食道癌術後嚥下障害に対する顎引き嚥下の効果

抄録

Three-field (neck, mediastinal, abdominal) lymphadenectomy (3FL) following esophagectomy for esophageal cancer may sometimes cause swallowing dysfunction, with a risk of severe pulmonary complications. Early determination and prevention of aspiration may reduce or prevent these potential complications. We first demonstrated by a videofluoroscopic swallowing study (VFSS), that pharyngeal swallowing dysfunction in post-esophagectomy patients who undergo 3FL is significantly correlated with impaired laryngeal elevation, and consequently, reduced pharyngeal clearance and upper esophageal sphincter (UES) opening. In another VFSS, use of the chin-down maneuver following 3FL helped accelerate swallowing function recovery by improving the pharyngeal contraction, possibly by altering the position of the base of the tongue in relation to the pharyngeal wall, reducing pharyngeal residue, stretching the UES, and improving laryngeal closure. The mechanism of swallowing dysfunction following esophagectomy + 3FL has been well investigated by VFSSs, but not sufficiently investigated by fiberoptic endoscopic evaluation of swallowing (FEES). With respect to the time and effort involved in the screening of the aspiration status post-esophagectomy without radiation exposure, FEES could be considered to be easier, more useful, and safer. Interestingly, we demonstrated that FEES performed for evaluation of the aspiration status post-esophagectomy + 3FL is as reliable as a VFSS. The chin-down maneuver is especially useful for reducing the degree of aspiration and improving pyriform sinus clearance in vocal fold paralysis patients postoperatively. Finally, by high-resolution manometric (HRM) examination, we demonstrated that the chin-down maneuver after esophagectomy + 3FL may improve bolus passage by prolonging the duration of the lowered swallowing pressure at the UES, possibly by enhancing laryngeal elevation. Overall, obtaining confirmatory evidence by multi-directional examination techniques, such as VFSS, FEES and HRM, would be useful to precisely understand the beneficial effects of certain rehabilitation maneuvers in patients with dysphagic pathologies.