异种(牛)脱细胞真皮基质修复咽喉肿瘤切除术后黏膜缺损的效果评估

Repairing mucosa defect with heterogeneity (cattle) acellular dermal matrix after pharyngolaryngeal neoplasm resection

目的:咽喉肿瘤切除后黏膜缺损的修复直接影响呼吸、发音、吞咽功能的恢复。文章评估了应用异种(牛)脱细胞基质修复膜修复咽、喉术后黏膜缺损的效果。方法:选择2006-08/2007-11青岛大学医学院附属烟台毓璜顶医院耳鼻咽喉头颈外科收治的咽喉肿瘤患者27例,口咽部扁桃体癌5例,下咽癌6例,喉癌16例,其中声门区癌15例,声门上区癌1例,肿瘤病理均为鳞状细胞癌。实验经医院伦理委员会批准,所有患者对实验及治疗方案均知情同意。实验采用烟台正海生物技术有限公司提供的异种(牛)脱细胞真皮基质修复膜,批号SS070603,规格(2×2.5)cm或(4×3)cm的白色、半透明、蜂窝状片块组织,基底膜面较粗糙,另一面较光滑。扁桃体癌患者将修复膜缝于创面后,采用碘仿纱条打包固定7d。喉癌患者如缺损组织小可以将修复膜直接铺于创面缝合,如缺损较大则先应用带状肌或带状肌筋膜修补喉部缺损,然后将修复膜铺于喉内创面与黏膜切缘对位缝合,采用喉扩张模局部压迫10～12d。下咽癌及颈段食管癌患者亦应用带状肌修补下咽部后壁或侧壁缺损,然后将修复膜与局部黏膜切缘直接对位缝合。术后对患者进行随访观察,以3,6个月,1年为观察时间;主要观察脱细胞真皮基质修复膜修复的愈合,呼吸功能、发音功能、吞咽功能的恢复情况。结果:27例患者中出院时经电子喉镜检查26例黏膜缺损修复一期愈合,1例下咽癌患者术后出现咽漏,经局部换药对症处理后愈合。4例扁桃体癌、4例下咽癌、6例喉癌患者在术后3～6个月应用电子喉镜复查,修复的局部已经恢复为肉眼可见的黏膜组织,吞咽、呼吸均恢复正常(1例声门上喉癌的患者在术后15d进食时有呛咳,经过锻炼进食恢复正常)。喉癌患者发音功能恢复,但是发音的清晰度欠佳;5例扁桃体癌中随访6个月以上4例无复发,1例术后放疗于2个月时局部复发及颈部转移,拒绝再次手术,现带瘤生存;随访1年以上者2例。6例下咽癌随访6个月以上者4例,其中1例患者术后出现咽瘘,经局部换药及对症处理后咽瘘愈合,放疗后3个月因口内大出血死亡。16例喉癌患者随访6个月者6例,随访1年以上者1例。27例患者均未发现排斥、过敏等反应。结论:异种脱细胞真皮基质修复膜为修复头颈肿瘤术后黏膜缺损提供了一种新的方法,手术操作简便,效果良好,为功能恢复提供了保证。

AIM： The repair of mucosa defect after resecting pharyngolaryngeal neoplasms plays a direct role on the functional recovery of breathing, pronouncing and swallowing. This study concerns the effect of applying heterogeneity （cattle） acellular dermal matrix on the repair of mucosa defect. METHODS： From August 2006 to November 2007, 27 cases of mucosa defect accepted treatment with heterogeneity （cattle） acellular dermal matrix in the Department of Otorhinolaryngology Cervical Surgery, Yantai Yuhuangding Hospital, including 5 cases of cancer of amygdala; 6 cases of cancer of hypopharynx; 16 cases of cancer of larynx, among whom there were 15 cases of cancer of vocal area and 1 cases of cancer of upper vocal area. Pathology of cancer was all epidermoid carcinoma. With the permission of the medical ethics committee and the informed approval of these patients for the experiment and treatment, all the patients were repaired with heterogeneity （cattle） acellular dermal matrix （Yantai Zhenghai Biotechnology Inc., Batch No. SS070603, Specification 2 × 2.5 cm or 4 × 3 cm）. The matrix was white and semitransparent tissue, presenting honeycomb appearance, while basal lamina was rough and the other surface was smooth. Patients of cancer of amygdala were treated by stitching behind wound, binding up with iodoform gauze for 7 days. For patients of cancer of larynx, the restoration mucous membrane was carpeted to surface of wound in the small coloboma tissues. If large, the tissue could be firstly mended by strap muscles or muscular fascia, then the restoration mucous membrane was carpeted to surface and stitched up, Afterwards the membrane was stretched for 10-12 days by means of laryngeal extending modules. For patients of cancers of hypopharynx and esophageal cancer, the posterior wall or lateral wall was mended with strap muscles, then the restoration mucous membrane was sutured contrapositionally with the edge of the mucous membrane, After the operation, all the patients were rechecked after 3, 6 and 12 months to observe the wound healing and the functional recovery of breathing, pronouncing and swallowing. RESULTS： For 26 patients of 27 included cases, the repair of mucosa defect was rechecked by electronic laryngoscopy and found healed after operation, while pharyngocutaneous fistula occurred in 1 patients of cancer of hypopharynx after operation and cured by the treatment of dressing change. Postoperative 3-6 months, 4 cases of cancer of amygdala, 6 cases of cancer of larynx and 4 cases of cancer of hypopharynx were checked by e electronic laryngoscopy, the defect was recovered with visible mucous membrane, and the function of breathing and swallowing was satisfying （ 1 case of the cancer of upper vocal area regained its function after exercise, though the patient coughed at 15 days postoperatively）, The patients of cancer of larynx recovered the function of pronouncing, but the resolution was not good; 4 cases of cancer of amygdala were survived for 6 months without recurrence, while 1 reoccurred after 2 months and refused to be treated again, cancer transferring to the neck; 2 cases kept being rechecked for more than one year. Four cases of cancer of hypopharynx kept being rechecked for more than 6 months, and 1 was infected by pharyngocutaneous fistula after operation. After treatment of dressing change and antibiotics, the wound healing was satisfying, but after radiation treatment for 3 months, the case died of massive haemorrhage. Among 16 cases of cancer of larynx, 6 patients kept being rechecked for 6 months, and 1 for one year. Neither rejection nor allergy was found in all the patients. CONCLUSION： Heterogeneity acellular dermal matrix is a new method to repair mucosa defect after otolaryngology cervical surgery. The operative procedure is easy to perform and obtains good effect, worthwhile to be applied for functional recovery.