Oki Tomonari, Iizuka Shuhei, Tomatsu Makoto, Nakamura Toru
Department of General Thoracic Surgery, Seirei Hamamatsu General Hospital, Hamamatsu, Shizuoka, Japan.
Department of Gastrointestinal Surgery, Seirei Hamamatsu General Hospital, Hamamatsu, Shizuoka, Japan.
Surg Case Rep. 2025;11(1). doi: 10.70352/scrj.cr.25-0170. Epub 2025 Jun 11.
Bronchopleural fistulae (BPFs) following pulmonary resection are potentially fatal complications, with right lower lobectomy being the most susceptible among lobectomies. As esophagectomy also increases the risk of tracheobronchial ischemia and postoperative malnutrition, performing a single-stage esophagectomy combined with right lower lobectomy may further elevate the risk of BPFs, underscoring the need for meticulous preoperative planning.
A 64-year-old male with a history of heavy smoking was referred to our hospital after an abnormal mass was detected on a chest radiograph during an annual health check. Chest CT revealed a 3.7 cm consolidative mass in the right lower lobe, resulting in a diagnosis of primary lung cancer, classified as T2aN0M0, stage IB. Additionally, abnormal fluorodeoxyglucose (FDG) uptake was observed in the lower thoracic esophagus, leading to a diagnosis of synchronous esophageal cancer, classified as T1bN0M0, stage I. As both lesions required upfront surgical resection via the right thoracic cavity, a single-stage esophagectomy and right lower lobectomy were planned. Initially, esophagectomy was performed using a five-port video-assisted thoracic surgery (VATS) approach in the prone position from the right side. To preserve the blood supply to the fifth intercostal muscle for subsequent harvesting as a muscle flap, the utility port in the corresponding intercostal space was placed as ventrally as possible. The esophagectomy was performed while preserving the right main bronchial artery. The patient was then repositioned to the left lateral decubitus position, and the preserved fifth intercostal muscle flap was harvested. A right lower lobectomy was completed, preserving the bronchial artery, and the bronchial stump was reinforced using the harvested muscle flap. Despite postoperative development of esophagogastric anastomotic leakage, the patient did not develop a BPF, and no signs of BPF have been observed during 12 months of follow-up.
Preservation of the right main bronchial artery and reinforcement of the bronchial stump with an intercostal muscle flap facilitated prevention of BPF following single-stage esophagectomy and right lower lobectomy, despite the patient's history of heavy smoking and transient postoperative malnutrition.
肺切除术后支气管胸膜瘘（BPF）是潜在的致命并发症，在肺叶切除术中，右下叶切除术最易发生。由于食管切除术也会增加气管支气管缺血和术后营养不良的风险，因此一期行食管切除术联合右下叶切除术可能会进一步提高BPF的风险，这突出了精心术前规划的必要性。
一名64岁有大量吸烟史的男性在年度健康检查时胸部X光片发现异常肿块后被转诊至我院。胸部CT显示右下叶有一个3.7 cm的实性肿块，诊断为原发性肺癌，分类为T2aN0M0，IB期。此外，在胸段下段食管观察到异常氟脱氧葡萄糖（FDG）摄取，诊断为同步性食管癌，分类为T1bN0M0，I期。由于两个病变都需要通过右侧胸腔进行前期手术切除，因此计划一期行食管切除术和右下叶切除术。最初，在右侧俯卧位采用五孔电视辅助胸腔镜手术（VATS）方法进行食管切除术。为了保留第五肋间肌的血供以便后续作为肌瓣采集，相应肋间间隙的实用端口尽可能靠近腹侧放置。在保留右主支气管动脉的情况下进行食管切除术。然后将患者重新定位为左侧卧位，采集保留的第五肋间肌瓣。完成右下叶切除术，保留支气管动脉，并用采集的肌瓣加固支气管残端。尽管术后出现了食管胃吻合口漏，但患者未发生BPF，在12个月的随访期间未观察到BPF的迹象。
尽管患者有大量吸烟史和术后短暂营养不良，但保留右主支气管动脉并用肋间肌瓣加固支气管残端有助于预防一期食管切除术和右下叶切除术后的BPF。
