气管造口复发癌手术探讨
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摘要
目的:探讨气管造口复发癌的手术切除及Ⅰ期缺损修复方法。方法:15例气管造口复发癌患者,术前均进行颈胸部增强CT扫描或PET-CT检查以了解病灶侵犯范围,并结合电子胃镜或食管造影了解食管黏膜是否受侵犯,术中采取扩大病灶切除+低位气管造瘘术。结果:术中缺损选择带蒂胸大肌肌皮瓣修复者7例(其中1例为双皮岛带蒂胸大肌肌皮瓣),选择胸廓内动脉穿支皮瓣修复者5例,选择气管造口临近皮肤及皮下组织带蒂旋转皮瓣、Z字成型皮瓣、V-Y推进皮瓣方法中的一种或多种修补方法者2例,胃代食管+临近皮瓣修复者1例,均顺利完成手术,无一例在围手术期内死亡。患者术后就诊于放疗科,给予术后放疗。结论:经过适当的检查评估的气管造口复发癌可行外科手术治疗,术前判断能否手术的关键是周围受累大血管能否进行安全的解剖或重建、复发灶切除后能否行气管造瘘术,切除复发灶的关键步骤是解剖气管造口下方正常气管前壁,术中采取合适的修复缺损方法可顺利完成手术,延长部分患者的生命。气管造口维持状态的患者要特别重视术后定期复诊,以早期发现复发灶,有利于手术及预后。
Objective:The aim of this study is to investigate the perioperative management of stomal recurrence after tracheostomy including the method of surgical resection and repairment of postoperative defect.Method:Fifteen cases of stomal recurrence after tracheostomy,all cases received preoperative neck to chest enhanced CT scan or PET-CT examination to determine the scope of the lesion,electronic gastroscope or esophageal radiography to understand whether the esophageal mucosa is invased.All cases received extended resection and low tracheostomy.Result:Seven cases were repaired with pedicle pectoralis major myocutaneous flap.Five cases were repaired with internal thoracic artery perforator flap.Two cases were chosed approaching the skin and subcutaneous tissue,such as pedicled rotator flap or Z-shaped flap or V-Y advance flap to repaire.1 case was chosed Stomach lifting instead of esophageal surgery and near skin flap for repairment.In all cases,the operations were completed successfully and none patient died during the perioperative period.All patients received postoperative radiotherapy after surgery.Conclusion:After proper examination,the selected stomal recurrence after tracheostomy can be surgically treated.The key to judgment before surgery is whether the surrounding large vessels can be safely dissected or reconstructed,and whether or not tracheostomy can be performed after resection.The appropriate method of repairing the defect during the operation can successfully complete the operation and extend the lives of some patients.Patients with tracheostomy maintenance should pay special attention to regular follow-up after surgery.
Objective:The aim of this study is to investigate the perioperative management of stomal recurrence after tracheostomy including the method of surgical resection and repairment of postoperative defect.Method:Fifteen cases of stomal recurrence after tracheostomy,all cases received preoperative neck to chest enhanced CT scan or PET-CT examination to determine the scope of the lesion,electronic gastroscope or esophageal radiography to understand whether the esophageal mucosa is invased.All cases received extended resection and low tracheostomy.Result:Seven cases were repaired with pedicle pectoralis major myocutaneous flap.Five cases were repaired with internal thoracic artery perforator flap.Two cases were chosed approaching the skin and subcutaneous tissue,such as pedicled rotator flap or Z-shaped flap or V-Y advance flap to repaire.1 case was chosed Stomach lifting instead of esophageal surgery and near skin flap for repairment.In all cases,the operations were completed successfully and none patient died during the perioperative period.All patients received postoperative radiotherapy after surgery.Conclusion:After proper examination,the selected stomal recurrence after tracheostomy can be surgically treated.The key to judgment before surgery is whether the surrounding large vessels can be safely dissected or reconstructed,and whether or not tracheostomy can be performed after resection.The appropriate method of repairing the defect during the operation can successfully complete the operation and extend the lives of some patients.Patients with tracheostomy maintenance should pay special attention to regular follow-up after surgery.
引文
[1]SISSON G A,GOLDMAN M E.Pectoral myocutaneous Island flap for reconstruction of stomal recurrence[J].Arch Otolaryngol,1981,107:446-449.
[2]NISA L,IMOBERSTEG N,SCHERTENLEIB P,et al.Combined use of free and pedicled flaps for stomal recurrence after total laryngectomy[J].J Plast Reconstr Aesthet Surg,2012,65:e226-228.
[3]MEI J,HUANG Z,WU K,et al.Risk Factors of Stomal Recurrence After Laryngectomy:A Systematic Review and Meta-analysis[J].Ann Otol Rhinol Laryngol,2017,126:654-668.
[4]盛晓丽,张思毅,宋新汉,等.喉癌喉全切除术后造瘘口复发癌相关因素的Meta分析[J].临床耳鼻咽喉头颈外科杂志,2013,27(18):995-999.
[5]PITTMAN A,LINDAU R,ANDERSEN P,et al.Stomal recurrence:salvage surgery and reconstruction utilizing microvascular free tissue transfer[J].Head Neck,2013,36:1431-1434.
[6]WANG Z Y,LI Z Q,JI H,et al.Influence of risk factors on stomal recurrence after total laryngectomy for laryngeal carcinomas:A meta-analysis[J].J Cancer Res Ther,2017,13:856-861.
[7]PEZIER T F,NIXON I J,JOSHI A,et al.Pre-operative tracheostomy does not impact on stomal recurrence and overall survival in patients undergoing primary laryngectomy[J].Eur Arch Otorhinolaryngol,2013,270:1729-1735.
[8]刘晓薇,孙敬武.喉切除术后造瘘口复发癌[J].临床耳鼻咽喉头颈外科杂志,2013,27(17):978-980.
[9]屠规益.喉癌下咽癌现代理论与临床[M].济南:山东科学技术出版社,2002:342-346.
[10]李晓明,尚耀东,邱斌,等.喉全切除气管造口复发癌挽救性手术治疗的相关问题探讨[J].中华耳鼻咽喉头颈外科杂志,2009,44(9):731-735.
[2]NISA L,IMOBERSTEG N,SCHERTENLEIB P,et al.Combined use of free and pedicled flaps for stomal recurrence after total laryngectomy[J].J Plast Reconstr Aesthet Surg,2012,65:e226-228.
[3]MEI J,HUANG Z,WU K,et al.Risk Factors of Stomal Recurrence After Laryngectomy:A Systematic Review and Meta-analysis[J].Ann Otol Rhinol Laryngol,2017,126:654-668.
[4]盛晓丽,张思毅,宋新汉,等.喉癌喉全切除术后造瘘口复发癌相关因素的Meta分析[J].临床耳鼻咽喉头颈外科杂志,2013,27(18):995-999.
[5]PITTMAN A,LINDAU R,ANDERSEN P,et al.Stomal recurrence:salvage surgery and reconstruction utilizing microvascular free tissue transfer[J].Head Neck,2013,36:1431-1434.
[6]WANG Z Y,LI Z Q,JI H,et al.Influence of risk factors on stomal recurrence after total laryngectomy for laryngeal carcinomas:A meta-analysis[J].J Cancer Res Ther,2017,13:856-861.
[7]PEZIER T F,NIXON I J,JOSHI A,et al.Pre-operative tracheostomy does not impact on stomal recurrence and overall survival in patients undergoing primary laryngectomy[J].Eur Arch Otorhinolaryngol,2013,270:1729-1735.
[8]刘晓薇,孙敬武.喉切除术后造瘘口复发癌[J].临床耳鼻咽喉头颈外科杂志,2013,27(17):978-980.
[9]屠规益.喉癌下咽癌现代理论与临床[M].济南:山东科学技术出版社,2002:342-346.
[10]李晓明,尚耀东,邱斌,等.喉全切除气管造口复发癌挽救性手术治疗的相关问题探讨[J].中华耳鼻咽喉头颈外科杂志,2009,44(9):731-735.