開胸食道癌切除後乳び胸に対し胸腔鏡下胸管結紮術を施行した1例

A case of post-esophagectomy chylothorax successfully treated by thoracoscopic clipping of the thoracic duct

◆要旨：開胸食道癌切除後の乳び胸を胸腔鏡下に治癒しえた症例を経験したので報告する．患者は65歳，男性．嚥下困難を主訴に来院し，食道癌T3, N0, M0, StageⅡと診断され，術前化学療法を施行後，右開胸開腹食道亜全摘術，胃管胸骨後再建，3領域郭清術を施行した．胸管は横隔膜上で2重結紮し切除した．第4病日に白濁胸水を認め，乳び胸と診断した．オクトレオチドの保存的加療で改善せず，第38病日に胸腔鏡下手術を施行した．胸管結紮部近傍に乳びの漏出を認め，胸管を剝離，再結紮し手術を終了した．術後胸水は減少し，第48病日に胸腔ドレーンを抜去した．胸腔鏡下胸管結紮術は低侵襲で安全に良好な視野で漏出部位の同定，処置が可能であり，開胸術後でも有用である．

Thoracoscopic clipping of the thoracic duct was successfully performed for the treatment of postoperative chylothorax. The case was a 65-year-old male. He visited our hospital for the chief complaint of a feeling of blockage during swallowing. He was diagnosed as esophageal carcinoma, T3N0M0 Stage Ⅲ. Subtotal esophagectomy by right thoracotomy, retrosternal gastric tube reconstruction, and three-field lymph node dissection was performed after 2 courses of preoperative chemotherapy （FP）. The thoracic duct was resected during the operation and the stump was ligated by double transfixing suture. On postoperative day（POD）2, enteral nutrition was initiated. On the following day, pleural effusion drainage markedly increased. On POD 4, the fluid in the chest tube turned into a milky appearance and the patient was diagnosed with chylothorax. Following unsuccessful conservative therapy for 5 weeks, we performed thoracoscopic surgery to examine the thoracic duct and found a transudation point of chylous fluid. An additional clip was performed on the thoracic duct. The drainage gradually decreased after surgery. The chest tube was removed on POD 48 after the first surgery. Thoracoscopic surgery in the prone position was a less invasive and useful procedure for identifying the transudation points and clipping of chylothorax cases, even in thoracotomy approaches.