有茎肋間筋弁で修復した食道癌術後気管膜様部穿孔の一例 <症例報告>

食道癌手術における気管膜様部損傷は致命的な合併症となる。77歳男性，Stage Ⅳ a の食道癌と診断して5-Fu とCDDP による術前化学療法を2Kur 施行したが，食道癌と縦隔および肺に瘻孔を生じたため手術に踏み切った。胸腔鏡下胸部食道全摘術３領域郭清を行い，胃管を用いた胸骨後経路で再建した。術後８日目気管膜様部の穿孔が確認され再手術となった。右後側方切開第５肋間開胸でアプローチすると気管膜様部に３cmの虚血様変化があり，その中心部に１cmの穿孔を認めた。第４肋間筋を有茎筋弁として用いて修復した。再手術後air leak がみられたが，気管切開してカフの位置を調節して穿孔部に当たらないように注意して管理した。再手術後68日目に気管内挿管チューブと胸腔ドレーンを抜去した。抜管時の気管支鏡の所見では瘻孔部位に陥凹は見られるが正常気管上皮で覆われていた。114日目に治癒退院となったが，初回手術より２年後に再発は無く肺炎で亡くなられた。食道癌の術後に気管膜様部損傷の合併症がみられた重篤な症例であったが集中管理で治癒退院できた貴重な症例を経験したので報告する。

During surgery for esophageal cancer, injury to the membranous trachea is a lethal complication. A 77-year-old male patient was diagnosed to have esophageal cancer T4 （AI）, N1, M0 Stage IVa. Therapy with 5-Fu and CDDP was administered. After 2 cycles of chemotherapy, a fistula developed in the mediastinum and the lung. Therefore, we decided to perform a subtotal esophagectomy and lymphadenectomy of the 3rd region. In addition, we performed a peeling operation with a vessel-sealing system fusion device （Thunder Beat） and lymphadenectomy. Pathological classification was AD, SCC and staging was T3, N2, and M0 Stage III. On the 7th post-operative day, air leakage was noted around the thoracic drain and computed tomography （CT） showed large amount of left pleural effusion. The membranous portion of the trachea fistula was found by bronchoscopy. Therefore, we immediately performed a reoperation. During the reoperation, a 3-cm sized ischemic change was found, and at the centre of the ischemic region, a 1-cm sized fistula was observed. We subsequently created a pedicled muscle flap using the 4th intercostal muscle. After the operation, we carefully manipulated the cuff of the tracheal tube to prevent attachment to the repaired region. On the 68th postoperative day, we were able to remove the tracheal intubation tube and the thoracic cavity drain. On bronchoscopy, the fistula resign was uneven; however, normal epithelial cells covered the surface. At the 114th post-operative day, the patient was discharged from the hospital with complete recovery. However, 2 years after the initial surgery, the patient died due to bronchial pneumonia.