【摘要】 目的 觀察全喉全下咽切除術后空腸游離移植術二次手術時同時保留動靜脈血管蒂或僅保留動脈血管蒂時對移植組織的影響。 方法 回顧分析2002年1月-2009年12月4例下咽癌行全喉全下咽切除術空腸游離移植術術后8~18個月因頸部轉移灶出現而需再行手術患者的臨床資料，其中3例行根治性頸清掃，1例行局部包塊擴大切除術。2例同時保留動靜脈蒂，2例僅保留動脈蒂。 結果 4例術后臨床Ⅰ期愈合。保留動靜脈蒂者吞咽功能與術前無異。僅保留動脈蒂者術后1個月仍有頸中份的明顯隱痛，胃腸造影移植空腸段的蠕動明顯減弱，吞咽固體食物時自覺較術前緩慢。 結論 再次手術時保留血管蒂對于保持空腸移植段的活力具有重要的意義。【Abstract】 Objective To observe the effect of keeping arteriovenous or venous pedicles during the second free jejunal transplantation after total laryngopharyngectomy on the transplanted tissues. Methods From January 2002 to December 2009,four patients underwent total laryngopharyngectomy and free jejunal. But 8-18 months later, the patients underwent another operation because of recurrent metastatic mass in the ipsilateral neck side of anastomosis; in whom three underwent radical neck dissection and one underwent local enlarged mass resection. In the four patients, two had arteriovenous pedicles remained and another two kept only venous pedicles. Results All of the four patients experienced first-stage healing. The deglutitive function in the two patients who had received the arteriovenous pedicles preservation didn’t differ much from that before the operation. While vague anguish in the anterior region of the neck, weak peristalsis of the transplanted jejunum, a little discomfort and slow swallowing were found in another two patients. Conclusion Keeping vascular pedicles during re-operation helps make the activity of the transplanted jejunum.
Objective To explore the value and limitation of transverse cervical artery flap in laryngeal function preservation surgery of hypopharyngeal carcinoma. Methods Between January 2013 and December 2019, 18 male patients with hypopharyngeal carcinoma were admitted. The patients’ age ranged from 48 to 77 years, with a median age of 65 years. The disease duration ranged from 3 to 8 months (mean, 5 months). All patients were diagnosed as squamous cell carcinoma by biopsy before operation. According to the American Joint Committee on Cancer (AJCC) guidelines (2017, 8th ed), TNM staging was T2N0M0 in 9 cases, T2N1M0 in 2 cases, and T3N0M0 in 7 cases, and cTNM staging was stage Ⅱ in 9 cases and stage Ⅲ in 9 cases. The lesions of 15 cases were located in the piriform fossa of hypopharynx on one side, among which the esophageal entrance was involved in 4 cases. The lesions of 3 cases were located in the posterior wall of the hypopharynx with esophageal entrance involvement. After partial pharyngo- laryngectomy and bilateral neck lymph node dissection, the hypopharyngeal and laryngeal defects were repaired with transverse cervical artery flaps, the size of the flap ranged from 4 cm×3 cm to 6 cm×4 cm. The accompanying vein of transverse cervical artery (7 cases), external jugular vein (6 cases), and combination of both (5 cases) served as venous reflux. Retrograde external jugular venous reflux exercise was performed in 2 flaps with venous reflux obstruction during operation. The incisions at donor sites were directly sutured or via relaxed incision sutured. Radiotherapy and chemotherapy were supplemented within 3 months after operation. Tracheal cannula with air bag was used to prevent patients from aspiration in the early postoperative stage. Results The operation time was 4-6 hours, with an average of 4.5 hours. All patients were followed up 1-5 years (mean, 2 years and 6 months). Postoperative pathological examination showed that 7 cases had cervical lymph node metastases on the affected side, and there was no lymph node metastasis in cervical region Ⅴ; the remaining 11 cases had no lymph node metastasis. After operation, 16 flaps survived successfully, and 2 flaps with external jugular vein reflux were covered with white pseudomembrane, no flap necrosis was found after the pseudomembrane fell off. Four cases had no obvious accidental aspiration after operation; 14 cases had obvious accidental aspiration, of which 13 cases were significantly reduced at 3 months after operation, and 1 case still had obvious accidental aspiration at 6 months after operation, and the accidental aspiration decreased significantly after pulling out the gastric tube. All patients had no aspiration pneumonia. One case developed upper mediastinal lymph node metastasis at 1 year and 2 months after operation, and died of recurrence and pulmonary infection at 1 year and 3 months after operation. No recurrence or metastasis was found in the remaining 17 cases during follow-up. Tracheal cannula was successfully removed in 7 cases at 2-5 months after operation. Different degrees of accidental aspiration in 11 patients were confirmed by esophagography, so the tracheal cannula was retained. All patients had pronunciation function after operation. All incisions at the donor sites healed by first intention, and the shoulder joint function was normal. Conclusion Using transverse cervical artery flap to repair the hypopharyngeal and laryngeal defects during hypopharyngeal carcinoma surgery in patients without lymph node metastasis in cervical region Ⅴ, can achieve good results of laryngeal function preservation. In cases with suspected lymph node metastasis in cervical region Ⅴ or venous dysplasia of accompanying vein of transverse cervical artery, there is a risk of tumor recurrence or flap necrosis, and the repair method needs to be cautiously employed.
Objective To explore the outcome of hypopharynx reconstruction by using remaining laryngeal mucosa flap and pectoralis major myocutaneous flap in advanced pyriform sinus cancer.Methods Twelve patients with pyriform sinus cancers underwent hemilaryngectomy and partial pharyngectomy, two patients underwentcervical esophagectomy at the same time. The defects were reconstructed by remaining laryngeal mucosa flap. Four cases were involved in the bilateral larynx, received total laryngectomy and were repaired by pectoralis major myocutaneous flap. Results There was no operative fatal case and all flaps survived. Only one suffered from postoperative pharyngocutaneous fistulas, whose defect was reconstructed by remaining laryngeal mucosa flap and had radiotherapy. All patients could swallow ordinary food and had no benign esophagostenosis and pharyngostenosis after operation. Out of 16 pateints, 1 case died of general metastasis;3 cases died of local tumor relapse, tumor relapse of cervical lymphonode and lung metastasis respectively within 1 year after operation; the other 12 casessurvived over 2 years.Conclusion The advantage of hypopharynx reconstruction with remaining laryngeal mucosa flap is simple and convenient with less trauma and complication. The reconstruction should be completed by using the pectoralis major myocutaneous flap when the bilateral larynx are involved in.