Moriwake Kazuya, Noma Kazuhiro, Kawasaki Kento, Matsumoto Tasuku, Hashimoto Masashi, Kato Takuya, Maeda Naoaki, Tanabe Shunsuke, Shirakawa Yasuhiro, Fujiwara Toshiyoshi
Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-Cho, Kita-Ku, Okayama, 700-8558, Japan.
Department of Surgery, Hiroshima City Hiroshima Citizens Hospital, 7-33 Motomachi, Naka-Ku, Hiroshima, Japan.
Surg Case Rep. 2024 May 22;10(1):128. doi: 10.1186/s40792-024-01919-5.
Pancreatoduodenectomy and subtotal esophagectomy are widely considered the most invasive and difficult surgical procedures in gastrointestinal surgery. Subtotal esophagectomy after pancreatoduodenectomy is expected to be extremely difficult due to complicated anatomical changes, and selecting an appropriate intestinal reconstruction method will also be a difficult task. Therefore, perhaps because the method is considered impossible, there have been few reports of subtotal esophagectomy after pancreatoduodenectomy.
A 73-year-old man with a history of pancreatoduodenectomy was diagnosed with superficial thoracic esophageal squamous cell carcinoma. Definitive chemoradiation therapy was recommended at another hospital; however, he visited our department to undergo surgery. We performed the robot-assisted thoracoscopic subtotal esophagectomy. There were some difficulties with the reconstruction: the gastric tube could not be used, the reconstruction was long, and the organs reconstructed in the previous surgery had to be preserved. However, the concurrent reconstruction was achieved with the help of a free jejunal flap and vascular reconstruction. All reconstructions from the previous surgery, including the remnant stomach, were preserved via regional abdominal lymph node dissection. After reconstruction, intravenous indocyanine green showed that circulation in the reconstructed intestines was preserved. On postoperative day 1, no recurrent nerve paralysis was observed during laryngoscopy. The patient could start oral intake smoothly 2 weeks after surgery and did not exhibit any postoperative complications related to the reconstruction. The patient was transferred to another hospital on postoperative day 21.
Owing to the free jejunal flap interposition method, we safely performed one stage subtotal esophagectomy and concurrent reconstruction, preservation of the remnant stomach, and pancreaticobiliary reconstruction in patients with a history of pancreatoduodenectomy. We believe that this method is acceptable and useful for patients undergoing complicated reconstruction.
胰十二指肠切除术和食管次全切除术被广泛认为是胃肠外科中最具侵入性和难度的手术。胰十二指肠切除术后行食管次全切除术由于解剖结构复杂变化预计极其困难，选择合适的肠道重建方法也将是一项艰巨任务。因此，或许由于该方法被认为不可行，胰十二指肠切除术后食管次全切除术的报道很少。
一名有胰十二指肠切除术病史的73岁男性被诊断为胸段食管浅表鳞状细胞癌。另一家医院建议行确定性放化疗；然而，他前来我院接受手术。我们实施了机器人辅助胸腔镜食管次全切除术。重建过程存在一些困难：不能使用胃管，重建长度较长，且必须保留先前手术中重建的器官。然而，在游离空肠瓣和血管重建的帮助下实现了同期重建。通过区域腹部淋巴结清扫保留了先前手术的所有重建结构，包括残胃。重建后，静脉注射吲哚菁绿显示重建肠道的血液循环得以保留。术后第1天，喉镜检查未发现喉返神经麻痹。患者术后2周可顺利开始经口进食，未出现任何与重建相关的术后并发症。患者于术后第21天转至另一家医院。
由于采用了游离空肠瓣置入法，我们成功地为有胰十二指肠切除术病史的患者安全地进行了一期食管次全切除术及同期重建、保留残胃和胰胆管重建。我们认为该方法对于接受复杂重建的患者是可接受且有用的。
