右下葉切除後の中間幹膜様部穿孔に対する中葉切除

Successful Treatment by Performing a Middle Lobectomy for a Postoperative Bronchus Intermedius Membrane Perforation After Right Lower Lobectomy

術後気管支瘻は，いったん発症した際には治療に難渋する肺癌術後の重篤な合併症である．その多くは気管支断端瘻によるものであり，中間気管支幹（中間幹）穿孔によって生じるものはきわめてまれである．われわれは右下葉切除術後に中間幹膜様部穿孔により膿胸をきたし，残存中葉切除を施行することで救命しえた症例を経験したので報告する．

We report a case of postoperative perforation in the bronchus intermedius membrane after pulmonary resection for lung cancer. An 83-year-old man with lung cancer underwent thoracoscopic right lower lobectomy＋ND2a-1 dissection. On postoperative day 11, subcutaneous emphysema appeared to him, and chest radiograph showed niveau formation and pleural effusion on the operative side. Chest computed tomography （CT） suggested a bronchial membrane defect of the bronchus intermedius. We confirmed a bronchial perforation in the bronchus intermedius membrane by bronchoscopy and performed urgent operation. The defect of the perforated membrane was too large to be sutured directly, so a middle lobectomy was performed. After this operation, the patient had a small bronchial stump fistula which was successfully treated with endoscopic bronchial occlusion. Although the patient required treatment for heart failure, he recovered and was discharged 44 days after the reoperation. This perforation could be caused not only by bronchial ischemia due to subcarinal lymph node dissection, but also by injury to the adventitia of the bronchus intermedius membrane due to rough handling and unrecognized burning of the injured area with an electric scalpel. Thermal damage caused by energy devices needs to be noted.