Radionecrosis of Soft Tissue: Surgical Treatment and Reconstruction

放射性軟組織壞死之治療與重建

蘇瑋智(Wei- Chih Su) ； 許宏達(Hon-Da Hsu) ； 孫宗伯(Tzong-Bor Sun) ； 鄭立福(Li-Fu Cheng) ； 王健興(Chien-Hsing Wang) ； 黃介琦(Chieh-Chi Huang) ； 簡守信(Sou-Hsin Chien) ； 李俊達(Jiunn-Tat Lee)

《臺灣整形外科醫學會雜誌》 21卷4期 (2012/12) Pp. 284-292

https://doi.org/10.7096/TJTSPS.201212.0284

摘要

背景：因近年來的發展，放射治療在各項癌症治療中扮演相當重要的角色，並且在頭頸部癌症中成為標準的治療之一。儘管由於放射治療的大幅度進步，以往常見的併發症已經不如過去嚴重和常見但是由於放射治療造成的傷口愈合不良甚或組織壞死，可能在臨床治療尚造成極大的困擾或造成極大併發症。目的及目標：在此篇論文中，我們嘗試以回溯性的方式來檢視我們處理此類傷口的經驗以及後續的結果；並且特別著眼於手術的治療以及後續的重建工作。材料及方法：以回溯性的方法搜尋本院病歷系統，總共於五年間找出六名病患罹患放射性組織壞死並接受後續手術治療與重建。這些患處皆位於頭頸部癌症接受放射治療後產生。所有的病歷內容皆被完整的評估並紀錄以供分析。結果：所有的病患在診治初期大部份合併局部感染的情形。除了靜脈抗生素治療之外，再接受次數不等的清創以及清創後的傷口照護；包括一般開放性的傷口敷料或是密閉性的敷料置放（如：真空抽吸海綿V.A.C.®）。重建的方式遵循重建階梯的順序。所有的病患皆接受皮辦重建；不論是帶莖皮瓣或是游離皮瓣的覆蓋。所有的病患皆恢復良好沒有產生併發症。結論：軟組織的放射性損傷是一個長期漸進且連續的過程，它很難用尋常的方式來癒合。當放射線治療的劑量超過6000毫格雷時，傷口壞死及潰瘍的機率就較常發生。由於臨床上缺乏正確而敏感的診斷，放射性組織壞死的發生率事實上有可能是被低估的。大部份的病患合併此類的併發症常常是輕微的而且能夠以高壓氧及保守的方式來治療。但是對於某些大範圍組織壞死並且合併重要器官暴露的病患，例如大血管或骨頭，則須以系統性的流程來治療。這些治療包括連續的清創直到重建前長成理想而無感染的傷口組織。在皮瓣的重建選擇上，儘管文獻上較支持游離皮瓣的使用，在我們的報告中帶莖皮瓣似乎是一個替代性的第二選擇。因為帶莖皮瓣與游離皮瓣比較上，不需要顯微手術以及較短的手術時間。

並列摘要

Background: Radiation therapy has been used increasingly in treating certain malignancies or often as a standard treatment combination in head and neck cancer. However, radiation related wounds can at times be devastating and troublesome. Aim and Objectives: In this paper, we reviewed retrospectively our experience in treating these types of wounds. We reviewed their surgical management and the different methods of reconstruction. Materials and Methods: A total of 6 patients were included in the study. All wounds were located at the head and neck region and associated with previous cancer treatment. Radiotherapy is an inclusion criteria. Medical records were retrospectively reviewed. All the clinical details including pre-reconstructive treatment and reconstructive methods were analyzed. Results: All patients received surgical debridement. Post-debridement wound care included both open type and occlusive type (V.A.C.®). Reconstructive methods followed the reconstructive ladder and all patients received flap coverage, whether as a pedicled flap or as a free flap. One patient received free tissue transfer and the rest received pedicled flap for wound coverage. Two patients received pectoralis major musculocutaneous flap (PMMF) and three patients received deltopectoral fasciocutaneous flap (DPFF). All patients recovered well without complications. Conclusion: Radiation injury to the soft tissue is a prolong progressive continuous process of injury which is hard to heal with ordinal procedure. When the radiation dosage was over 6000 cGy the possibility of wound necrosis and ulceration would be seen more often. The incidence might be underestimated due to poor recognition and identification among these patients. Most of the patients with minor necrosis can be treated with conservative methods and hyperbaric oxygen therapy . But those with extensive areas of necrosis with exposure of underlying major vessels or vital structures need to undergo serial debridements until a suitable wound bed without infection is obtained prior to reconstruction. The pedicled flap shown in our series seemed to be an alternative second choice for reconstruction for it does not require microsurgery and has a shorter operative time when compared to free flap transfer.

並列關鍵字

radiation necrosis ； pedicled flap ； free flap