咽喉食摘後の音声再建 遊離空腸移植によるエレファント型シャント法

Abstract

A modified technique was devised for simultaneous esophageal reconstruction and voice restoration after laryngopharyngoesophagectomy. This technique minimizes the length of intestinal tract which is sacrificed and uses a free jejunal graft to create an elephant-type shunt aimed at improving the chances for successful voice restoration. The results of voice restoration with this free jejunal graft technique compared favorably with results in cases reexamined after application of Ehrenberger & Kawahara's reconstructive technique. This free jejunal graft technique is briefly described, together with endoscopic findings and barium contrast findings at the time of phonation. The endoscopic findings revealed that the grafted intestinal mucosa on the oral-cavity side constricted simultaneously with phonation. The shape of this constriction differed among patients, showing three basic patterns: uniform constriction, anteroposterior constriction and side-to-side constriction. At the time of phonation, barium fluoroscopy revealed, a dilation of the reconstructed esophagus in the vicinity of the junction with the shunt and constriction of the grafted intestinal tract. However, phonation was not always accompanied by images of constriction. Based on these findings, two possible sites for the neoglottis permitting phonation after this reconstruction technique were hypothesized: the mucosa of the shunt aperture opening mucosa and the constricting portion of the reconstructed esophagus. However, the actual site remains to be elucidated.Possible causes and solutions are also discussed for the potential problems involved with this modified reconstruction, including reflux, stenosis of the shunt opening, permanent stenosis of the tracheal opening etc.