大動脈食道瘻に対して胸腔鏡下食道亜全摘術を行った2例

Two case reports of thoracoscopic esophagectomy for aorto-esophageal fistula

◆要旨：症例1：患者は70歳，男性．弓部大動脈瘤に対して大動脈弓部置換術を施行後，4か月後の上部消化管内視鏡検査で食道に瘻孔を認めた．瘻孔内部で大動脈弓部の人工血管の露出を認め，大動脈食道瘻（AEF）と診断した．症例2：患者は68歳，女性．内服薬のPTP包装を誤飲した4日後，吐血を主訴に近医を受診し当科紹介となった．CTで胸部下行大動脈に仮性動脈瘤を認め，異物誤飲によるAEFと診断した．2例とも胸腔鏡下食道切除術，頸部食道瘻，腸瘻造設術を施行し，全身状態の改善を待って二期的食道再建術を行った．AEFにおける食道亜全摘術は右側方開胸を基本としているが，出血や炎症の波及が軽度の症例では侵襲低減のため胸腔鏡下手術も考慮すべきと思われた．

　A 70-year-old man underwent total aortic arch replacement for aortic arch aneurysm. Four months later, esophageal fistula was discovered by upper gastrointestinal tract endoscopy. We diagnosed the case as aorto-esophageal fistula （AEF） because a synthetic graft was revealed in the fistula. A 68-year-old woman vomited blood four days after swallowing a press-through package by mistake. Because pseudoaneurysm of thoracic descending aorta was confirmed by CT, we diagnosed the case as AEF. Emergency surgery was performed on both cases : thoracoscopic subtotal esophagectomy, cervical esophagostomy, and tube jejunostomy. After improvement of general condition, they both underwent two-stage reconstruction of the alimentary tract. Although open subtotal esophagectomy is the standard for AEF, thoracoscopic surgery is feasible in cases with mild inflammation and bleeding for less invasiveness.