Investigations and Treatments

During the following weeks, the patient required recurrent hospital admissions due to progressive dysphagia, intermittent bolus impaction, and ongoing weight loss. Endoscopic evaluation consistently demonstrated a high‐grade distal esophageal stricture (31–36 cm from the incisors) with marked inflammatory changes and granulation tissue (see Figure 1A). A CT scan confirmed these findings without evidence of malignancy at that time. Despite multiple endoscopic interventions, including Savary bougienages and balloon dilatations (9–15 mm), as well as implantation and repositioning of a fully covered esophageal stent with additional clip fixation (see Figure 1B), the clinical course remained refractory. The disease trajectory was further complicated by proton pump inhibitor (PPI)‐resistant reflux esophagitis, repeated stent migration, partial stent embedding resembling a buried bumper phenomenon, and secondary Candida esophagitis. Pharmacological therapy included high‐dose PPIs, combined PPI and H2‐receptor antagonist therapy, and short‐term systemic antifungal treatment with fluconazole.

FIGURE 1: (A) Severe reflux esophagitis with ulcerations (LA‐D). (B) Stent fixation with four clips.

Due to progressive malnutrition and a cumulative weight loss of nearly 40 kg, a PEG tube was placed after exclusion of surrounding malignancy by targeted biopsies (see Figure 2A). During this procedure, repeated biopsies from the esophageal stricture unexpectedly revealed a moderately differentiated, keratinizing invasive squamous cell carcinoma.

FIGURE 2: (A) Endoscopic view of PEG tube. (B) Laparoscopic view of PEG tube.

Subsequent staging by contrast‐enhanced CT of the chest and abdomen showed marked esophageal wall thickening but no distant metastases. Following interdisciplinary tumor board discussion, surgical treatment was recommended. The patient was transferred back to the surgical department and underwent a hybrid Ivor Lewis esophagectomy consisting of laparoscopic gastric mobilization and transthoracic en bloc esophagectomy with two‐field lymphadenectomy, combined with simultaneous cholecystectomy (due to severe cholestasis).