyema or hydropneumothorax. Definitive options include endoscopic therapies such as covered self-expanding metal stents and endoluminal vacuum therapy (EVT), both of which promote closure of the defect and control of sepsis (4). EVT has gained increasing popularity, with reported closure rates of up to 90% in selected series, and fewer complications compared with stenting [7] [8] .

Surgical re-exploration is reserved for uncontrolled sepsis, conduit necrosis, or failure of less invasive measures [6] . In our patient, endoscopic stenting and EVT facilitated recovery after stabilization with antibiotics and drainage, underscoring the value of a stepwise, multidisciplinary approach.

For emergency clinicians, the key learning point is that a patient presenting post-esophagectomy with acute respiratory distress and pleural findings should be presumed to have AL until proven otherwise. Empyema and hydropneumothorax in this context demand urgent drainage and stabilization prior to transfer to specialized care. Timely recognition and intervention in the ED can prevent progression to multi-organ dysfunction and improve survival [2] [5] .