胸腔鏡下食道切除後の胃管気管瘻に対する胸腔鏡下気管瘻閉鎖術

Minimally invasive surgery for gastro-tracheal fistula after esophagectomy

◆要旨：胃管気管瘻孔は食道癌術後の稀な合併症である．その要因は多岐にわたり，その治療法も非常に複雑かつ困難である．これまで，胸腔鏡下食道亜全摘出術後に胃管気管瘻をきたし，胸腔鏡下に治療しえた症例を2例経験した．両症例とも，瘻孔形成の原因が胃管側にあり，また気管膜様部側の瘻孔の径は5mm程度と小さく周囲組織の脆弱性も認めなかった．気管側の瘻孔部は単純閉鎖を行ったのち，1例は自己心膜を，もう1例は胃管の大網をパッチとして固定した．両症例とも術後経過は良好であった．胸腔鏡下気管瘻閉鎖術は初回手術が胸腔鏡下手術であること，また気管側の瘻孔の径が小さく，かつ単純閉鎖が可能であることが重要であると考えられた．

　Gastro-tracheal fistula after esophagectomy for esophageal cancer is a comparatively rare complication. Various factors, such as prolonged intubation, anastomotic leakage, necrosis of gastric conduit, microabscess of staple line on the conduit, contribute to gastro-tracheal fistula development. Some reports have suggested that conservative therapy is effective, but in most cases, surgical intervention is necessary. In our institution, we have had two cases in which we were able to treat gastro-tracheal fistula successfully with thoracoscopic surgery. Both patients had undergone minimally invasive esophagectomy for esophageal cancer. In both cases, gastro-tracheal fistula developed between anastomotic site of gastric conduit and trachealis muscle. Various examinations showed that the cause of the fistula was located on the anastomotic site of gastric conduit and the fistula was small, measuring 5 mm in diameter. Because esophagectomy had been performed with thoracoscopy and gastro-tracheal fistula was comparatively small, we decided that it could be repaired with thoracoscopic surgery. Intraoperative findings revealed a small hole on trachealis muscle and its surrounding tissue was not so damaged. Therefore, we decided that the hole on the trachea could be closed with simple interrupted sutures. In one case pericardium was used for reinforcement of the closure, and omentum of gastric conduit for the other. Their postoperative courses were uneventful. In this report, we presented two cases in detail and discussed about the criteria of minimally invasive surgery for gastro-tracheal fistula after esophagectomy.