We report a very rare case of delayed necrosis of the reconstructed colon 6 months after esophagectomy.

A 67-year-old male patient had undergone esophagectomy with gastric tube reconstruction for esophageal cancer in 2014. Subsequently, total gastrectomy and ileo-colon reconstruction via a retrosternal route was performed for gastric tube cancer in 2022. Six months later, he suffered acute chest pain and came to our hospital. Contrast-enhanced CT showed severe dilation of the reconstructed colon with poor enhancement of the wall opposite mesentery, without arterial obstruction. Endoscopy showed no ischemic changes in the esophago-ileum anastomosis; however, mucosal color change to black was observed in the reconstructed colon. We diagnosed ischemic colitis of the reconstructed colon and started conservative treatment; however, 18 days later, he developed a right pyothorax due to perforation of the reconstructed colon. We performed necrosed colectomy with right chest drainage and cervical esophageal fistula was made. Histopathological examination revealed mucosal detachment, thinning of the muscularis propria, and ghost-like appearance of crypt. If necrosis of the reconstructed colon is suspected in the late postoperative period, endoscopic findings of the colonic mucosa may be useful in determining surgical treatment, even in the absence of arterial blood flow obstruction.