下咽颈段食管重建方法的选择

Reconstructive methods for hypopharynx and cervical esophagus

目的:探讨下咽颈段食管癌切除后下咽颈段食管重建的方法和疗效。方法:采用不同方法重建下咽及颈段食管25例,其中下咽癌14例,下咽颈段食管癌11例,按1997年The International Union Against Cancer分期标准T2N05例,T2N12例,T3N04例,T3N13例,T4N17例,T4N24例。治疗方式:单纯手术治疗5例,放疗后再手术2例,手术加术后放疗18例,保留喉功能手术8例,行颈淋巴清扫术21例。重建方法为游离空肠移植代咽-颈段食管、胃上提代下咽-食管、残喉和气管黏膜瓣修复、肌皮瓣修复。结果:游离空肠和胃代咽-食管共3例,残喉和气管黏膜瓣修复4例,术后2周均较快恢复进食功能,无并发症。肌皮瓣和皮瓣修复18例中,10例无术后并发症,8例发生1种以上并发症,其中咽瘘6例,咽食管狭窄7例,胸大肌皮瓣完全坏死1例,并发症者经换药、再次修复及咽食管扩张术后5例恢复进食功能,3例作永久性胃造瘘解决营养。25例中,无围术期死亡者,3年生存率为38.9%(7/18)。结论:利用内脏代下咽食管和喉气管黏膜瓣修复者术后恢复进食快,吻合口瘘和狭窄的发生率低。肌皮瓣修复者术后吻合口瘘和狭窄的发生率高。

Objective To review the surgical treatment for reconstructing hypopharynx and cervical esophagus after hypopharyngo-oesophagectomy, and to evalue its efficacy. Methods Different methods were adopted to reconstruct the hypopharynx and cervical esophagus among 25 cases, including 14 cases of carcinoma of the hypopharynx and 11 of carcinoma of hypopharynx and cervical esophagus. In accordance with the standard of the International Union Against Cancer in 1997, the 25 cases were divided into different clinic stages, among which 5 were in T2N0, 2 in T2 N1 , 4 in T3 N0 , 3 in T3 N1 , 7 in T4 N1 and 3 in T4 N2. Treatment protocol was as follow ： Pure operation for 5 cases, reoperation after radiotherapy for 2 cases, operation plus radiotherapy for 18 cases, laryngeal conservation operation for 8, and neck dissection for 21 cases. Reconstruction was done by using free jejunal transplantation, gastric pull-up, the laryngotracheal flap, and myocutaneous flap. Results After the reconstruction, 3 cases of free jejunal graft and gastric pull-up, 4 of laryngotracheal flap recovered oral fleeding within 2 weeks. No serious complications occurred. After 18 cases underwent the myocutaneous flap reconstruction, no complications occurred in 10 patients, but there were different complications in 8 cases, including pharyngocutaneous fistula （6 cases ） , haryngoesphageal stenosis （7 cases ） , and pectoralis major myocutaneous flap necrotic （1 case ）. The 3-year survival rate was 38.9% （ 7 / 18 ） . Conclusion Reconstruction with free jejunal graft, gastric pull-up, and laryngotracheal flap constitutes is a safe and reliable method to restore the continuity of the upper digestive tract after pharyngo-laryngo-oesophagectomy. After the reconstruction with myocutaneous flap, there is high incidence of pharyngocutaneous fistula and haryngoesophageal stenosis.