全舌或近全舌切除术后功能重建

Functional reconstruction after total or neartotal glossectomy

目的评价带蒂胸大肌肌皮瓣与游离组织瓣用于全舌或近全舌切除缺损修复术后患者的功能恢复情况。方法回顾性分析38例舌癌患者行全舌或近全舌切除后带蒂胸大肌肌皮瓣或游离组织瓣修复，比较两组患者术后拔管率、进食及言语功能恢复情况。结果38例患者中，行全舌切除5例，近全舌切除33例。胸大肌肌皮瓣修复25例次（含游离瓣修复失败胸大肌肌皮瓣补救2例），1例术后肌皮瓣完全坏死，成活率96．0％（24／25）。游离组织瓣修复15例次，2例术后组织瓣完全坏死，成活率86．7％（13／15），两组皮瓣成活率差异无统计学意义（P=0．545）。胸大肌修复组和游离瓣修复组术后恢复经口进食率分别为65．2％（15／23）和100％（13／13），气管套管拔管率分别为52．2％（12／23）和100％（12／12），两组差异均有统计学意义（P值均〈0．05）。术后进食功能游离瓣修复组优于胸大肌修复组（P=0．011）。单因素分析显示，采用游离组织瓣修复和保持下颌骨连续性的患者术后恢复经口进食的比例更高。多因素Logistic回归分析显示，下颌骨连续性的保留是影响恢复进食的惟一因素。术后言语功能两组间差异无统计学意义（P=0．434）。结论保持下颌骨连续性是影响舌癌全舌、近全舌切除舌重建术后进食功能恢复的主要因素。采用游离组织瓣较胸大肌肌皮瓣修复更有利于保留或重建下颌骨的连续性。因此，建议首选体积合适的游离组织瓣进行全舌、近全舌重建。

Objective To evaluate the functional outcomes of patients who underwent total or neartotal glossectomy with pectoralis major myoeutaneous flap （PMMF） or free flap （FF） reconstruction. Methods Retrospective study of 38 consecutive patients undergoing total or neartotal glossectomy with PMMF or FF reconstruction. The outcomes of decannulation, feeding and speech function recovery were compared. Results Neartotal glossectomy was performed in 33 patients and total glossectomy was performed in 5 patients. Twenty five patients underwent reconstruction with PMMF including 2 salvage reconstructions after free flaps failure. All PMMFs survived except one complete necrosis. The success rate of PMMF was 96. 0% （ 24/25 ）. Fifteen patients underwent reconstruction with FF. Two flaps developed complete necrosis and the success rate of FF was 86. 7% （ 13/15 ）. The difference in the rates between the two groups was not significant （P = O. 545 ）. In the PMMF and FF groups, the renewal of oral feeding were 65.2% （ 15/23 ） and 100% （ 13/13 ） , P 〈 0. 05, and the tracheostomy decannulation were 52. 2% （ 12/23 ） and 100% （12/12）, P 〈 O. 05, respectively. Postoperative feeding function recovery was better in FF group than that in PMMF group （P = 0. 011 ）. Single factor analysis showed that using FF and maintaining the continuity of the mandible were related to successful rate of renewal of oral feeding. Multivariate Logistic regression analysis showed that the continuity of the mandible was the only independent predictor for renewal of oral feeding. There was no significant difference in the postoperative speech functions between the two groups. Conclusions The continuity of the mandible is the major factor to restore the functional outcomes in feeding after total or neartotal glossectomy. Compared with PMMF, using FF is more beneficial to retain or rebuild the continuity of the mandible.