気管壁に浸潤した甲状腺癌切除後の頸部気管再建術—1次的頸部廓清術と併用し得る術式の検討

PRIMARY RECONSTRUCTION OF THE CERVICAL TRACHEA FOLLOWING EXTIRPATION OF THE FHYROID CANCER THAT INVADED THE TRACHEA

　I．はじめに

　血管造影法の応用^1）により甲状腺癌の術前の診断はかなり確実に行なえるようになり，甲状腺腫の切除範囲の決定に，また気管壁に強く癒着した甲状腺腫では気管壁の処置を考える上に役立つている。

　乳頭状腺癌・濾胞状腺癌などの分化型腺癌は局所の腫瘍を十分に切除すれば予後はぎわめて良好であるが，一方照射療法，化学療法は効果がない。術中に食道または気管に浸潤した腫瘍の一部が残存しても，臨床上再発が明らかとなるまでの期間が長く，一見経過良好のようにみえるが，結局は気道狭窄症状，嚥下障害を起こす事になり，また遠隔転移の原因ともなる。分化型甲状腺腺癌における局所の処置は他の癌腫とは異なつて周囲の組織をも含めて広範囲に切除する必要はないが，気管壁への浸潤が肉眼的に明らかな症例では腫瘍とともに気管壁を切除する必要がある。

　The surgical procedures primarily directed towards the reconstruction of the cervical trachea which can be satisfactorily combined with primary radical neck dissection are described.

　In thyroidectomy, a low-collar incision along the border of the clavicula is routinely used. The thyroid gland is exposed and if angiographic findings or other clinical findings suggest malignancy, the paratracheal and deep jugular lymph nodes are further examined histologically by frozen sections.

　If these examinations are, in any way positive, radical neck dissection is performed with modified MacFee skin incision.

　To reconstruct the total loss of the cervical trachea. the medially based rectangular low cervical skin flap is designed on the same side in which the radical neck dissection is performed.

　The cervical skin flap is folded longitudinally and turned in the midline of the neck to cover the inner side of the tracheal space.

　The medially based anterior chest flap is designed and transposed superiorly and medially and is folded on itself longitudinally with the skin surface outside. This flap covers the donorsite of the cervical flap and also covers the other half of the tracheal space. The free-edges of the chest flap and the cervical flap are sutured on the mid-line of the cervical esophagus.

　The donorsite of the chest flap is primarily closed.

　After primary operation the entire circle of the tracheal space is covered by the flap leaving a narrow longitudinal fistula in the midline.

　The rib cartilage graft is made in the superolateral wall of the reconstructed trachea in thesecond stage.

　The tracheal fistula is closed in the third stage.

　Three other reconstructive procedures of the trachea to be employed in accordance to the extent of the defect. age and the general condition of patients are, also, described.