20. 気管分岐部の切除を要する肺切除と周術期管理

Carinal Resection with Lung Resection and Perioperative Management

日本胸部外科学会の報告によると，2017年の呼吸器外科手術85,303例のうちスリーブ肺葉切除が492例（0.58％）であるのに対し，気管分岐部再建は31例（0.036％），スリーブ肺摘除は12例（0.014％）であり，気管分岐部の切除は非常にまれな術式となっている．また，院内死亡率はスリーブ肺葉切除が0.4％であるのに対し，気管分岐部再建では6.5％，スリーブ肺摘除では16.7％であり，気管分岐部の切除には非常に高いリスクを伴う1）．しかしながら，気管分岐部切除を行うことでしか救えない患者のために呼吸器外科専門医はその技術を習得しておく必要がある．本稿では当科で経験した気管分岐部切除を要した右上葉肺癌の2例を提示するので，気管分岐部切除・再建における注意点とそのリスクを再認識してもらいたい．

Carinal resection with lung resection is a rare surgical procedure with high risk. In-hospital mortality rates for carinal reconstruction and sleeve pneumonectomy were 6.5％ and 16.7％, respectively. Thus, thoracic surgeons need to learn the procedure for patients who need the surgery. This time, we will account for preoperative evaluation, intraoperative advice, and postoperative management in carinal resection with right upper lobectomy presenting 2 cases in our hospital.

Case 1 had a high caliber mismatch of bronchial stumps because of partial carinal resection, which was corrected by simple sutures of the anterior cartilage. That allowed us to perform sleeve right upper lobectomy avoiding carinal reconstruction. Case 2 was a case in which lung and bronchial tissue sticking to mediastinum due to obstructive pneumonia prevented us from anastomosing intermediate bronchus to the trachea or left main bronchus. We had to choose sleeve right pneumonectomy, and a fistula on the anastomotic site occurred later resulting in a bad course. We hope our experiences aid future patients who need the carinal resection.