Free Thigh Flaps for Pharyngoesophageal Reconstruction after Hypopharyngeal Cancer Ablation

以大腿自由皮瓣行下咽癌廣泛切除後的重建

Meng-Ta Chen(陳孟達) ； Meng-Chien Hsieh(謝孟謙) ； Yi-Chia Wu(吳益嘉) ； Yur-Ren Kuo(郭耀仁)

《臺灣整形外科醫學會雜誌》 31卷4期 (2022/12) Pp. 245-257

摘要

Background: Free flap is the standard procedure for head and neck reconstruction. However, reconstruction of pharyngoesophageal defects is still challenging, and the complication rates are high due to the need for complete survival of a sizeable flap. Several monitoring strategies for buried flaps have been proposed to detect arterial or venous occlusion, but marginal flap necrosis is usually found no earlier than the occurrence of leakage or neck infection. Aim and Objectives: To ensure flap perfusion, we implemented intraoperative Indocyanine Green(ICG) fluorescence angiography in pharyngoesophageal reconstruction using thigh free flaps. The surgical outcomes and postoperative morbidities were analyzed. Materials and Methods: 32 patients with hypopharyngeal cancer undergoing wide excision and reconstruction with free flaps between March 2016 and January 2020 in our institution were enrolled in this study. The flaps are harvested form the thigh. Intraoperative ICG fluorescence angiography was implemented. The surgical outcomes and postoperative morbidities were analyzed. Results: 28(87.5%) defects were reconstructed with anterolateral thigh flap, 3(9.4%) with tensor fascia lata flap, and 1(3.1%) with lower medial thigh flap. There was no flap loss. The mean ICU length of stay was 5.1±1.7 days and the mean hospital length of stay was 22.5±12.3 days. One patient experienced arterial thrombosis, which was explored and salvaged successfully. 7(21.9%) patients developed neck hematoma, and neck infection occurred in 1(3.1%) case. Pharyngocutaneous fistula occurred in 5(15.6%) patients, and 2(6.3%) patients had evidence of stricture as seen on esophagogram. After reconstruction, 23(71.9%) patients restored unrestricted diet after surgery, 5(15.6%) patients tolerated soft diet, 2(6.3%) patients tolerated liquid diet, and 2(6.3%) patients did not tolerate oral intake and thus depended on tube feeding. Conclusion: Free thigh flaps are reliable methods for pharyngoesophageal reconstruction. The ALT flap is the first choice, and the TFL flap serves as a backup procedure. Intraoperative ICG fluorescence angiography is useful to ensure adequate perfusion of the flap, and it's application in future clinical practice is promising.

關鍵字

hypopharyngeal cancer ； tensor fascia lata flap ； anterolateral thigh flap

並列摘要

背景：自由皮瓣是頭頸癌重建的標準治療，然而下咽癌的重建需要大面積的皮瓣完整存活，仍具有挑戰性且易造成併發症。許多內部皮瓣的監測技術已被發表以偵測動脈或靜脈阻塞，但皮瓣的邊緣壞死通常在滲漏或感染等併發症發生後才得以發現。目的及目標：為了確保皮瓣邊緣有良好循環，我們在下咽癌自由皮瓣重建的手術中使用循血綠血管攝影，並分析其成果及併發症。材料及方法：本文收集32位在本院從2016年3月至2020年1月間，使用自由皮瓣行下咽癌的重建的病患。皮瓣皆取自大腿且使用術中循血綠血管攝影確認皮瓣循環，並分析手術成果及併發症。結果：28（87.5%）位使用大腿前外側皮瓣，3（9.4%）位使用闊筋膜張肌皮瓣，1（3.1%）位使用大腿下內側皮瓣。皮瓣重建成功率為100%。平均加護病房住院日數為 5.1±1.7日，平均總住院日數為22.5±12.3日。一位病人術後產生動脈栓塞並搶救成功。7（21.9%）位病患產生頸部血腫，1（3.2%）位發生頸部感染。5（15.6%）位產生皮咽廔管，2（6.3%）位發生咽喉窄縮。重建完成後，23（71.9%）位患者能夠正常飲食，5（15.6%）位患者只能接受軟質飲食，2（6.3%）位患者只能忍受流質飲食，而有2（6.3%）位患者無法經口進食而需仰賴管灌。結論：大腿自由皮瓣是可靠的下咽癌重建方法。以大腿前外側皮瓣是為首選，而闊筋膜張肌皮瓣可為一個好的備案。術中循血綠血管攝影的使用能確認皮瓣邊緣有良好循環，未來在臨床上能有更廣泛的應用。