lymphangiomas are rare benign tumors , and are located preferentially in head , neck , and axilla in children . of all the lymphangiomas in the peritoneal cavity , about 70% of them have been found in the mesentery of small intestine . this report describes a case of omental cystic lymphangioma of the stomach associated with earlier subtotal gastrectomy for gastric cancer . a 76-yr - old man who presented with an 8-month history of postprandial abdominal discomfort and bowel habits change was referred from a local clinic , because of a huge intraabdominal cystic lesion on abdominal computed tomographic ( ct ) scan . according to his medical history , he underwent subtotal gastrectomy ( billroth ii operation ) 10 yr ago for early gastric cancer at st . gastrointestinal endoscopic examination revealed no local recurrence at the previous gastrojejunostomy anastomosis or intraluminal pathologic lesion . an abdominal computed tomography showed about 1215 cm sized non - enhancing cystic mass , suspicious of a cystic neoplasm of pancreas , mesenteric cyst , or omental lymphangioma ( fig . the patient underwent exploration which showed no evidence of ascites , peritoneal dissemination , or metastasis in abdominal cavity . during exploration and resection , the cystic tumor was found not to involve mesentery of the colon , remnant stomach and retroperitoneum , however , technically complete removal of the tumor without resection of distal pancreas and spleen was not feasible . therefore , enbloc resection of the cystic tumor with the greater omentum , distal pancreas and spleen with no spillage of cystic fluid was performed . after resection , cystic tumor was grossly measured 16.512.03.5 cm , but the attached distal pancreas and spleen were grossly unremarkable ( fig . the encapsulated cystic mass had a pinkish smooth external surface attached with distal pancreas and spleen in continuity , and cut sections showed grayish white , trabeculated , and glistening in the inner cut surface of multilocular cyst . the cyst was filled with strawberry colored serous fluid , the thickness of cystic wall was measured less than 0.1 cm , and there was no solid area . histologically , the cystic wall consisted of a fibroconnective tissue accompanied by dilated lymphatic spaces of varying sizes and lymphoid cell aggregations in the endothelial lining of lymphatic vessels , and there was no evidence of recurrence or metastasis from gastric cancer . immunohistochemical stainings showed positive for cd31 and smooth muscle actin ( sma ) ( fig . the patient had an uneventful postoperative course , and no evidence of recurrence had also been found in a 3-yr follow - up period . cystic lymphangioma is a rare congenital malformation of the lymphatics which is found predominantly in children , and abdominal lymphangioma is far more extremely rare , especially in adult population ( 1 - 5 ) . although the etiology remains unclear , lymphangioma is thought to be due to a developmental failure and possible lymphatic obstruction followed by the inflammation of lymphatic channels ( 1 - 5 ) . cystic lymphangiomas can be located in any part of the body except the brain , and they are most frequently a single cyst and also affect a single organ ( 2 , 5 ) . the tumors are usually located in the neck ( 75% ) , axilla ( 20% ) , and other part of the body ( 4 - 5% ) ( 2 , 5 ) , and less than 1% of lymphangiomas affect the mesentery , greater omentum , and retroperitoneum ( 5 ) . abdominal lymphangiomas can occur at any age and most are asymptomatic . in adults , symptoms and signs are commonly insidious in onset rather than acute ( 1 , 2 , 4 - 6 ) . it is important to distinguish cystic lymphangioma from other cystic neoplasms such as mesenteric cyst , peritoneal mesothelioma , and retroperitoneal cystic neoplasm . histologically , lymphangioma is characterized by a flat epithelial endothelium and a wall containing alternatively lymphoid tissue , small lymphatic spaces , smooth muscle , and foam cells ( 5 - 7 ) . furthermore , this endothelial lining and stroma cells are usually stained positively with anti - factor viii - related antigen or anti - cd 31 by immunohistochemistry ( 7 , 8) . the treatment of choice is complete resection to yield a cure for this benign lesion , but resectability depends on its size , location , and adhesions or invasions to vital structures ( 1 - 6 ) . in the present case , en - bloc resection of cystic tumor with distal pancreatectomy and splenectomy was indicated because this huge neoplasm could be a malignant tumor and a possible local recurrence if the resection was incomplete . in english - written literatures , cystic lymphangiomas arising from the omentum have mostly been described as congenital primary lesions , and some secondary lesions concurrently with other primary tumors have also been reported . to the best of our knowledge , this could be the first case report of an acquired intraabdominal cystic lymphangioma arising from the greater omentum , associated with earlier gastric resection for gastric cancer . in general , during subtotal gastrectomy for distal gastric cancer , the greater omentum at the high body and around the spleen is not indicated for dissection and resection . in the present case , as described above in the operative findings , cystic lymphangioma was thought to originated from the remnant greater omentum after incomplete omentectomy in the previous subtotal gastrectomy for distal gastric carcinoma . long standing lymphatic obstruction and stasis during the past 10 yr after subtotal gastrectomy is strongly suggested as the pathophysiologic predisposing factor to the development of this unusual case .
we herein describe a case of cystic lymphangioma in the greater omentum of the remnant stomach , which is thought it to be related with subtotal gastrectomy 10 yr ago for early gastric cancer . 
 a 76-yr - old man was admitted to our department with postprandial abdominal discomfort and bowel habit change . 
 intraabdominal multilocular cystic mass was detected by ultrasonography and computed tomography . 
 we performed a complete en - bloc tumor resection including spleen and distal pancreas , and histological examination confirmed cystic lymphangioma originated from the greater omentum of the remnant stomach . 
 although the etiology of omental lymphangioma remains largely unclear , these findings suggested strongly that obstruction of the lymphatic vessels after gastric resection for gastric carcinoma might be the most plausible cause . 
 the surgical extirpation with resection of organs involved appears to be a treatment of choice for such unusual case .