[Migration of Internal Pancreaticojejunostomy Stents into the Bile Ducts in Patients Undergoing Pancreaticoduodenectomy].

The patient was a 68-year-old male. Pancreaticoduodenectomy(PD)for papillary carcinoma was performed. Computed tomography(CT)3 months after surgery revealed the migration of a lost Pit-stent into the bile duct. However, there were no symptoms. On CT 2 years after surgery, the lost stent had spontaneously fallen off. However, hepaticolithiasis was observed, and lithotripsy was performed using endoscopic retrograde cholangiopancreatography(ERCP). A pancreatic fistula after PD is an important complication. To prevent pancreatic fistulae, pancreatic stenting at the site of PD is performed in many cases. The postoperative in vivo kinetics of a lost stent remains to be clarified. Several case reports on complications have been published. In this study, we report a patient in whom the migration of a lost Pit-stent into the intrahepatic bile duct after PD led to hepaticolithiasis, and review the literature.

Clinicopathological Features of Remnant Gastric Cancer After Gastrectomy.

BACKGROUND: Remnant gastric cancer (RGC) encompasses all cancers arising from the remnant stomach. Various studies have reported on RGC and its prognosis, but no consensus on its surgical treatment and postoperative management has been reached. Moreover, the correlation between the clinicopathological characteristics and long-term outcomes of RGC remains unclear. This study investigated the clinicopathological factors associated with the long-term survival of RGC patients. METHODS: The medical records (March 1993-September 2020) of 104 RGC patients from Tokyo Medical University Hospital database were analyzed. Of these 104 patients, the medical records of 63 patients who underwent surgical curative resection were analyzed using R. Kaplan-Meier plots of cumulative incidence of RGC were made. Differences in survival rates were compared using the log-rank test. Prognostic factors were analyzed using multivariate Cox regression analysis (P < .05). RESULTS: Of the 104 RGC patients, 63 underwent total remnant stomach excision. The median time from the first surgery to the total excision was 10 years. The 5-year survival rate of the 63 RGC patients was .55 ((95% CI); .417-.671). The clinicopathological factors that were significantly associated with the long-term outcome of the RGC patients were tumor diameter (≥3.5 cm), presence or absence of combined resection of multiple organs, tumor invasion (deeper than T2), TNM stage, and postoperative morbidity. The multivariate Cox regression analysis showed that tumor invasion depth was the only independent prognostic factor for RGC patients [HR (95% CI): 5.49 (2.629-11.5), P ≤ .005]. CONCLUSIONS: Among prognostic factors, tumor invasion depth was the only independent factor affecting RGC's long-term outcome.

Cholecystectomy in a patient with paroxysmal nocturnal haemoglobinuria undergoing ravulizumab maintenance treatment.

A 47-year-old male with paroxysmal nocturnal haemoglobinuria (PNH) controlled with routine ravulizumab administration suffered a massive haemolytic crisis due to choledocholithiasis. Laparoscopic cholecystectomy was performed 6 weeks after a regular ravulizumab infusion. After surgery, the patient presented with anaemia without marked elevation in lactate dehydrogenase and required two blood transfusions. Tumour necrosis factor-α increased more than twofold with reticulocyte suppression after surgery, suggesting the involvement of myelosuppressive cytokines. This case suggests that laparoscopic surgery may be safely performed in patients with PNH receiving ravulizumab maintenance treatment. However, attention should be paid to postoperative anaemia, regardless of breakthrough haemolysis.

Validation of Urinary Charged Metabolite Profiles in Colorectal Cancer Using Capillary Electrophoresis-Mass Spectrometry.

This study aimed to validate and reanalyze urinary biomarkers for detecting colorectal cancers (CRCs). We previously conducted urinary metabolomic analyses using capillary electrophoresis-mass spectrometry and found a significant difference in various metabolites, especially polyamines, between patients with CRC and healthy controls (HC). We analyzed additional samples and confirmed consistency between the newly and previously analyzed data. In total, we included 36 HC, 34 adenoma (AD), and 214 CRC samples, which were used for subsequent analyses. Among the 132 quantified metabolites, 16 exhibited consistent differences in both datasets, which included polyamines, etc. Pathway analyses of the integrated data revealed significant differences in many metabolites, such as glutamine, and metabolites of the TCA (tricarboxylic acid cycle) and urea cycles. The discrimination ability of the combination of multiple metabolites among the three groups was evaluated, which yielded higher sensitivity than tumor markers. The Mann-Whitney test was employed to evaluate the prognosis predictivity of the assessed metabolites and the difference between the patients with or without recurrence, which yielded 16 significantly different metabolites. Among these 16 metabolites, 11 presented significant prognosis predictivity. These data indicated the potential of metabolite-based discrimination of patients with CRC and AD from HC and prognosis predictivity of the monitored metabolites.

[A Case of Preoperatively Diagnosed Early Cystic-Duct Carcinoma].

A 88-year-old man presented with abdominal discomfort. Computed tomography(CT)images showed gallbladder tumor, and the patient was referred to our hospital. In addition to the above, CT images showed a tense gallbladder and EUS showed papillary raised lesions mainly from the cystic duct to the gallbladder neck. Based on the above, we diagnosed cystic duct cancer and performed full-thickness cholecystectomy, extrahepatic bile duct resection, regional lymph node dissection at our department. Macroscopic findings of the resected specimen showed a Villous ridge in the cystic duct. Histopathological findings revealed well-differentiated adenocarcinoma with an irregular papillary structure centered on the cystic duct. The depth of invasion remained within the epithelium, and a diagnosis of primary early cystic duct cancer was made. Primary cystic duct cancer is a relatively rare disease and often does not lead to preoperative diagnosis. This time, we experienced a case in which cystic duct cancer was diagnosed preoperatively due to complaints of abdominal discomfort and could be surgically resected.

[A Case of Small Intestinal GIST Diagnosed by Intussusception].

The patient was a 34-year-old female. She consulted our hospital with epigastric pain. Abdominal computed tomography (CT)revealed a small intestinal tumor, measuring 30 mm in diameter, with contrast effects. For detailed examination, enteroscopy was scheduled, but abdominal pain suddenly occurred. CT showed marked dilatation of the small intestine and intussusception, and emergency surgery was performed on the same day. Intussusception was observed on the anal side 70 cm from Treitz' ligament. The intestinal wall was black, and fissures of the serosa were partially noted. It was difficult to release the intussusception, and a 55 cm area of the jejunum involving the site of intussusception was resected. The patient was discharged on the 8th postoperative day. At the tip of the intussusception, a submucosal tumor measuring 25 mm in maximum diameter was present. Pathologically, the proliferation of spindle-shaped cells originating from the muscularis propria was observed, comprising an intricate structure. On immunostaining, KIT-positive and CD34, S-100, α-SMA-negative reactions were detected, leading to the diagnosis of a gastrointestinal stromal tumor(GIST). Nuclear divisions were noted in <5/50 visual fields. According to the risk classification, the risk was evaluated as low. The patient is being followed-up in accordance with guidelines.

[Patient with Monomorphic Epitheliotropic Intestinal T-Cell Lymphoma with Small Intestinal Perforation Development during Chemotherapy].

Monomorphic epitheliotropic intestinal T-cell lymphoma(MEITL)is classified under type Ⅱ enteropathy-associated T-cell lymphoma(EATL). It is a rare disease with a low incidence rate. This study reports a case of a patient with MEITL who developed small intestinal perforation during chemotherapy. The patient was a 55-year-old woman who presented to a previous clinic with epigastric pain. Enteroscopy results showed a map-like ulcer in the jejunum. Examination of the tissue specimen collected from this site suggested T-cell lymphoma. The patient was referred to our hospital for chemotherapy. Seven days following the initiation of chemotherapy, an abdominal computed tomography(CT)revealed free air, leading to a diagnosis of gastrointestinal perforation. Emergency surgery was performed. Intraoperatively, bowel perforation and a degenerative ulcer were observed at 95 cm and 80 to 115 cm from the Treitz' ligament, respectively. In addition, all-layer intestinal necrosis was noted 150 and 90 cm from the terminal ileum. Total resection and anastomosis were performed. Postoperatively, the patient developed sepsis due to chemotherapy-related pancytopenia but recovered. She was discharged on postoperative day 24. Subsequently, positron emission tomography(PET)-CT revealed residual intestinal tumor cells and peritoneal dissemination. Chemotherapy was initiated, but there was no response. The patient died after 6.5 months. A radical treatment for MEITL has not yet been established. More case reports are needed to improve the prognosis of this disease.

[An Early Gastric Cancer with Sarcoid Reactions of the Regional Lymph Nodes].

The patient was a 73-year-old male who was referred to our hospital for detailed examination because computed tomography(CT)revealed lymph node swelling. Upper gastrointestinal endoscopy revealed a 0-Ⅱc lesion in the greater curvature of the middle gastric body. The periphery of the lesion site was not reached using endoscopy. CT revealed lymph node swelling, but positron emission tomography(PET)-CT did not show abnormal accumulation in any area other than the lesion site involving the lymph nodes. Under a diagnosis of cT2N0M0, Stage Ⅰ tumor, total gastrectomy via laparotomy and lymph node dissection(D2+No.10)was performed. The histopathological diagnosis suggested early gastric cancer pT1b (SM)N0M0, Stage ⅠA. Although lymph node metastasis was not observed, the outgrowth of non-caseating epithelioid cell granulomas was observed in all lymph nodes. There was no granulomatous lesion at any other site, including the lung, leading to a diagnosis of sarcoid reactions. The"sarcoid reaction"refers to non-caseating epithelioid cell granuloma formation in a local area or the regional lymph nodes of a malignant tumor through reactions to extraneous foreign bodies in the absence of the general condition or signs as sarcoidosis. Sarcoid reactions to early gastric cancer are rare. In this study, we report a patient with early gastric cancer who showed sarcoid reactions of the regional lymph nodes and review the literature.

[A Case of Elective Laparoscopic Resection for Sigmoid Colon Cancer with Irreducible Intussusception].

An 85-year-old man was hospitalized for a right greater trochanteric fracture. Rectal intussusception was found by diagnostic imaging but left untreated because of minor gastrointestinal symptoms. As a result of work-up for persistent mucous stool, he was diagnosed with sigmoid colon cancer with intussusception. The intussusception could not be reduced during barium enema examination but could undergo elective laparoscopic surgery with a good postoperative course. Adult intussusception may be asymptomatic and require no emergency treatment. In such a case, elective surgery can be performed. Many facilities employ laparotomy as a standard of care for intussusception. With the recent technological advances in endoscopic surgeries, laparoscopic surgery can be considered as a treatment option.

Primary malignant melanoma of the esophagus with multiple lymph node metastases: A case report and literature review.

RATIONALE: Primary malignant melanoma of the esophagus (PMME) is a very rare malignancy accounting for only 0.1% to 0.2% of all malignant esophageal lesions. Presently, there are no standard strategies or clear guidelines for PMME treatment. PATIENT CONCERNS: Herein, we report a patient who had PMME with multiple lymph node metastases (LNMs) who was treated successfully by esophagectomy. In March 2018, a 74-year-old man with symptoms of continuous dysphagia was referred to our hospital. DIAGNOSIS: Upper gastrointestinal endoscopic examination revealed melanin pigmentation in the middle thoracic esophagus and a pigmented polypoid mass in the lower esophagus. Histopathological examination of the endoscopic biopsy specimen revealed malignant melanoma. Contrast-enhanced computed tomography showed a 3 cm tumor lesion with several enlarged lymph nodes without distant metastasis. The preoperative diagnosis based on the TNM classification was cT2N2M0 stage III. INTERVENTIONS: The patient underwent esophagectomy with lymph node dissection. OUTCOMES: Histopathological examination showed that the tumor extended to the submucosal layer of the esophageal wall, with multiple LNMs. Although multiple LNMs were detected, computed tomography scan 15 months after surgery showed no recurrence. Additionally, we analyzed the relationship between the overall survival and the clinicopathological factors including LNMs in 48 previously reported cases of PMME that were surgically treated. LESSONS: To our knowledge, this is the first report on the effect of LNMs on the prognosis of PMME patients. The analysis revealed the prognostic value of the TNM stage. Early tumor detection and esophagectomy with lymph node dissection may play as key factors for achieving a better overall survival of PMME patients.

Postoperative outcomes of gastric carcinoma with lymphoid stroma.

BACKGROUND: Gastric carcinoma with lymphoid stroma (GCLS) is a rare subtype of gastric cancer. There have been several reports demonstrating the favorable prognosis of early GCLS without lymph node metastasis (LNM) compared with gastric adenocarcinomas. However, it remains unknown whether advanced GCLS (AGCLS) with LNM has a similar prognosis and clinicopathological features. This study aimed to assess the clinicopathological features of GCLS of all stages. METHODS: We retrospectively assessed 375 patients who were pathologically diagnosed with gastric cancer and underwent curative surgical resection at Tokyo Medical University, Japan, between September 2013 and October 2019. Of these patients, 357 (95.2%) patients were pathologically diagnosed with gastric adenocarcinomas, and 18 (4.8%) patients were diagnosed with GCLS. The GCLS patients (n = 18) were compared with the gastric adenocarcinoma patients (non-GCLS patients, control) (n = 357) in terms of their clinicopathological features and clinical outcome. RESULTS: The GCLS patients showed significantly predominant upper gastric locations (P = 0.003), lower number of LNM (P = 0.01), and better overall survival rate than the non-GCLS patients (P = 0.029). The predominant upper gastric locations (P = 0.0002), lower number of LNM (P = 0.003), and better overall survival rate (P = 0.04) were significantly correlated in the AGCLS with LNM patients compared with the advanced non-GCLS with LNM patients. For survival analyses, surgical procedure, tumor location, and numbers of positive LNM were adjusted by 1:1 propensity score matching. After adjustment, the overall survival rate was significantly higher in the AGCLS group than in the advanced non-GCLS group (P = 0.03). CONCLUSION: AGCLS has distinct clinicopathological features and clinical behavior that are similar to those of early GCLS. AGCLS with LNM patients showed a significantly lower number of LNM and a better survival rate than advanced non-GCLS with LNM patients. To our knowledge, this study is the first report to describe the clinicopathological features of AGCLS.

[A Case of Local Remnant Esophageal Cancer after Chemotherapy Getting Complete Response by Radiotherapy].

This is a case of a 72-year-old woman who presented without anymajor complaint. An anemia was indicated during follow-up for diabetes at the internal medicine unit and an upper gastrointestinal endoscopy(GS)was performed. A type 2 tumor was detected in the middle thoracic esophagus and biopsyrevealed a squamous cell carcinoma. A tumor was detected in the middle thoracic esophagus bycervical thoracoabdominal computed tomography(CT)scan and no invasion of surrounding organs was noted. The lymph node 104R had enlarged significantlybut no distant metastasis was observed. The patient was diagnosed with advanced esophageal cancer, Mt, type 2, cT2N2M0, stage Ⅱ. For preoperative chemotherapy, CDDP plus 5-FU(FP)therapywas administered. Lung metastasis was found on CT examination and surgical resection was not indicated. Hence, 4 courses of docetaxel plus CDDP plus 5-FU(DCF)therapywere administered. Following treatment, lung and lymph node metastases disappeared on the image. However, the main tumor remained at the GS. Radiotherapy was administered as a local additional treatment. Thereafter, GS showed mucous membrane redness and white spots of the lesion. Biopsyfrom the same site showed no malignant findings. The patient has remained malignancy-free since 18 months.

Phase II Study of Docetaxel, Cisplatin, and 5-Fluorouracil Chemoradiotherapy for Unresectable Esophageal Cancer.

BACKGROUND/AIM: We performed a phase II study of triple-drug combination chemoradiotherapy (DCF-R therapy), in which docetaxel was added to the standard chemoradiotherapy (cisplatin [CDDP]/5-fluorouracil [5-FU]) for unresectable advanced esophageal cancer. PATIENTS AND METHODS: Sixty-one patients with unresectable advanced esophageal cancer underwent the following DCF-R therapy: intravenous infusion of l60 mg/m2 docetaxel and 60 mg/m2 of CDDP (day 1), and 600 mg/m2 of 5-FU (days 1-5); 2 courses administered within a 4-week interval. Radiotherapy comprised 60 Gy in total. RESULTS: Response rates were 85.2% for the main lesion, 80.7% for metastasized lymph nodes, and 67.6% for distant organ metastases. Common adverse effects were leukopenia, anemia, and nausea, in 98.4%, 62.3%, and 60.7% of patients, respectively. Treatment completion rate was 90.2% and no treatment-associated deaths occurred. Median survival time was 406 days and 1-, 2-, and 5-year survival rates were 58.6%, 39.1%, and 22.8%, respectively. CONCLUSION: DCF-R therapy for unresectable advanced esophageal cancer demonstrated a high antitumor effect with sufficient safety.

[Resection of Synchronous Liver Metastasis from Ascending Colon Cancer with Aplastic Anemia-A Case Report].

The aplastic anemia(AA)syndrome is characterized by pancytopenia and bone marrow hypoplasia. Although anemia, bleeding tendency, and susceptibility to infection are issues of concern during surgery, few reports have been published on the perioperative management, and management methods have not been established. A 77-year-old woman visited our hospital with chief complaints of melena and fatigability. Marked pancytopenia was observed at the first visit. After a detailed examination, she was diagnosed with ascending colon cancer accompanied by AA and solitary liver metastasis. As AA responded poorly to treatment, without improvement in pancytopenia, we decided to perform colectomy. The perioperative management, including blood transfusion and administration of a G-CSF preparation, was performed in collaboration with a hematologist, followed by right hemicolectomy and hepatic lateral segmentectomy. She was transferred to the department of hematology on hospital day 8 without complications. In conclusion, a highly invasive surgery, as in the present case, can be performed safely with an appropriate perioperative management even in cases complicated by AA.

Bronchogenic cyst removal via thoracoscopic surgery in the prone position: A case report and literature review.

INTRODUCTION: Mediastinal bronchogenic cysts are encountered relatively often, but in many cases, diagnosis using imaging modalities, is difficult. Early surgical excision of bronchogenic cysts is recommended as a diagnostic and therapeutic measure. Here, we report the case of patient with a lower mediastinal bronchogenic cyst, who was treated using thoracoscopic surgery with prone positioning and include a review of literature on diagnosis and treatment of this condition. PRESENTATION OF CASE: The patient was a 66-year-old woman with an asymptomatic cystic lesion in the posterior, lower mediastinum. The lesion was diagnosed as an esophageal cyst using preoperative imaging and was scheduled for thoracoscopic removal with the patient in the prone position. Intraoperatively, the lesion was found to have no continuity with the esophageal wall and was easily separated from it. Moreover, a cord extending to the lesion, appeared to arise from the crura of the diaphragm. On histopathological examination of the extracted mass, the lesion was diagnosed as a bronchogenic cyst. Postoperatively, the patient recovered uneventfully and was discharged after 7 days. CONCLUSION: Thoracoscopic mediastinal cystectomy with the patient in the prone position may be an optimal surgical strategy for the treatment of bronchogenic cysts in the posterior, lower mediastinum.

[Spontaneous Disappearance of Undifferentiated Pleomorphic Primary Mesenteric Sarcoma-A Case Report].

The patient was a 49-year-old man with persistent fever since the introduction of hemodialysis(HD). Vomiting and abdominal swelling appeared 4 months after initiating hemodialysis. Computed tomography(CT)scan revealed a tumor measuring 9 cm, and disorders of passage from the jejunum. Surgery was performed, and resection was impossible because of peritoneal dissemination. Histopathological examination of the disseminated nodes suggested an undifferentiated pleomorphic sarcoma. Postoperatively, drainage from the gastric fistula was approximately 2,000mL/day. Chemotherapy was considered impossible because of HD, and palliative therapy was selected. However, the volume of drainage from the gastric fistula gradually decreased, and the disorders of passage reduced. CT scan confirmed marked reduction in the size of the intraperitoneal tumor and its subsequent disappearance. At the 2-year-and-5-month postoperative follow-up, no relapses were observed, and the course had been uneventful. Undifferentiated pleomorphic sarcomas develop in the soft tissue of adults and have a poor prognosis. However, mesenteric development is rare. Total tumorectomy is the first choice of treatment. A consensus on the usefulness of chemotherapy or radiotherapy has not been reached. Furthermore, no studies have reported spontaneous tumor disappearance in the absence of treatment. Here, we report a case of minor undifferentiated primary mesenteric sarcoma and its spontaneous disappearance and review the literature.

Usefulness of robot-assisted thoracoscopic esophagectomy.

OBJECTIVES: We started robot-assisted thoracoscopic esophagectomy using the da Vinci surgical system from June 2010 and operated on 30 cases by December 2013. Herein, we examined the usefulness of robot-assisted thoracoscopic esophagectomy and compared it with conventional esophagectomy by right thoracotomy. METHODS: Patients requiring an invasion depth of up to the muscularis propria with preoperative diagnosis were considered for surgical adaptation, excluding bulky lymph node metastasis or salvage surgery cases. The outcomes of 30 patients who underwent robot-assisted surgery (robot group) and 30 patients who underwent conventional esophagectomy by right thoracotomy (thoracotomy group) up to December 2013 were retrospectively examined. Five ports were used in the robot-assisted thoracoscopic esophagectomy: 3rd intercostal (da Vinci right arm), 6th intercostal (da Vinci camera), 9th intercostal (da Vinci left arm), 4th and 8th intercostals (for assistance). RESULTS: There was no significant difference in patient characteristics. Robot group/right thoracotomy group: Operation time, 563/398 min; thoracic procedure bleeding volume, 21/135 ml; number of thoracic lymph node radical dissections, 25/23. Postoperative complications were recurrent nerve paralysis, 16.7/16.7%; pneumonia, 6.7%/10.0%; anastomotic leakage, 10.0/20.0%; surgical site infection, 0/10.0%; hospitalization, 17/30 days. For the robot group, the operation time was significantly longer, but the amount of intraoperative bleeding and postoperative hospitalization were significantly reduced. CONCLUSIONS: Robot-assisted thoracoscopic esophagectomy enables delicate surgical procedures owing to the 3D effect of the field of view and articulated forceps of the da Vinci. This procedure reduces bleeding and postoperative hospitalization and is less invasive than conventional esophagectomy by right thoracotomy.

[Surgical Case of Ulcerative Colitis Accompanied with Rectal Cancer Combined with Transanal Minimally Invasive Surgery].

A46 -year-old man developed ulcerative colitis at the age of 19 years. Although the colitis was medically treated, it relapsed and repeated over time. Periodic lower gastrointestinal endoscopy revealed lower rectal cancer, and he was referred to our department of surgery. Previous steroid therapy induced diabetes, and he was obese, with a height of 170.3 cm, weight of 89.6 kg, and BMI of 30.89 kg/m2, indicating that laparoscopic dissection near the anus would be difficult to perform. Therefore, the patient was scheduled for transanal minimally invasive surgery(TAMIS). The surgery involved as much laparoscopic rectal dissection as possible in the ventral to dorsal direction, followed by the TAMIS procedure. Dissection was started from the dentate line, and, after the closure of the anal stump, GelPOINT was placed, and made continuous with the previous dissection layer by applying the technique of down-to-up total mesorectal excision(TME)by TAMIS. The large intestine was excised through a small abdominal incision to create an ileal pouch, hand-sewn anastomosis was performed transanally to create a temporary colostomy, and the surgery was completed. Regarding TAMIS-TME several problems remain to be solved, including an understanding of its unique anatomy and the mastery of single-port surgical techniques. However, the herein reported patient with a high BMI had a definite indication for TAMIS-TME.

Collision Tumor of Adenocarcinoma and Gastrointestinal Stromal Tumor in the Small Bowel.

We report a very rare case of collision tumor composed of primary adenocarcinoma of the jejunum and gastrointestinal stromal tumor (GIST). The patient was a 63-year-old man who visited our hospital for epigastralgia and vomiting. Abdominal computed tomography revealed a mass in the upper jejunum, with gastric and duodenal dilatation. Endoscopy of the small bowel showed a circumferential tumor in the upper jejunum, which was diagnosed as primary adenocarcinoma by tissue biopsy. Thereafter, partial resection of the small bowel from the third part of the duodenum over the upper jejunum was performed. A tumor colliding with the primary adenocarcinoma was identified on the serosal side of the jejunum in the excised specimen and was histologically diagnosed as GIST. The annual incidence of primary adenocarcinoma of the small bowel (i.e., jejunum and ileum excluding the duodenum) has been reported to be 7 in 1 million people, and only 6 cases of collision tumor of the small bowel (i.e., duodenum: 5, ileum: 1) have been reported thus far. Although esophageal, gastric, and large intestinal collision tumors composed of primary cancer and GIST have been reported, to our knowledge, the present patient is the first case of the small bowel. The cause of or correlation between 2 tumors forming a collision tumor remains unclear. In the present patient, there was no pathological finding of infiltration between the 2 tumors. Although the collision of the 2 tumors was unclear, the findings indicate their independent development in closely located regions consistent with collision tumors.

[A Case of T4 Esophageal Cancer with Refractory Chylothorax Developed Postoperatively].

A 65-year-old man was diagnosed as having middle thoracic esophageal cancer(c-T3N2M0, stage III ), and neoadjuvant chemoradiotherapy was performed.We performed surgical therapy.However, tumor and #113 lymph node invasion into the aortic arch was observed; therefore, it was judged that curative resection was difficult, and R2 surgery was performed instead. Postoperative diagnosis was Mt, CRT-type 5b, s-T4(aortic arch)N4(#113)M0, stage IV a.After surgery, pleural effusion was abundant and was diagnosed as chylothorax.Even though intestinal rest and octreotide administration were performed as a conservative treatment, chylothorax was not improved.Therefore, thoracoscopic thoracic duct ligation was performed on 8POD.After that, pleural effusion was still sustained, and pleural adhesions were performed.However, it did not prove to be effective.Furthermore, when Lipiodol lymphangiography was performed to identify the leakage site, the leakage of contrast medium was observed from the remaining lymph node.After lymphangiography twice(in total), pleural effusion disappeared, and the patient was discharged on the 75POD.In this case, we report an example in which lymph leakage disappeared due to lymphangiography for diagnostic purpose, while no improvement was observed in the lymphatic leakage from the remaining metastatic lymph node in T4 esophageal cancer with R2 surgery, nor with some treatments for chylothorax, including thoracic duct ligation.