Martins A S
Department of Surgery, Faculty of Medical Sciences (Unicamp), Cidade Universitaria, Campinas, Brazil.
Surgery. 1999 Mar;125(3):357-62.
Extensive posterior tracheal wall invasion in pharyngoesophageal carcinomas is considered by many authors to be a contraindication for total pharyngolaryngoesophagectomy and gastric transposition (TPLEGT). The purpose of this report is to challenge this concept and to illustrate posterior tracheal wall resection in selected cases followed by reconstruction of the trachea by anastomosis of the remnant trachea to the anterior gastric wall without thoracotomy.
Four of 36 consecutive patients (11%) undergoing TPLEGT were treated with the following procedure: 3 patients had cervical esophageal carcinomas and 1 had a postcricoid carcinoma. All the patients had longitudinal involvement of the posterior wall of the trachea, which necessitated resection within 1.5 to 2.0 cm of the carina. The technique consisted of removing the specimen en bloc with the posterior wall of the trachea. Without the specimen in place, the surgical field at the thoracic inlet was large enough to permit a continuous running suture between the remnant tracheal wall and the serosa of the transposed stomach. The pharyngogastric anastomosis was subsequent to this procedure.
One patient died in the hospital after complications of chylothorax and sepsis, but this was unrelated to the gastrotracheal anastomosis. One patient died of pneumonia after a cerebrovascular accident 2 months after the procedure. Two patients had effective palliation for 9 and 18 months, respectively.
TPLEGT may be used in selected patients with pharyngoesophageal tumors. The anterior wall of the stomach is a suitable substitute for the posterior tracheal wall. The gastric bulging into the trachea is not enough to obstruct the lumen. However, we caution that tracheal involvement should be limited to the midline and that there is a potential for a gastrotracheal fistula.
许多作者认为，下咽食管癌广泛侵犯气管后壁是全下咽喉食管切除术及胃转位术（TPLEGT）的禁忌证。本报告的目的是对这一观念提出质疑，并阐述在特定病例中进行气管后壁切除，然后在不进行开胸手术的情况下，将残余气管与胃前壁吻合重建气管的方法。
在连续接受TPLEGT的36例患者中，有4例（11%）接受了以下手术：3例为颈段食管癌，1例为环状软骨后癌。所有患者气管后壁均有纵向受累，需要在隆突1.5至2.0厘米范围内进行切除。该技术包括将标本与气管后壁整块切除。在标本移除后，胸廓入口处的手术视野足够大，能够在残余气管壁与转位胃的浆膜之间进行连续缝合。在此操作之后进行咽胃吻合。
1例患者因乳糜胸和脓毒症并发症在医院死亡，但这与胃气管吻合无关。1例患者在术后2个月因脑血管意外后死于肺炎。2例患者分别获得了9个月和18个月的有效姑息治疗。
TPLEGT可用于部分下咽食管肿瘤患者。胃前壁是气管后壁的合适替代物。胃突入气管不足以阻塞管腔。然而，我们提醒，气管受累应限于中线，且存在胃气管瘘的可能性。
