游离空肠修复下咽及颈段食管肿瘤切除后组织缺损的临床分析

Reconstruction with free jejunal interposition for defect after tumor resection of hypopharyngeal and cervical esophageal cancer

目的探讨游离空肠修复下咽及颈段食管肿瘤切除术后组织缺损的方法和疗效。方法对1984年9月至2004年8月收治的51例下咽、颈段食管癌及喉癌复发患者以游离空肠修复肿瘤切除术后下咽及颈段食管组织缺损的临床资料进行回顾性分析。结果51例患者中,5例游离空肠修复术后出现游离空肠坏死,46例(90%)成功修复组织缺损。修复术后1年生存率为62%,3年生存率为48%。影响预后的因素有:(1)肿瘤切除切口边缘(切缘)情况:阴性切缘患者1年生存率为75%,3年生存率为58%;阳性切缘患者的1年生存率为34%,3年生存率为0。两者比较,差异均有统计学意义(P<0·01)。(2)肿瘤外侵情况:无甲状腺、皮肤、椎前组织、颈总动脉受侵(包括喉、气管、口咽受侵)34例,1年生存率为70%,3年生存率为42%;有甲状腺和(或)皮肤和(或)椎前组织和(或)颈总动脉受侵17例,1年生存率为44%,3年生存率为29%,两者比较,差异均有统计学意义(P<0·05)。放疗与否、肿瘤细胞分化类型对预后的影响,差异无统计学意义。5例术后出现游离空肠坏死的患者中,1例感染死亡,其余无严重并发症。结论以游离空肠修复下咽及颈段食管部位肿瘤切除术所致缺损,并发症较少,切缘阴性及无甲状腺、皮肤、椎前组织、颈总动脉受侵患者的1年、3年生存率较高;改善了患者的进食状况;对能保证切缘阴性、肿瘤切除局部及颈部淋巴结无明显外侵的患者,可应用游离空肠修复。

Objective To discuss the use of free jejunal flap in reconstruction for circumferential defect after tumor resection of hypopharyngeal and cervical esophageal cancer. Methods Retrospective review of 51 patients who underwent circumferential pharyngoesophageal reconstruction with free jejunal flap after tumor ablation. Results In 51 patients, 5 had flap failure and the flap success rate was 90% （46/ 51 ）. Forty-five patients had oral intake after operation excluding one who had anastomosis stenosis and 5 who had flap failure. The 1-year and 3-year survival rate was 62% and 48% respectively. Positive surgical marginal status and external invasion including thyroid gland, carotid artery, skin and pre-vertebral area were indicators for bad prognosis. Except 5 patients who had flap failure, one of which died from mediastinal infection, no other severe complications occurred. Conclusions Patients reconstructed with free jejunal flap after resection of hypopharyngeal and cervical esophageal cancer had low mortality and few complications. Those without positive surgical margin and external invasion including thyroid gland, carotid artery, skin and pre-vertebral area had higher survival rate. Most of them had good quality of life. The choice of free jejunal flap for reconstruction of hypopharyngoesophageal defect was appropriate in selected patients who had guarantee of negative surgical margin and no external invasion.