胸骨後経路再建術後の胃管癌に対する胃管全摘術—腹腔鏡下縦隔アプローチの有用性

Resection of gastric tube cancer after retrosternal reconstruction : Usefulness of laparoscopic mediastinal approach

◆要旨：食道亜全摘・胸骨後経路再建術後の胃管癌に対して腹腔鏡下縦隔アプローチにて胃管全摘術を行った症例を経験したので報告する．症例は66歳の男性．53歳時に食道癌に対し右開胸食道亜全摘・胸骨後経路胃管再建術，63歳時に喉頭癌に対し咽頭喉頭頸部食道全摘・遊離空腸再建術を施行された．経過観察中に胃管癌を発症し手術を施行した．手術は腹腔鏡下縦隔アプローチにて胃管と周囲臓器との癒着を剝離し，次に頸部から縦隔剝離層と交通させ空腸を切離，胃管と郭清組織を腹腔内に抜去後に開腹下に結腸再建を行った．本術式では術前シミュレーションによるポート位置などの工夫により良好な視野で低侵襲に胃管全摘術を行うことが可能であった．

We encountered a 66-year-old man with gastric tube cancer after retrosternal reconstruction who underwent gastric tube resection through a laparoscopic mediastinal approach. Right transthoracic subtotal esophagectomy with gastric tube reconstruction through a retrosternal route had been performed for esophageal cancer at the age of 53 years; total laryngopharyngectomy combined with cervical esophagectomy and free jejunum reconstruction were performed for laryngeal cancer at the age of 63 years. He was diagnosed with gastric tube cancer on follow-up studies 3 years later, and underwent surgery. We initially approached the gastric tube laparoscopically and dissected adhesions between the gastric tube and pleura, pericardium, and sternum. We then incised the skin at the neck and extended the dissected space from the neck to the mediastinum. After transection of the reconstructed jejunum, the gastric tube was moved to the peritoneal cavity. Reconstruction was performed with the left hemicolon. The laparoscopic mediastinal approach was useful for resection of the retrosternal gastric tube, with less invasiveness and better view, through adequate preoperative planning of port positions and preparation of surgical instruments.