全咽喉切除術後以胃轉位手術重建之臨床經驗

Gastric Pull-up Reconstruction for Radical Pharyngolaryngectomy in Advanced Hypopharyngeal Cancer Patients

花俊宏(Chun-Hung Hua) ； 陳建志(Chien-Chih chen) ； 蔡銘修(Ming-Hsui Tsai) ； 施志勳(Chih-Shiun Shih) ； 許南榮(Nan-Yung Hsu)

《Mid-Taiwan Journal of Medicine》 8卷s_1期 (2003/11) Pp. s65-s70

https://doi.org/10.6558/MTJM.2003.8(s_1).10

摘要

目的 晚期下咽癌的手術治療，通常須施以徹底的咽喉切除及頸部淋巴廓清術，手術後常需接受輔助性放射治療，或者手術範圍常是已接受過放射線治療的區域，以致於術後併發症的發生率可高達58%至78%，而且術後死亡率亦可高達8%，因此可靠的咽喉重建手術一直是頭頸外科醫師努力的目標。
方法 收集自1995年3月到2002年10月間，分析本部42例接受咽喉切除術的病人，其中10例接受胃轉位手術的重建，15例接受胸大肌肌皮瓣的重建，有17例下咽部黏膜直接縫合。分析咽喉切除術後以胃轉位手術重建，在術中、術後的併發症，皮瓣存活率，住院時間，進食情況，及術後恢復情形並與胸大肌肌皮瓣重建之一組做比較。
結果 十例接受胃轉位手術重建的病人，平均年齡為57.7歲，術後咽皮瘻管及傷口感染有4例佔40%，少於胸大肌肌皮瓣重建的53%，其中有一例於術後62天死亡；平均住院22.4天，少於胸大肌肌瓣重建的31天；可正常進食固體食物的有5例佔50%，多於胸大肌皮瓣重建的20%；胃轉位手術及胸大肌肌皮瓣重建，兩組均無皮瓣壞死。胃轉位手術重建的病人中，發現有3例同時有第二原發癌（食道癌）; 胸大肌肌皮瓣重建的病人中因無法檢視食道病理切片，只發現有1例同時有第二原發癌（軟顎癌）。
結論 咽喉切除術後重建方式的選擇，可能因手術者的偏好、醫療設備及手術的範圍而不同。對於全咽喉切除術後造成無法直接縫合的病患以及合併有食道侵犯之病患，從本研究的分析當中，胃轉位重建手術比胸大肌肌皮瓣重建手術因有較少的手術併發症及較佳的術後進食狀況，所以對於晚期下咽癌需全咽喉切除之病患，除卻游離皮瓣（free flap）重建之外，胃轉位重建手術比胸大肌肌皮瓣重建手術提供較佳之選擇。

關鍵字

胃轉位手術 ； 下咽癌 ； 胸大肌肌皮瓣

並列摘要

Objectives. Radical pharyngolaryngectomy with neck lymph node dissection is a common procedure for patients with advanced hypopharyngeal cancer. Preoperative or postoperative radiotherapy is often necessary for this group of patients and as a result, the rate of complications is as high as 78%, while the mortality rate can reach 8%. Therefore, head and neck surgeons are in need of a reliable pharyngolaryngeal reconstructive surgical technique which will reduce the surgical and postradiation complications.
Methods. We retrospectively investigated 42 patients with advanced hypopharyngeal cancer who received radical pharyngolaryngectomy from March 1995 to October 2002. Ten of the patients received esophagus resection and gastric pull-up reconstruction. Fifteen patients received pectoralis major myocutaneous flap (PMMCF) reconstruction. The rest of the patients (17) received primary mucosal closure of the pharyngeal defect. We analyzed the differences in intraoperative and postoperative complications, success rate of the reconstructed flap, hospitalization duration and swallowing function between the groups of patients who received gastric pull-up reconstruction and those who received PMMCF reconstructions.
Results. The average age of patients who received gastric pull-up reconstruction was 57.7 years. The rate of postoperative pharyngocutaneous fistula and surgical wound infection for patients who underwent gastric pull-up was about 40% (4/10), compared with 53% for the PMMCF reconstruction group (8/15). The average duration of hospitalization for the gastric pull-up group was 22.4 days, compared with 31 days for the PMMCF reconstruction group. Solid food consumption was achieved in 50% of the gastric pull-up group, while it was achieved in only 20% of the PMMCF group. Flap reconstruction was successful in both groups. In the gastric pull-up group, second primary esophageal cancer was found in three of the patients. In the PMMCF reconstruction group, second primary soft palate cancer was found in one patient. In pharyngolaryngectomy with PMMCF reconstruction, esophageal specimens are not taken; therefore, we could not assess whether any second primary esophageal cancer was present.
Conclusions. Gastric pull-up reconstruction is suitable for patients who receive radiotherapy before the operation or have limited residual healthy mucosa of the posterior pharyngeal wall. It is also suitable for patients with coexisting esophageal defects is a reliable choice for patients with advanced hypopharyngeal cancer. The procedure produces few complications and good postoperative swallowing results.

並列關鍵字

gastric pull up ； hypopharyngeal cancer ； pectoralis major myocutaneous flap