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以術中超音波偵測舌動脈來輔助經口機械手臂治療睡眠呼吸中止症

Locating Lingual Artery with Intraoperative Ultrasound to Increase Safety in Performing Transoral Robotic Surgery for Obstructive Sleep Apnea

摘要


背景:經口機械手臂舌根減積手術治療睡眠呼吸中止症時,舌根出血等嚴重併發症必須謹慎面對。本研究試圖在執行這項手術中,藉由超音波輔助定位舌根舌動脈解剖位置,並在安全範圍内確實切除舌根扁桃腺軟組織。方法:自2016年迄今在本院接受經口機械手臂懸壅垂顎咽成形術併舌根減積手術的病患參與本研究。術前上呼吸道解剖構造評估包括Friedman分級,與利用纖維內視鏡評估在閉口捏鼻用力吸氣時的塌陷部位和程度(Müller maneuver)。以多頻道睡眠生理檢查評估阻塞性睡眠呼吸中止症嚴重度。利用超音波與微型探頭偵測舌根舌動脈解剖位置,包括動脈直徑、至舌根中線水平距離與至舌根表面深度等,利用統計軟體分析各項臨床變項和舌動脈位置的相關性。結果:共收集66名病人(84.8%為男性),平均年齡42.4±9.9歲,平均身體質量指數29.0±4.5 kg/m^2。具Friedman解剖分級I與II者共41名(62.1%)。睡眠呼吸中止或低下指數為57.2 ± 20.6次/時。超音波顯示舌動脈平均直徑2.9±0.7 mm、至舌根中線平均水平距離16.5±2.8 mm、至舌根表面平均深度5.4±2.1 mm。術中皆無發生任何舌動脈相關併發症;術後2週内有4例患者(6.1%)發生術後出血併發症。結論:藉由術中超音波輔助經口機械手臂舌根減積手術,能讓外科醫師更有信心辨識舌動脈位置,可提高舌根減積效率與降低手術傷及舌動服併發症。

並列摘要


BACKGROUND: Injury of lingual artery (LA) is a devastating complication during transoral tongue base resection. Our study aimed to investigate the feasibility of using intraoperative ultrasound imaging to accurately locate the position of LA when performing tongue base reduction in obstructive sleep apnea (OSA) operation with transoral robotic surgery (TORS). METHODS: Adult obstructive sleep apnea (OSA) patients who received TORS for base of tongue (BOT) resection were recruited in this study. All patients received a pre-operative full-night polysomnography (PSG) and Friedman OSA Staging. During TORS procedure, intraoral ultrasound imaging was utilized to locate the accurate position, and to measure the anatomic parameters of LA within BOT, which included horizontal distance to midline, depth to mucosal surface and the diameter of LA. RESULTS: From November 2016 to September 2018, 66 patients with OSA (56 male, 84.8%) were included. The mean age was 42.4 ± 9.9 years old, and their mean body mass index (BMI), 29.0 ± 4.5 kg/m^2. Apnea hypopnea index (AHI) was 57.2 ± 20.6 events/hour, pre-operatively. There were 41 (62.1%) patients in Friedman stages I and II. The position of lingual artery was successful detected intraoperatively in all patients (100.0%). The average horizontal distance of LA to midline was 16.5 ± 2.8 mm. The average depth of LA to mucosal surface was 5.4 ± 2.1 mm. The average diameter of LA was 2.9 ± 0.7 mm. BMI ( p = 0.012), AHI-REM (rapid eye movement sleep) ( p < 0.001), tonsil size ( p = 0.002) and Friedman tongue position ( p = 0.036) were significantly correlated with the depth of LA. Postoperative bleeding occurred in 4 patients (6.1%). But none of these patients had bleeding related to LA injury (3 at tonsillar fossa, 1 at surface of tongue base). CONCLUSION: Intraoperative ultrasound can accurately locate the position of lingual artery when performing tongue base reduction in OSA surgery with TORS. The catastrophic injury of lingual artery could thus be minimized.

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