Matsubara T, Ueda M, Takahashi T, Nakajima T, Nishi M
Department of Surgery, Cancer Institute Hospital, Tokyo, Japan.
J Am Coll Surg. 1997 Dec;185(6):520-4. doi: 10.1016/s1072-7515(97)00102-6.
Pulmonary complications have been a major cause of mortality after operations for cancer of the thoracic esophagus. Although the risk involved in esophagectomy associated with a major pulmonary operation is expected to be high, it has seldom been evaluated on the basis of clinical experience.
Of 408 patients who underwent esophagectomy, 8 had previously undergone major pulmonary operation (7 for tuberculosis and 1 for pulmonary cancer) and 10 underwent concurrent major pulmonary resection (7 for pulmonary invasion of esophageal cancer, 2 for synchronous pulmonary cancer, 1 for extensive bronchiectasia). All patients underwent systematic lymph node dissection for esophageal cancer, except one patient with mucosal cancer. To prevent postoperative complications, the operative approach and dissection procedures for esophageal cancer were modified according to the associated pulmonary operation and the extent of cancer invasion. All thoracotomies for esophagectomy were performed on the same side as the major pulmonary operation. Additional median sternotomy was performed when necessary. In the most recent 8 patients who underwent major pulmonary resection concurrent with esophagectomy, the bronchial stump was covered with a pedicle flap.
Of the 18 patients who underwent pulmonary operation, postoperative complications developed in 13 of the 18 object patients, but none was fatal. The 3-year survival rate was 45%. All deaths were caused by esophageal cancer or another cancer.
Aggressive esophagectomy associated with major pulmonary operation is not contraindicated in patients with fair risk conditions. The operative procedures for esophagectomy should be appropriately modified to minimize the effect of the associated pulmonary operation. Special care should be taken with respect to the approach for mediastinal dissection and closure of the bronchial stump.
肺部并发症一直是胸段食管癌手术后死亡的主要原因。尽管食管癌切除术与大型肺部手术相关的风险预计很高，但很少根据临床经验进行评估。
在408例行食管癌切除术的患者中，8例曾接受过大型肺部手术（7例因肺结核，1例因肺癌），10例同时接受了大型肺切除术（7例因食管癌肺侵犯，2例因同时性肺癌，1例因广泛支气管扩张）。除1例黏膜癌患者外，所有患者均接受了系统性食管癌淋巴结清扫术。为预防术后并发症，根据相关肺部手术及癌症侵犯范围对食管癌的手术入路和清扫程序进行了改良。所有食管癌开胸手术均在与大型肺部手术同侧进行。必要时加做正中胸骨切开术。在最近8例同时行食管癌切除术和大型肺切除术的患者中，支气管残端用带蒂皮瓣覆盖。
在18例行肺部手术的患者中，18例目标患者中有13例发生了术后并发症，但无一例死亡。3年生存率为45%。所有死亡均由食管癌或其他癌症引起。
对于风险状况尚可的患者，与大型肺部手术相关的积极食管癌切除术并非禁忌。应适当改良食管癌切除术的手术操作，以尽量减少相关肺部手术的影响。在纵隔清扫入路和支气管残端闭合方面应特别小心。
