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症例は60 歳代, 男性. 身長162.6 cm, 体重40.0 kg, Body Mass Index（BMI）15.1 kg / m2であり, 既往歴に慢性閉塞性肺疾患（COPD）を認めた. 胸部上部食道癌 T1b N0 M0 Stage Iに対して食道亜全摘, 3領域リンパ節郭清, 胸骨後胃管再建を施行した.術当日に抜管したが, 術後肺炎に伴う呼吸不全のため, 術後6日目に気管内挿管を試みたが、食道挿管となった．再挿管, 人工呼吸管理の後に軽快し術後13日目に抜管となったが, 術後透視で吻合部周囲に造影剤漏出を認めた. 2ヶ月間の保存的加療で造影剤漏出は消失したが吻合部に長径4 cmの高度狭窄を認めた．内視鏡的拡張術での改善は困難であり, 術後243日目に消化管再建術を施行した. 手術所見として, 第2肋間より頭側の胸骨を切除したところ, 胃管の口側断端は第2肋間の高さの胸骨後面に位置していた.食道断端までは肉芽で置換されていた.胸骨前経路回結腸再建を施行し, 再建術後 8日目に食事を開始し, 合併症なく再建術後30日目に退院となった. 回結腸再建後2年経過後も食道癌の再発は認めず, 通過障害なく経口摂取のみでの生活が可能となっている．, A 60s-year-old man underwent endoscopic screening during which a tumor was detected in the upper thoracic esophagus, which was diagnosed as T1bN0M0 Stage I esophageal squamous cell carcinoma. He had a history of chronic obstructive pulmonary disease. He underwent subtotal esophagectomy with 3 field lymph node dissection. Reconstruction was performed by gastric tube through the posterior sternal route. Extubation was performed on the day of surgery. Respiratory failure by postoperative pneumonia occurred, and ventilatory management was performed on the sixth postoperative day. However, the intubation was put into the esophagus. He became well and extubation was performed on the 13th postoperative day. Postoperative fluoroscopy showed contrast leakage around the anastomotic site. After 2 months of conservative treatment, the contrast leak disappeared, but there was a severe stenosis of 4 cm in length at the anastomosis. Endoscopic dilatation was not sufficient to improve the stenosis. Gastrointestinal reconstruction was performed on the 243rd postoperative day. The cephalic sternum was resected, and the gastrointestinal canal opening margin was located on the posterior surface of the sternum, at the level of the second intercostal space. The segment was replaced by a granulation. The patient underwent anterior sternal ileocolic reconstruction. Oral intake started on the 8th day after the reconstruction, and hospital discharge was on the 30 th day after the reconstruction without any complications. Two years after ileocolic reconstruction, there has been no cancer recurrence, and he lives well on oral intake only.

【はじめに】超高齢社会が到来し高齢食道癌患者も増加している。食道癌手術は高侵襲で高齢者には併存疾患も多く、80歳以上の手術適応はより慎重な判断を要するため、当科での成績を基にその妥当性について考察する。【対象】2014年10月から2021月7月に手術を施行した80歳以上の食道癌8例の成績を検討した。当科では低侵襲を目指した胸腔鏡手術、当日抜管、翌日の離床を試みている。全例栄養瘻を造設し翌日より経腸栄養を開始している。【結果】80歳以上の食道癌は8例(男性7例、女性1例)、術前Performance status (PS)は全例0。全例併存疾患あり。腫瘍主占拠部位は胸部上部:1例、中部:4例、下部:3例。臨床病期はStage I:1例、Stage III:7例。全例で胸腔鏡下食道亜全摘、胸骨後胃管再建、開胸移行なし。リンパ節郭清範囲は2領域5例、3領域3例。手術時間中央値415分、出血量中央値203ml。術後合併症は縫合不全2例、肺炎3例、反回神経麻痺1例、せん妄1例、非閉塞性腸管虚血での在院死1例。術後在院日数中央値25日。生存退院7例中5例は同居家族のサポートのもと自宅退院、2例は独居であったが訪問看護を導入し自宅退院可能であった。【結語】一般的に食道癌手術は高度侵襲を伴う治療だが、80歳以上の高齢者でも家族の協力や社会的サービスなど在宅支援の充実により自宅退院が可能であった。高齢者は高率に併存疾患を有するため重篤な合併症を発症すると救命困難となる可能性があり、手術適応は慎重な判断を要する。, Background: The elderly patient with esophageal cancer is increasing. The surgical indications for esophageal cancer in elderly patients over 80 years old requires more careful judgement, because surgical resection of esophageal cancer is highly invasive and the elderly have many comorbidities.Method: We evaluated the surgical outcomes in 8 patients of esophageal cancer over 80 who underwent esophagectomy between October 2014 and July 2021. As perioperative management, thoracoscopic surgery aimed at minimally invasive, extubation on POD（postoperative day）0 were attempted. In all cases, we created transgastric jejunostomy and started enteral nutrition on POD1 for early recovery of intestinal peristalsis and suppression of increased catabolism.Results: There were 8 patients of esophageal cancer (7 males, 1 female), and preoperative performance status (PS) was 0 in all cases. The clinical stage was as follows: one case in Stage I, 7 cases in Stage III. All patients underwent thoracoscopic esophagectomy, posterior sternal gastric tube reconstruction, and no open chest transition. The lymph node dissection was as follows: two fields in 5 cases and three fields in 3 cases. Median operation time was 415 minutes, median intraoperative blood loss was 203 ml. Seven patients have some comorbidities. Postoperative complications were observed as follows: two cases of anastomotic leakage, 3 cases of pneumonia, 1 case of recurrent nerve palsy, and 1 case of hospital death due to non-occlusive intestinal ischemia, respectively. Median postoperative hospital stay was 25 days. Of the 7 patients who were discharged alive, 5 were discharged home with the support of their family, and 2 were discharged home with the using of home nursing.Conclusions: In the elderly with esophageal cancer, careful judgement of surgical resection was necessary, due to high rate of postoperative mortality and morbidity. Support of family or social services was necessary for elderly patients over 80 years old.

背景：胃癌の治療においては根治切除手術が必要不可欠であるが、近年は早期胃癌、高齢者の増加に加え、腹腔鏡手術やロボット支援下手術による低侵襲化が進んでいる。一方で胃切除術後の体重減少やダンピング症候群などの生活の質を低下させる「胃切除後障害」が問題となっている。目的：本試験は流動食のみでなく実際に患者が食すであろう食事にできるだけ近づけた形態の半固形食を作成し、健常volunteerに服用してもらい13C-acetate呼気試験を行うことで胃排出能の評価を行うことである。方法：試験は過去に行われた同様の13C-acetate呼気試験と同様に行い、食事は半固形食を使用することで過去の報告の液状食、固形食との胃排出速度との違いを比較した。結果：健常volunteerは年齢45(40–58)歳、男性:女性=5:15、BMI 23.1(20.2-30.5) kg/m2。Cmaxの中央値は32.4 (16.2 – 44.1) (‰), T1/2の中央値は36.8 (13.0 – 75.4)分であった。試験食摂取前から摂取240分までの呼気中の13CO2排出変化量を測定したところ、ピークは摂取後60分であった。過去の同様の研究報告と比較すると、液状食でピークは摂取後30分、固形食では80分といずれとも異なる結果であった。結語：健常volunteerにおいて半固形食を摂取した後の胃排出能は固形食、液状食いずれの結果とも異なるものであった。, Background:Radical resection surgery is essential in the treatment of gastric cancer. However, in recent years, in addition to an increase in the number of early-stage gastric cancers and elderly patients, minimally invasive surgery using laparoscopic or robotic gastrectomy has become popular. With this, post-gastrectomy syndromes that reduce patients’ quality of life, such as weight loss and dumping syndrome, have become a problem. However, the mechanism responsible for these disorders remains unclear. Purpose: In this study, we prepared not only a liquid diet but also a semi-solid diet that was as close as possible to the actual diet that patients would eat. Materials and Methods: The 13C-acetate breath test was performed as described in other studies with a semi-solid diet, and the difference in gastric evacuation rate between the liquid and solid diets reported in previous studies was compared. Results: Forty-five healthy volunteers were included (age range: 40–58 years, male: female = 5:15, Body Mass Index [BMI] 23.1 [range: 20.2–30.5] kg/m2). The median Cmax and median T1/2 was 32.4 (range: 16.2–44.1) ‰ and 36.8 (range: 13.0–75.4) minutes, respectively. The change in 13CO2 emission in exhaled air from before to 240 minutes after ingestion of the test meal was measured, with the peak being 60 minutes after ingestion. A similar study reported the peaks occurred 30 and 80 minutes after ingestion for the liquid and solid diets, respectively. Conclusion: Gastric emptying in healthy volunteers after ingestion of a semi-solid diet differed from that after ingestion of solid or liquid diets—the original diets. In the future, more gastric cancer patients must be evaluated in comparative studies.

【背景】食道切除術では胃管再建が第一選択とされることが多いが、胃管再建が困難な場合は小腸、結腸などを用いる．食道切除回結腸再建は侵襲が高く、ハイリスク症例においては二期分割手術が選択されることがある．【対象と方法】2017年1月から2021年8月に施行した二期分割食道切除回結腸再建例8例の短期治療成績を検証した．, 【結果】男性 7 例、女性 1例、年齢中央値69（58-79）歳．臨床病期はI :3例、II:1例、III 期: 4例．胃管再建困難の理由は、胃癌合併4例、胃切除既往1例、食道胃接合部癌3例．一期目手術から二期目手術までの期間は中央値で33日（28-49）．手術時間、出血量の中央値は、一期目で390分（269-613）、184ml（72-584）、二期目で270分（233-401）、324 ml（50-1648）であった．術後合併症として、一期目手術で反回神経麻痺、二期目手術で肺炎をそれぞれ1例（12.5%）に認めた．縫合不全は認めなかった．再建術後経口摂取開始日中央値は7日（5-10）で、術後在院日数中央値は再建術後23日(16-39)であった．, 【結語】二期分割手術は手術侵襲の軽減を図ることが可能であり、回結腸再建におけるハイリスク症例に対して術後合併症の減少に寄与する可能性があり、手術適応拡大にもつながる可能性があると考えられた．, Background:Esophageal reconstruction by ileocolic interposition for esophageal cancer is highly invasive. We evaluated the two-stage operation by ileocolic reconstruction for high-risk esophageal cancer patients., Method:We investigated the clinical outcomes in 8 patients who underwent the two-stage operation by ileocolic reconstruction at our hospital between January 2017 and August 2021. Results: Of the 8 patients investigated, 7 were men. Median patient age was 69 (range 58–79) years, the median intraoperative blood loss was 184 (72-584) ml at first and 324 (50-1648) ml at second operation. The median operation time was 390 (269-613) min at first and 270 (233-401) min at second operation. The following postoperative complications were observed: 1 (12.5%) case of recurrent nerve palsy at first operation; 1 (12.5%) case of pneumonia, 1 (12.5%) case of wound infection, and 0 (0%) cases of anastomotic leakage at second operation., Conclusions:The two-stage operation by ileocolic reconstruction is safe and feasible. The two-stage operation would lead to expand the indication of operation for high-risk esophageal cancer patients.