胸管の走行異常を伴う食道癌に対し腹臥位胸腔鏡下食道切除術を行った1例

Thoracoscopic esophagectomy in the prone position for esophageal cancer with a thoracic duct anomaly : A case report

◆要旨：胸管の走行異常は稀であるが，食道癌手術では術後乳び胸に注意した手術操作と術後管理を要する．症例は61歳，女性．胸部中部食道癌の診断で，術前化学療法後に胸腔鏡下食道切除術を行った．右反回神経周囲リンパ節郭清の際に，食道右側を横断し右静脈角へ向かう胸管の走行異常を認めた．術中損傷による乳び胸のリスクから切除した．術後は胸腔ドレーン排液量が1,000ml/日を超え，細胞外液・アルブミン製剤による補正を行った．第4病日から減少し，第5病日に経腸栄養を開始した．性状の変化がないことを確認し，第6病日にドレーンを抜去した．走行異常を伴う胸管を確実に処理し，循環動態と乳び胸に留意した術後管理により合併症を回避できた．

　The rate of anomalies of the thoracic duct is relatively low, however, surgical procedure and postoperative management with careful attention have to be performed in terms of prevention of postoperative chylothorax. A 61-year-old female with middle thoracic esophageal cancer underwent curative esophagectomy with lymph node dissection thoracoscopically followed by preoperative chemotherapy. During the lymph node dissection along the right recurrent laryngeal nerve, we recognized the anomaly of the thoracic duct, which crossed to the right side of the esophagus and joined the right venous angle. Hence, the thoracic duct was cut in order to avoid chylothorax caused by intraoperative injury. After the surgery, more than 1,000 mL/day discharge was confirmed through the thoracostomy tube, thus extracellular fluid and albumin preparation were administered intravenously. The discharge decreased day by day, and enteral nutrition was started on postoperative day （POD） 5. The drainage tube was removed on POD 6 after confirming the absence of chylothorax. We believe that complications can be avoided with the careful management for the anomalous thoracic duct.